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Advisory Council August 2016 Meeting Presentation: CMMI Palliative Care Project

Monday, August 1, 2016


CMMI Project Demonstrating the Value of Palliative Care

Janet Bull MD, MBA, FAAHPM
CMO Four Seasons


  • Discuss components of palliative care
  • Demonstrate the benefits to dementia patients
  • Discuss payment reform in hospice and palliative care

Four Seasons

  • Located in Hendersonville, NC
  • Retirement community
  • 25% population over 65 years old (compared to 13%)
  • High dementia population -- number 1 referring diagnosis for both hospice and palliative care

Why Palliative Care?

  • Need to improve care for seriously ill patients
  • Aligned with Mission of providing exceptional end of life care
  • Provide care across the continuum of care settings
  • Unsustainable financial model under current reimbursement structure

Palliative Care Services Focus on...

  • Symptom management
  • Prognostication
  • Advance care planning
  • Establish goals of care
  • Educate patients on their disease process
  • Spiritual and psychosocial support
  • Assist with community resources
  • Coordination of Care
  • Help patients navigate the healthcare system

Mary's Story

74 year old black female with advanced dementia, living with her daughter at home

  • major behavioral issues -- combativeness, agitation
  • polypharmacy
  • hospitalized 2 times in past 12 months (fall, pneumonia)
  • daughter quit work to provide care - exhausted & stressed
  • no advanced care planning

Impact of Palliative Care

  • Improving Helath of Individuals & Populations
  • Improving Patient Experience
  • Reducing the Cost of Care

CMS Innovations Grant

  • Scale model into 14 counties, delivered longitudinal across all care settings
  • Track Quality
  • Define Costs
  • Test innovation -- Tele-palliative care
  • Developing/Testing a New Payment System

Four Seasons Expanding Palliative Care Across Western NC and Upstate SC

Western North Carolina Update South Carolina
Shows what's available in counties of Western NC. Shows what's available in counties of Upstate SC.

Goals and Driver Diagram

Screen shot of goals and driver diagram.


  • Medicare Age Eligible
  • Patients with life limiting illness in last 3 years of life
  • Uncertainty of appropriateness of therapy (curative, palliative, hospice)
  • Excludes 54% of palliative care patients (younger, Medicare Advantage, etc)

Screening Tool for Palliative Care Referrals

Screen shot of screening tool.

Four Seasons Palliative Care Model

Palliative Care Team diagram.

Standardizing Care

  • Developing good processes/procedures
  • Data collection
  • Data analysis/tracking
  • Quality improvements
  • Measuring satisfaction

The Initial Palliative Care Visit by MD, DO, NP, PA, and RN

    • Determine reason for consult
    • Review H&P, meds, labs, xray, etc.
    • Identify other agency involvement
    • Clinic -- New Patient Packet at Sign-In
    • New Patient Packet:
      • Confident Care booklet
      • Consent
      • Letter
    • RN
      • Explain program and review New Patient Packet
      • Review symptoms
      • Reconcile meds and list allergies
      • Obtain social history
      • Do spiritual assessment
      • Discuss ACP
      • Identify goals
      • Assess functional status and safety
      • Assess VS, O2 sat, ht/wt, consitution, eyes, ENT, lymph, resp, cardio, GI, GU, MS, skin, neuro, psych
      • Formulate care plan with patient/family
    • MD, DO, NP, PA
      • Explain program and review New Patient Packet
      • Review symptoms
      • Reconcile meds and list allergies
      • Obtain social history
      • Do spiritual assessment
      • Discuss ACP
      • Identify goals
      • Assess functional status and safety
      • Assess VS, O2 sat, ht/wt, constitution, eyes, ENT, lymph, resp, cardio, GI, GU, MS, skin, neuro, psych
      • Determine prognosis
      • Formulate care plan with patient/family
    • Determine Risk Level
    • Complete visit documentation- to include QDACT
    • Forward copy of notes to facility and/or referrer
    • Collaborate with other members of IDG

Rist Assessment

Transition Transition from hospital within last 2 weeks Transition from hospital within last 15-30 days No hospitalization or ER visits within last 3 months
Symptom Mod-Severe Symptoms: pain, dyspnea, constipation, N&V    
Function 20% drop in PPS 10% drop in PPS PPS stable by <50%
  • 3 or more medication changes within last week
  • Initiation of opioids
1-2 medication changes within last 15-30 days (opioids, anti-psychotics, cardiac meds) <1 medication change within last 3 months
  • Sudden nutritional decline (5% weight loss in 1 month) with BMI <21
  • Albumin <2.5
  • >5% weight loss over last 2-3 months with BMI <21
  • Albumin 2.5-3
<5% weight loss in last 3 months
  • Infection with systemic symptoms within last 2 weeks
  • > Stage 2 pressure ulcer
  • Aspiration
  • 2 infections within last 2 months
  • Stage 2 pressure ulcer within last 2 months
No infections within last 3 months


RISK High Medium Low
  • Sudden cognitive changes
    • Delirium
    • Confusion
  • Mental health diagnosis accompanied by disruptive verbalizations/behaviors. Concern for patient or caregiver safety.
  • Suicidal ideation, especially with plan. Despair.
  • Signs/Symptoms of abuse/neglect. Unsafe situation for patient.
  • Caregiver decompensation. Immediate safety concerns.
  • Anhedonia- flat affect and not participating in > 3 activities
  • Significant losses in last 2 years. Unresolved grief issues.
  • Depression.
  • Expresses fear/anxiety about money, worried about caring for family, concerned about paying for services
  • Caregiver stressed, showing some signs of burnout, but no immediate danger to patient or caregiver. Placement issues.
  • Transition to hospice- pt/family require psychosocial support in making decision for hospice care. Complex family dynamics.
  • Caregiver available and adequate to manage patient care. May need some self-care strategies or information on community resources.
  • Advance care planning needs.

