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

Objectives

• 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

Goals and Driver Diagram

Eligibility

• 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

Four Seasons Palliative Care Model

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

• PRE-VISIT
  • 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
• VISIT
  • 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
• POST-VISIT
  • 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

PRIORITY OF VISIT	High	Medium	Low
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%
Meds	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
Nutrition	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	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

PSYCHOSOCIAL RISK ASSESSMENT

RISK	High	Medium	Low
Psychosocial	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

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

Dementia

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

Palliative Care -- Dementia CMMI patients

Add

Functional Status of PC Dementia Patients

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

Code Status -- Dementia Patients - PC

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

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)

2013

• 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

2016

• 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

Questions?

jbull@fourseasonscfl.org