Advisory Council October 2017 Meeting Presentation: Clinical Subcommittee Update

10/27/2017

Advisory Council on Alzheimer's Research, Care, and Services Meetings

ADVISORY COUNCIL ON ALZHEIMER'S RESEARCH, CARE, AND SERVICES

Friday, October 27, 2017

Printer Friendly Version in PDF Format (9 PDF pages)

 

CLINICAL SUBCOMMITEE UPDATE

Shari Ling, MD

Basics of CMS Regulatory Authority

  • Congress passes a law or statute (e.g. 21st Century Cures Act, amendments to the Social Security Act, Medicare Access and CHIP Reauthorization Act)
  • CMS then creates regulations to implement the law, typically through a Notice of Proposed Rulemaking where the Agency takes public comment, then issuance of a Final Regulation that responds to comment
  • Sometimes CMS publishes a Request for Information, also to take public comment, on an issue important to the Agency's operations and programs
  • CMS can also issue an Interim Final Rule in rare instances where it has good cause to believe the notice and comment process is impractical or unnecessary
  • CMS also regularly issues policy guidance such as memorandums, letters (e.g. State Medicaid, Survey and Certification), interpretative guidelines, State Medicaid Manual, Medicare Benefit Policy Manual) that build on the above

Getting Involved

Dementia in the Context of Other Chronic Conditions

Figure 15: Co-morbidity among Chronic Conditions for Medicare Fee-for-Service Beneficiaries: 2015
Stacked Bar Chart.

Medicare and Medicaid Services That Assist People with Dementia

  • MEDICARE
    • Chronic Care Management
    • Complex Chronic Care Management
    • Cognitive Impairment Assessment
    • Advance Care Planning
    • Annual Wellness Visit
    • Outpatient Mental Health Counseling
    • Home Health
    • Hospital
    • Short-term Nursing Home Care
    • Hospice
    • Telehealth
  • MEDICAID
    • Home and Community-Based Services
    • Health Homes
    • Targeted Case Management
    • Home Health
    • Rehabilitative Services
    • Programs for All-Inclusive Care
    • Hospital
    • Short and Long-Term Nursing Home Care
    • Hospice
    • Telehealth

Unlike Medicare, many Medicaid services are optional -- each State decides what, who, and how much to make available

National Partnership to Improve Dementia in Nursing Homes

  • CMs has partnered with federal and state agencies, nursing homes, advocacy groups, and others improve dementia care and implement practices that enhance the quality of life for people with dementia, protect them from substandard care and promote goal-directed, person-centered care for every nursing home resident
  • The national prevalence of antipsychotic use in long-term care residents has now been reduced by 34.1%--decreasing nationwide usage from 23.9% at the beginning of the initiative to 15.7% by the end of the first quarter of 2017
  • This surpassed our original goal of reducing the national prevalence by 30% by the end of 2016
  • Nursing homes with high rates of use are to work to decrease antipsychotic medication use by 15 percent, for long-stay residents, by the end of 2019

(Strategy 3.D)

Regional Data

Quarterly Prevalence of Antipsychotic Use for Long-Stay Residents, CMS Regions 2011Q2 to 2017Q1
Line Chart.

State Dementia Care Coalitions

  • Best Practice Strategies:
    • Direct facility outreach
    • Workshops and conferences
    • Training opportunities (i.e., Hand in Hand training series)
    • Use of Civil Money Penalty fund) for
      • Education/Training
      • Conferences
      • Implementation of person-centered intervention strategies (e.g. Music and Memory Program)

Information at: https://www.nhqualitycampaign.org/files/State_Dementia_Care_Coalition_Best-Practice_Strategies.pdf

What's Ahead

  • Collaboration with State Dementia Care Coalitions, CMS Regional Offices, and State Survey Agencies
  • Comprehensive focus on poor performing nursing homes
  • Focused Dementia Care and Schizophrenia Surveys
  • Revision of Hand in Hand training series
  • Data tracking and distribution
  • Federal CMP fund initiative
  • Medicare Learning Network (MLN) national provider calls

Information at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve-Dementia-Care-in-Nursing-Homes.html