Quality Data Assessment Tool

Screen shot of assessment tool.

PC Tracking

Enrollment N = 2450 Total N = 522 Dementia
Hospice Transitions 700 (33%) 181 (35%)
Palliative Care Deaths 237 (11%) 59 (11%)
Palliative Care Discharges 665 (31 %) 141 (27%)
Active PC Caseload 457 (24.3%) 141 (27%)

Story tells....

  • 50-60% die within 1 year (80% from data 2 years ago)... PC moving upstream
  • 33% discharged after acute episode; of these ~ 10% readmitted


  • Challenges
    • Difficult to prognosticate
    • Slow disease trajectory
    • High caregiver distress/burnout
    • Often stabilize/improve with supportive services

Palliative Care -- Dementia CMMI patients


Bar chart: Home (97), Hospital (84), Long-term care (251), Clinic (5), Other (20).

Functional Status of PC Dementia Patients

Bar chart: 10 (4), 20 (12), 30 (75), 40 (136), 50 (141), 60 (36), 70 (7), 80 (5), Unknown (3), Not indicated (38).
Palliative Performance Scale (PPS)
% Ambulation Activity and Evidence of Disease Self-Care Intake Level of Conscious
100 Full Normal activity, no evidence of disease Full Normal Full
90 Full Normal activity, some evidence of disease Full Normal Full
80 Full Normal activity with effort, some evidence of disease Full Normal or reduced Full
70 Reduced Unable to do normal work, some evidence of disease Full Normal or reduced Full
60 Reduced Unable to do hobby or some housework, significant disease Occasional assist necessary Normal or reduced Full or confusion
50 Mainly sit/lie Unable to do any work, extensive disease Considerable assistance required Normal or reduced Full or confusion
40 Mainly in bed Unable to do any work, extensive disease Mainly assistance Normal or reduced Full, drowsy, or confusion
30 Totally bed bound Unable to do any work, extensive disease Total care Reduced Full, drowsy, or confusion
20 Totally bed bound Unable to do any work, extensive disease Total care Minimal sips Full, drowsy, or confusion
10 Totally bed bound Unable to do any work, extensive disease Total care Mouth care only Drowsy or coma
0 Death --- --- --- ---

Prognostication by Clinicians

Bar chart: less than 7 days (3), less than 4 weeks (20), 1-6 months (140), more than 6 months (219), Unknown (33), Not indicated (42).

Code Status -- Dementia Patients - PC

Bar chart: DNR/DNI (299), DNR/not DNI (5), Mostly DNR/DNI (8), Full code (119), Unknown (10), Not indicated (16). Bar chart: DNR/DNI (345), DNR/not DNI (5), Mostly DNR/DNI (8), Full code (73), Unknown (10), Not indicated (16).

Policy Issues

  • Lack of long term care benefit
  • Little reimbursement for other disciplines
  • New Care Management codes
    • Advance care planning
    • Transitional care codes
    • Chronic care codes

Diagnosis Hospice Claims 2015

Bar chart: Alzheimer's (12), CHF (8), Lung Cancer (6), COPD (5), Senile Dementia (3), CVA (2), Dementia Unspec (2), Parkinson's (2).

Differences - Hospice vs Palliative

  Hospice Palliative Care
Life Expectancy < 6 months Any stage of illness
Treatment Comfort Curative or comfort
Care settings All All
Resources Significant Limited
Delivery model Interdisciplinary Team Interdisciplinary Team
Payment Model Medicare Hospice Benefit Medicare Part B E/M codes


How to Pay for Services?

Developing Alternative Payment Approaches

  • Covered Services
    • Advance care planning
    • Goals of care (3 meetings)
    • Social work, chaplain, patient family volunteers
    • RN case management and care coordination
    • Not covered (hospitalization, primary care, specialty care)

As the World Turns (Grant submission to today)


  • Transitional Fee for Service payment for CPC
  • 1-3yr analysis
  • Bundled PBPM Payment for CPC
  • Promote PC clinical care model Expansion
  • Promote best practice ACO integration of transitional care models
  • Financial Ecosystem changes through Legislation and Policy
    • Changing Accountable Care Act implementation
    • Accountable Care Organization alignment -- Incentives
    • Hospice -- Hospital -- Transitional Facility FFS/PBPM changing
  • Payment Approach Replication Throughout Medicare
    • Dependent on Financial alignment
    • Value Proposition in patient outcomes
    • Value Proposition in reducing Total Cost of Care


  • Jan 1, 2016 *2 CPT codes for Advanced Care Planning (MD only, Outpatient Primarily, State interpretation)
  • 2015 *CCM Chronic Care Management $42 monthly PBPM

Questions Around Payment Approaches

Challenges for Evaluation

  • Medicare Part A vs Part B -- increase Part B while reducing Part A costs
  • PBPM payment 30/60/120
  • Bundled payment (60/120 days) Who holds?
  • Care management codes (increase Part B bucket)
  • Changes in hospice payment (two tiered payment, Service Add on)

Susan's Story

82 year old white female with end stage dementia admitted to the hospital with second episode of aspiration pneumonia

  • wandering, behavioral issues
  • feeding issues -- considering PEG tube
  • lives with son and his wifej who are overwhelmed