Advisory Council October 2015 Meeting Presentation: Clinical Services Update

Monday, October 26, 2015

Clinical Services Federal Update

Shari Ling, MD CMS
Joan Weiss, RN HRSA

Dementia-Related Activities

• Innovative Models of Care
• National Quality Forum Gaps Task on Home and Community-Based Services
• Medicaid Innovation Accelerator Program
• Medicaid Demonstration Waivers that Target Alzheimer’s Disease
• Telehealth Options in Medicare and Medicaid
• Advancements in Hospice Care
• QIO/QIN Coordination of Care

Innovative Models of Care

• The Congress created the Center for Medicare & Medicaid Innovation (Innovation Center) in the Affordable Care Act
• Its purpose is to test “innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care” for people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program

CMS Innovation Center Priorities

• Testing new payment and service delivery models that build on ideas from stakeholders, clinical and analytical experts, and Federal agencies; test improvements in care delivery and payment; confirm findings from previous tests; and inform changes in payment, policy, and development of new models
• Evaluating results and advancing best practices including analysis of quality outcomes at the person-level and changes in spending; use of performance data for continuous quality improvement; and rapid spread of best practices through learning collaboratives
• Engaging a broad range of stakeholders to develop additional models for testing through regional meetings, listening sessions, open door forums, a website; and other activities

Health Care Innovation Awards (HCIA) Objectives

• Engage a broad set of innovation partners to test new models from the field that produce improved outcomes and reduced costs for specified target groups
• Identify new models of workforce development and deployment, and related training and education
• Support innovators that can rapidly deploy care improvement models through new ventures or expansion of existing efforts to new populations, working with other public and private partners when appropriate

HCIA -- Round One, 2012

• 107 participants were selected
• Awards ranged from $1M-$3M
• Funding Period: July 2012 - June 2015
• 1st Annual Reports have been issued, and 2nd Annual Reports are expected in early 2016

Disease-Specific and Complex/High-Risk Targeting Reports

• Disease-Specific
• Dementia-related are Trustees of Indiana University, and Regents of the University of California-Los Angeles
• Complex/High-Risk
• Dementia-related are University of Arkansas for Medical Sciences, University of North Texas Science Center, and University of Rhode Island

HCIA Round One Projects Targeting People with Dementia

Awardee	Brief Description
Regents of the University of California, Los Angeles	Coordinated, comprehensive, person and family-centered program. Five key components: (1) patient recruitment and a dementia registry; (2) structured needs assessments of individuals and their caregivers; (3) creation and implementation of individualized dementia care plans; (4) monitoring and revising care plans as needed; and (5) providing access 24/7, 365 days a year for assistance and advice
Trustees of Indiana University	The Aging Brain Care program incorporates the common features of several evidence-based collaborative care models into one program designed to deliver high quality, efficient medical care to older adults with dementia and/or depression
University of Rhode Island	The Living Rite Innovations project is delivering holistic coordinated care through the project’s two Living Rite Centers which provide comprehensive chronic care management in order to coordinate services between multiple community providers, improve health, and decrease unnecessary hospitalizations and ER visits
University of Arkansas for Medical Sciences	Project is providing enhanced training of both family caregivers and the direct-care workforce in order to improve care for elderly persons requiring long-term care services, including Medicare beneficiaries qualifying for home health services and Medicaid beneficiaries who receive homemaker and personal care assistant services (home and community-based services)
University of North Texas Health Science Center	The awardee in partnership with Brookdale Senior Living (BSL), is developing and testing the Brookdale Senior Living Transitions of Care Program, based on an evidenced-based assessment tool called Interventions to Reduce Acute Care Transfers (INTERACT) for people in independent living, assisted living and skilled nursing facilities.The goal of the program is to prevent the progress of disease, thereby reducing complications, improving care, and reducing the rate of avoidable hospital admissions for older adults

HCIA Round Two - 2013

• Proposals solicited in four specific categories of care, including “care for populations with specialized needs,” such as proposals that target persons with Alzheimer’s Disease (AD) as a funding priority
• 39 participants
• 2 awards funded for Alzheimer’s Disease
• Funding Period: Sept 1, 2014 to Aug 31, 2017

HCIA Round Two Prospective Participants Targeting Dementia

Prospective Recipient	Brief Description
The Regents of the University of California, San Francisco	This project will test a model to provide high quality dementia care. The model consists of four specific modules targeting caregivers, decision-making, medications, and functional monitoring
Johns Hopkins University	This project will test a comprehensive care management program for people with Alzheimer's disease/dementia designed to help them remain in their homes and communities

CMS Quality Strategy

• Foundational Principles
  • Enable Innovation
  • Foster learning organizations
  • Eliminate disparities
  • Strengthen infrastructure and data systems
• Goals
  • Make care safer
  • Strengthen person and family centered care
  • Promote effective communications and care coordination
  • Promote effective prevention and treatment
  • Promote best practices for healthy living
  • Make care affordable

