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Advisory Council April 2018 Meeting Presentation: Clinical Subcommittee Update

Friday, April 27, 2018

Printer Friendly Version in PDF Format (5 PDF pages)

 

Clinical Subcommittee Update

Shari Ling, MD

VA Geriatric Scholars Program

  • A workforce development program to integrate geriatrics into primary care practices
  • Longitudinal, multi-modal continuing education program for healthcare professions:
    • Intensive education, clinical practicum experiences, self-paced learning through webinars and on-line learning communities, demonstration of knowledge through quality improvement projects
  • Focus on rural VA clinics; outreach to rural Indian Health Service clinics
  • Funded by VA Offices of Rural Health and Geriatrics/Extended Care
  • Collaboration of 12 VA Geriatric Research, Education and Clinical Centers (GRECC), in partnership with VA Employee Education System (EES), academic affiliates and HRSA-funded Geriatric Workforce Education Programs (GWEP)

FY18Q2 VA Geriatric Scholars Dementia Education and Resources

  • Rural Interdisciplinary Team Training for Toiyabe Nation (February 14, 2018)
    • On-site training for all clinic staff on teamwork in care of older adults; recognition of geriatric syndromes and "red flags," including dementia. Staff from VA Office of Tribal Government Affairs identified opportunities to coordinate care between VA and IHS for Veterans who are eligible for both healthcare organizations. The program was also conducted in partnership with the UCLA GWEP, the Banner Institute and the VA Office of Tribal Government Relations
  • Webinars, accredited through VA Employee Education System and TRAIN inter-agency learning network for VA and community clinicians:
    • PTSD and Memory (January 24, 2018)
  • Geriatric Scholars Toolkits: Dementia

REACH-VA Caregiver Support Intervention

  • National Program to Provide REACH VA to Caregivers of Veterans
  • In addition to training VA staff to work with Caregivers, the Memphis Caregiver Center is providing the REACH intervention directly to Caregivers of Veterans with Dementia or Veterans who are Caregivers of a person living with dementia
  • Four sessions between the Caregiver and a Program Coach (more if needed) by phone
    • Information about dementia, problem solving skills, and to stress management, cognitive reframing/mood management
    • Caregiver Notebook that provides suggestions and strategies
  • Funded by VA Office of Rural Health and Caregiver Support Program

ß Amyloid PET in Dementia and Neurodegenerative Disease

  • The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is insufficient to conclude that the use of positron emission tomography (PET) amyloid-beta (Aß) imaging is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member for Medicare beneficiaries with dementia or neurodegenerative disease, and thus PET Aß imaging is not covered under §1862(a)(1)(A) of the Social Security Act ("the Act").
  • However, there is sufficient evidence that the use of PET Aß imaging is promising in two scenarios: (1) to exclude Alzheimer's disease (AD) in narrowly defined and clinically difficult differential diagnoses, such as AD versus frontotemporal dementia (FTD); and (2) to enrich clinical trials seeking better treatments or prevention strategies for AD, by allowing for selection of patients on the basis of biological as well as clinical and epidemiological factors.

(Strategy 1.C)
CMS, Decision Memo for Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease (CAG-00431N); 2013 September 27.

  • CMS will cover one PET Aß scan per patient through coverage with evidence development (CED), under §1862(a)(1)(E) of the Act, in clinical studies that meet the criteria in each of the paragraphs below.
  • Clinical study objectives must be to:
    1. develop better treatments or prevention strategies for AD, or, as a strategy to identify subpopulations at risk for developing AD, or
    2. resolve clinically difficult differential diagnoses (e.g., frontotemporal dementia (FTD) versus AD) where the use of PET Aß imaging appears to improve health outcomes.
  • These may include short term outcomes related to changes in management as well as longer term dementia outcomes.
  • Clinical studies must be approved by CMS, involve subjects from appropriate populations, and be comparative and longitudinal. Where appropriate, studies should be prospective, randomized, and use postmortem diagnosis as the endpoint. Radiopharmaceuticals used in the PET Aß scans must be FDA approved.

CMS, Decision Memo for Beta Amyloid Positron Emission Tomography in Dementia and Neurodegenerative Disease (CAG-00431N); 2013 September 27.

