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Advisory Council April 2016 Meeting Presentation: Clinical Services Federal Update

Friday, April 29, 2016


Clinical Services Subcommittee Federal Update

Shari Ling, MD

Goal One: Prevent and Effectively Treat Alzheimer's Disease by 2025

Department of Veteran's Affairs Terminology Update/Collaboration

  • In addition to Alzheimer's Disease, VA's Research office updated the wording in its specialty AD Request for Applications for biomedical laboratory or clinical research to include frontotemporal dementia, Lewy body dementia, and/or vascular contributions to cognitive impairment and dementia
  • VA's Research office is working with the National Institute on Aging (NIA) to increase funding opportunity collaboration, including collaborating more closely on dementia research (e.g., recruitment/retention of in clinical trials, data sharing, biorepository use, use of VA's electronic health records in research studies)

Goal Two: Enhance Care Quality and Efficiency

Department of Veteran's Affairs Geri-Scholars Toolkit

  • VA's Geri-Scholars program has a Geri-Scholars "Toolkit" covering twelve clinical topics including dementia
  • Each topic contains two sections: clinical assessment, management, and treatment; and educational materials for people with ADRD and their caregivers
  • 2,820 Toolkits have been disseminated to VA rural clinics; community living centers, program participants, local and national VA officials, and the public

(Strategy 2A)

Department of Veteran's Affairs Provider Training/HCBS

  • The VA continues to participate actively in the HRSA-led process to develop a unified AD curriculum for use in training primary care providers and other members of the health care team, providing input and feedback on multiple modules under development
  • The VA shared a Summary Report of completed home and community-based services (HCBS) pilot programs with dementia components sent to Federal partners, who then shared with the Advisory Council

(Strategy 2.A, Action Item 2.A.7; Strategy 5.A, Action Item 5.A.7)

National Partnership to Improve Dementia Care Quality Assurance and Performance Improvement

  • MLN Connects® National Provider Calls are educational conference calls conducted for the Medicare provider and supplier community that educate and inform participants about new policies and changes
  • MLN call on the Partnership and QAPI was held Thursday, April 28 on infection control, highlighting antibiotic stewardship and community-wide efforts
  • Infection control is critical for residents with dementia, who often struggle to complete complex tasks and may have issues with continence

(Strategy 2.A)
Registration and archived materials:

National Quality Forum - Home and Community-Based Services

  • As part of its HHS project to define HCBS, examine quality measurement in HCBS, and identify gaps in HCBS measurement, NQF held a two day in-person Committee meeting in March
  • The Committee finalized HCBS "domains" and sub-domains and is working on recommendations
  • NQF is preparing a final report to be issued in the fall

(Strategy 2.D, Strategy 2.G)

National Quality Forum - Neurology

  • Members of a new NQF Committee are reviewing neurological performance measures by soliciting measures from developers - including ADRD measures - and reviewing endorsed measures
  • In April NQF approved Measure #2872, Dementia- Cognitive Assessment for trial use as an "e-measure" and re-endorsed Measure #2111, Antipsychotic Use in Persons with Dementia
  • #2872: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period

(Strategy 2.D)
Measures Under Review 4-16:
Neurology Project:

Other Endorsed Dementia Measures

NQF-Endorsed Quality Measures for Dementia
2091: Persistent indicators of dementia without a diagnosis--long stay
2092: Persistent indicators of dementia without a diagnosis--short stay
2111: Antipsychotic Use in Persons with Dementia

Health Care Innovation Awards Round 2 - Update

  1. The Regents of the University of California, San Francisco is testing a model to provide high quality dementia care targeting caregivers, decision-making, medications, and functional monitoring
  2. Johns Hopkins University is testing a comprehensive care management program for people with ADRD designed to them remain in the community

Year 2 results from the Independent Evaluation for Round One are pending

(Strategy 2.E)

Comprehensive Primary Care (CPC+) Model

  • In April CMS announced CPC+, a five-year multi-payer model that begins in January, 2017 and will include more than 20,000 clinicians
  • Payments are structured through two different tracks will encourage physicians to focus on outcomes
  • Enrolled beneficiaries with complex needs (e.g. cognitive impairment, chronic conditions, frailty) will be better able to achieve their goals and become engaged in care, have 24 hour access, and receive preventive services and care coordination

(Strategy 2.E)

National Partnership to Improve Dementia Care Antipsychotic Medication Use Trend Update

  • In 2011Q4, 23.9% of long-stay nursing home residents were receiving an antipsychotic medication
  • Since then, there has been a decrease of 27% to a national prevalence of 17.4% in 2015Q3
  • Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 25%

(Strategy 3.D)

Mapping Medicare Disparities Tool

  • In March CMS released a new interactive tool to increase understanding of geographic disparities in chronic disease - including Alzheimer's Disease - among Medicare beneficiaries
  • Understanding geographic differences in disparities is important to informing policy decisions and targeting populations and geographies for interventions

(Strategy 2.A, Strategy 2.H)

Goal Three: Expand Supports for People with Alzheimer's Disease and their Families

Medicaid Home Health - Final Rule

  • In February CMS issued a Final Rule on Home Health
  • The rule adds requirements that clinicians timely document the occurrence of a face-to-face beneficiary encounter (including through the use of telehealth)
  • The rule also amends the Medicaid definition of medical supplies, equipment, and appliances and clarifies that the items may be used anywhere normal life activities take place (no homebound requirement)
  • CMS is working to determine what the new definition above might encompass
  • State officials must compare their home and community-based services programs against the new definition to determine what could become available to a larger group through the Medicaid State plan as part of the mandatory home health service