NQF Work on Home and Community-Based Services Quality Measurement

CMS has contracted with the National Quality Forum to:

• Create a conceptual framework for home and community-based services (HCBS) quality measurement, and a standard definition for HCBS to cross public and private payers
• Perform an environmental scan of existing HCBS measures and concepts
• Identify gaps and promising HCBS quality measures
• CMS, the Administration for Community Living, the Office of the Assistant Secretary for Planning and Evaluation, and the Substance Abuse and Mental Health Services Administration are Federal partners

Medicaid Innovation Accelerator Program

• Addresses Medicaid innovation in four areas: substance use, long-term care, physical/mental health integration, and complex care
• Recent work will address Medicaid “beneficiaries who, because of their health and/or social conditions, are vulnerable to experience high levels of costly and often preventable service utilization, and whose care patterns and costs are potentially impactable”
• New opportunities for community integration/long-term services and supports were announced last week

Medicaid Demonstration Waivers That Address Alzheimer’s Disease

• RHODE ISLAND
  • In 2014 CMS granted expenditure authority for adults aged 19-64 who have been diagnosed with Alzheimer’s Disease or a Related Dementia as determined by a physician, who are at risk for Long-Term Care admission, who are in need of home and community based services, and whose income is at or below 250 percent of the Federal Poverty Line
• VERMONT
  • In 2015 CMS granted authority for the Companion Aide Pilot Project, which provides assistance to nursing facilities in advancing culture change with a focus on person-centered dementia care to include dedicated Companion Aides to participating nursing facilities. The Companion Aide is a trained licensed nursing assistant to champion person-centered dementia care and be a supportive resource for residents and co-workers

Telehealth in Medicare and Medicaid

• In 2015 Medicare began covering a chronic care management service that does not require a beneficiary to be present, and included seven new procedure codes for telehealth including psychotherapy, Annual Wellness Visit, prolonged office services, etc.
• Medicare historically covers telehealth if the beneficiary is seen under certain circumstances
• Medicaid permits for state flexibility and choice in the provision of telehealth including originating site, types of telecommunications, and geographic areas where telemedicine can be utilized

Improvements in Hospice Care

• Effective January 1, 2016, hospices serving Medicare beneficiaries will provide for two routine home care rates to provide separate, budget-neutral payments for the first 60 days of hospice care, and care beyond 60 days
• In addition to the two routine home care rates, CMS will provide for a service intensity “add-on” payment that will promote and compensate for the provision of skilled visits at the very end of a person’s life

CMS Focus on ADRD

CMS regularly convenes its staff experts through an Alzheimer’s Disease and Related Dementias “Affinity Group” to align and coordinate efforts, and to advance programs and policies in this area

Questions and Contact Information:
shari.ling@cms.hhs.gov

Geriatric Workforce Enhancement Program

Purpose:

• Establish and operate geriatric education centers
• Develop a health care workforce
• Maximizes patient and family engagement
• Improves health outcomes for older adults
• Integrating geriatrics with primary care

Required Collaboration Members

• Primary care clinical sites and agencies
• Community-based organizations

Summary of Funding

• Funded 44 awards
• Total Amount of Awards: $35.7 M
• Approximately $5.2 Million for ADRD Education
• Primary Applicant:
  • Schools of Medicine: 25 awardees
  • Schools of Nursing: 11 awardees
  • Schools of Social Work: 1 awardee
  • Schools of Allied Health: 1 awardee
  • Health Care Facilities: 5 awardees
  • Certified Nurse Assistant Programs: 1 awardee

Populations and Topics

• Populations Served
  • Medically Underserved - 44
  • Rural – 26
  • Hispanic/Latinos – 10
  • Native Americans - 8
  • Homeless - 2
• Topics
  • Dementia – 39
  • Public Health – 12
  • Telehealth – 12
  • Elder Justice – 7
  • Palliative Care – 5

Partners

• Community-Based
  • Alzheimer’s Association – 29
  • Area Agencies on Aging – 25
  • Veterans Administration - 16
  • Area Health Education Centers – 13
  • Quality Improvement Organizations – 13
  • Program for All-Inclusive Care of the Elderly – 10
• Primary Care
  • Federally Qualified Health Center/Community Health Center – 21
  • Tribal Organizations/Indian Health Service – 6
  • Academic Medical Center – 27
  • Community Hospital – 19

Unified Alzheimer’s Disease Curriculum

• Purpose
  • Build a workforce with the skills to provide high-quality care,
  • Ensure timely and accurate detection and diagnosis of ADRD
  • Identify high-quality dementia care guidelines and measures across care settings
• Project Activities
  • Develop and pilot test between 30 to 40 modules that build upon the ACT on Alzheimer’s Preparing Minnesota Communities training materials
  • Address various high-priority issues related to the detection, management, and treatment of ADRD
  • Identify key learning objectives
  • Summarize current clinical guidelines
  • Modules will be able to be used as part of a unified curriculum or as stand-alone units