  • Approved studies must address one or more aspects of the following questions. For Medicare beneficiaries with cognitive impairment suspicious for AD, or who may be at risk for developing AD:
    • Do the results of PET Aß imaging lead to improved health outcomes? (Meaningful health outcomes of interest include: avoidance of futile treatment or tests; improving, or slowing the decline of, quality of life; and survival)?
    • Are there specific subpopulations, patient characteristics or differential diagnoses that are predictive of improved health outcomes in patients whose management is guided by the PET Aß imaging?
    • Does using PET Aß imaging in guiding patient management, to enrich clinical trials seeking better treatments or prevention strategies for AD, by selecting patients on the basis of biological as well as clinical and epidemiological factors, lead to improved health outcomes?
  • Several studies have been submitted for consideration; approval is based on whether a study designed to answer at least one of the questions; and whether the study adheres to CMS's published standards of scientific integrity and relevance to the Medicare population
  • To date, CMS has approved the following studies:
    • Cognitive Training and Practice Effects in MCI (University of Utah)
    • Imaging Dementia--Evidence for Amyloid Scanning (IDEAS) Study (American College of Radiology Imaging Network)
    • Effect of Aerobic Exercise on Pathophysiology in Preclinical Alzheimer's Disease (National Institute on Aging)
    • The largest of these studies, IDEAS, is enrolling more than 18,000 Medicare beneficiaries. Information about this study can be found here: http://www.ideas-study.org/

Geriatric Competent Care 2018 Webinar Series

  • Safe and Effective Use of Medications in Older Adults, was presented on April 18
  • Beneficiaries dually eligible for Medicare and Medicaid have on average, a 25 percent higher rate of chronic conditions than beneficiaries who are not dually eligible
  • The webinar provided an overview of critically important issues related to older adults, and the need for management and coordination among care team members and the beneficiary
  • It is archived on-line at: https://resourcesforintegratedcare.com/GeriatricCompetentCare/2018_GCC_Webinar_Series/Overview

(Strategy 2.D)

Medicare Part D Payment and Policy Updates

  • In March CMS released changes in 2019 for the Medicare Advantage Organizations (MAOs) that allow more options and new benefits
  • CMS has redefined "health-related supplemental benefits" to include services that increase health and improve quality of life, including potential coverage of non-skilled in-home supports such as portable wheelchair ramps and other assistive devices and modifications, and other home and community-based services
  • CMS has previously not allowed an item or service to be eligible as a supplemental benefit if the primary purpose included daily maintenance, but under the new policy CMS allows supplemental benefits if they: 1) compensate for physical impairments, 2) diminish the impact of injuries or health conditions, and 3) and/or reduce avoidable emergency room utilization
  • Additional information is at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-02-01.html

(Strategy 2.G)

April 27, 2018 -- Advisory Council Meeting #28

The meeting was held on Friday, April 27, 2018, in Washington, DC. During the meeting, the Clinical Care Subcommittee took charge of the theme, focusing on advancing consensus on dementia care elements to guide new outcomes measurement. The Council heard speakers in two sessions, one focused on developing consensus about dementia care elements, and the second on models that are informing outcomes measurement. The meeting also included updates on work from the previous meetings, a presentation on the final report from the October 2017 Care Summit, and federal workgroup updates. Material available from this meeting is listed below or at https://aspe.hhs.gov/advisory-council-alzheimers-research-care-and-services-meetings#Apr2018.

Comments and questions, or alerts to broken links, should be sent to napa@hhs.gov.

 

General Information

 

Handouts

  • Main Summit Recommendations -- [HTML Version] [PDF Version]

  • National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers: Report to the National Advisory Council on Alzheimer's Research, Care, and Services -- [HTML Version] [PDF Version]

 

Presentation Slides

 

Videos

  • Introductions and Updates -- [Video]

  • Clinical Care Agenda Session 1 -- [Video]

  • Public Comments -- [Video]

  • Clinical Care Agenda Session 2 -- [Video]

  • Care Summit Final Report -- [Video]

  • MEETING WRAP-UP: Final Report to the NAPA Advisory Council -- [Video]