(Strategy 2.A)

Use of Civil Monetary Penalty Funds (CMPs) for Nursing Home Improvements

  • In 1986, Congress passed the Nursing Home Reform Act, which permitted sanctions against nursing homes; CMPs are one type of sanction
  • CMPs are imposed on facilities for certain instances of noncompliance
  • Some CMP funds may be reinvested to improve the quality and care and life of residents
  • Many "qualified entities" can request CMP funds for projects by contacting their state; consumer advocacy organizations, resident/family councils, private contractors, etc.
  • State officials review the proposal, then forward to the CMS Regional Office Projects could include improved dementia care, antipsychotic utilization, person-centered care improvements, and reducing avoidable hospitalizations

(Strategy 2.A, Strategy 2.C, Strategy 3.A, Strategy 3.D)

Nursing Home Improvements through CMPs

  • The Eden Alternative, Inc. received a grant in 2015 to support the National Partnership to Improve Dementia Care in Nursing Homes, Creating a Culture of Person-Directed Dementia Care
  • Staff training on non-pharmacological interventions for dementia-related behaviors
  • Additional training and education for staff in accurate assessment of residents' cognitive ability, and to reduce the number of inpatient hospital admissions
  • Host training on abuse, neglect and exploitation for administrators and front line staff in Jefferson County, Alabama and surrounding counties
  • Development of a sensory garden and walking trail to create a functional, pleasant and safe outdoor space for residents
  • CMS Region IV is working with AL, FL, GA, KY, MS, SC to improve access to best practices/improved skills
  • Music & Memory Project – personalized music for residents with dementia

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

  • In March CMS announced a new phase starting this fall to provide practitioners with additional payments for multidisciplinary care planning
  • Medicare currently pays physicians less for a comprehensive assessment at a nursing facility than for the same assessment at a hospital; this model equalizes payments between sites
  • Nursing facilities will offer additional treatment for common medical conditions that often lead to avoidable hospitalizations
  • There will be more practitioner engagement when a resident needs higher-intensity interventions due to a change in condition
  • Participating nursing facilities will also enhance staff training and purchase new equipment to improve certain capacities

(Strategy 2.A, Strategy 2.E, Strategy 2.F, Strategy 2.G)

Medicaid Mental Health Parity -- Final Rule

  • In March CMS issued a Final Rule to address parity in lifetime and annual dollar limits for mental health benefits and medical/surgical benefits in Medicaid
  • States have increased flexibility to provide behavioral health services through managed care delivery systems
  • The rule better aligns Medicaid with commercial insurance products

(Strategy 2.A)

Virginia Alzheimer's Disease HCBS - Update

  • Virginia has the only Medicaid home and community-based services waiver "targeted" to people with AD
  • The Commonwealth is proposing that current AD Assisted Living services continue to be covered under a proposed new managed care waiver (as fee-for service)

(Strategy 2.A)

Goal Four: Enhance Public Awareness and Engagement

Indian Health Service-VA REACH Update

  • The IHS and ACL continue work with the Department of Veterans Affairs to adapt and implement the REACH (Resources for Enhancing Alzheimer's Caregiver Health) VA program of caregiver support in Tribal communities through both public health nursing and the Tribal aging network
  • REACH VA is an evidence-based translation that uses structured interventions to provide caregivers of people with dementia with tools and skills to manage ongoing caregiving challenges
  • The VA is a a source of clinical expertise in diagnosis and management of dementia for many Native Veterans
  • The IHS is building on VA work to test strategies for early recognition among family members as well as clinical and aging services staff

(Strategy 2.C, Strategy 4.B)

Medicaid Indian Health Payment Policy

  • In February CMS issued an update that affects federal funding for services received by Medicaid-eligible American Indians and Alaska Natives receiving care through the Indian Health Service
  • IHS/Tribal facilities may enter into care coordination agreements with non-IHS/Tribal providers for certain services eligible at an enhanced Federal match rate of 100 percent
  • Services include LTC covered under the State Plan

(Strategy 2.C, Strategy 4.B)

Brain Health

  • In April HHS's Administration for Community Living, in collaboration with NIA and the CDC, updated its Brain Health Resources to include additional materials on medications and the aging brain designed for use by staff  and volunteers at senior centers, Area Agencies on Aging, health departments, local clinics, and other community organizations
  • The Medicine, Age, and Your Brain set includes a power point presentation, a brochure for educators, and a one page handout for consumers
  • Spanish translations of two of the Brain Health Resource materials are now available, furnished in collaboration with the Alzheimer's Association

(Strategy 2.A, Strategy 4.A)

CMS Caregiver Workgroup

  • Ongoing joint effort between CMS and its partner organizations (non-profit organizations, Federal partners, other)
  • Held quarterly in Washington; call-in attendance option
  • Agenda topics are open - partners present and give updates
  • Next meeting is May 11, 9AM-11AM, RSVP to

(Strategy 3.B)

Goal Five: Track Progress and Drive Improvement

ICD-9/ICD-10 Coding for Dementia

  • HHS is examining ADRD dementia diagnostic codes and coding practices for Federal agencies to use in analyses of administrative data, to enhance reporting
  • The work will help prioritize research, clinical services, and caregiving resources

(Strategy 5.A, Action Item 5.A.7)


Shari Ling