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents

  • CMS just released the final independent evaluation report for the first phase of the Initiative, from 2014-2016
  • All seven sites reduced hospitalizations, with six of the seven achieving statistically significant improvement in either all-cause hospitalizations, potentially avoidable hospitalizations, or both
  • Medicare expenditures were reduced in six of the seven sites, with statistical significance in most
  • The strongest improvements in both cost and quality were at intervention sites with a full-time nurse at each facility providing direct care to residents where greater changes in facility culture, greater support for the need to reduce avoidable hospitalizations, and greater overall buy-in to the Initiative from facility occurred
  • The second phase of the Initiative underway tests new payment reform models, both in conjunction with the Phase One interventions or on their own

(Strategy 2.D )
Information at: https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/InitiativetoReduceAvoidableHospitalizations/Evaluation-.html

Integrated Care Resource Center

  • CMS dually-eligible Medicare-Medicaid Resource Center has continued to sponsor the Geriatric Competent Care Series, which helps providers in all settings and disciplines expand their knowledge and skills in the unique aspects of caring for older adults and in working with their caregivers
  • Many of these Webinars have examined dementia, including one held in September on involving and supporting unpaid caregivers in care planning and delivery

(Strategy 2.G)
Information at: https://resourcesforintegratedcare.com/GeriatricCompetentCare/2017_GCC_Webinar_Series/Series_Overview

Health Care Innovation Awards Second Annual Report

  • The Report covers awardees' implementation experiences during the 2nd program year, 2015-16, highlighting changes in program features including the modifications the 39 awardees made to their service delivery and payment models
  • One HCIA award directly addresses people with ADRD; the Johns Hopkins Maximizing Independent at Home, a care coordination intervention for people ADRD who live in the community and for their caregivers

(Strategy 2.E)
Information at: https://innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/Round-2.html

CMS Behavioral Health Payment and Care Delivery Innovation Summit

  • In September CMS held an in-person public Summit in Baltimore to discuss ideas for a potential behavioral health model for ADRD
  • Ideas shared during the meeting are now assisting staff to explore model development
  • Presentations focused on substance use disorders, telehealth, workforce issues, payment, and ADRD
  • The Summit materials are archived at: https://innovation.cms.gov/resources/behavioral-health-paymentcare-summit.html
  • Comments submitted to the Innovation Center RFI may address suggestions for a potential dementia model, including on such topics as: service array including care management and coordination, caregiver assessment/training/supports, home and community-based services (e.g. personal care, respite care, home-delivered meals, adult day health, environmental assessment/modifications, assistive technologies), person-centered planning, medication management, payment structure, eligibility criteria, peer supports, participant qualifications, service delivery modes such as self-direction and managed care

(Strategy 2.E)

The Center for Medicare & Medicaid Innovation New Direction

  • CMS has issued a "Request for Information" to seek public feedback on a new direction for the Innovation Center, to promote person-centered care and test market-driven reforms that empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes
  • CMS is focused on these areas: Increased participation in Advanced Alternative Payment Models; Consumer-Directed Care & Market-Based Innovation Models; Physician Specialty Models; Prescription Drug Models; Medicare Advantage Models; State-Based and Local Innovation, including Medicaid-focused Models; Program Integrity, and Mental and Behavioral Health Models

THE RFI IS OPEN FOR PUBLIC COMMENT UNTIL NOVEMBER 20: https://innovation.cms.gov/initiatives/direction/

Dementia-Specific Training Sponsored by Bureau of Health Workforce

  • Medscape article: Bidirectional Impact of Alzheimer's Disease and Common Comorbid Conditions
    • Online access to training module available from September 2016 through August 2017 7,937 learners, primarily physicians, nurse practitioners, other nurses, physician assistants, and pharmacists
  • Number of Geriatric Workforce Enhancement Program (GWEP)-sponsored interprofessional continuing education sessions provided on Alzheimer's Disease
    • 402 in FY15
  • Number of trainees participating in GWEP-sponsored interprofessional continuing education on Alzheimer's disease
    • 43,148 in FY15

Dementia Training at HRSA

  • ADRD teaching curriculum
    • With federal partners and public stakeholders, HRSA created the Alzheimer's Disease and Related Dementias training curriculum to provide training for the primary care workforce about dementia care, and to help providers address caregiver needs.
    • The curriculum consists of 16 core modules (12 that address specific dementia topics and 4 that address the role of specific professions in dementia care), and four supplemental modules to assist providers in understanding and addressing caregiver needs.
  • Anticipated users of this curriculum include, but are not limited to:
    • Health professions faculty
    • Students
    • Primary care practitioners
    • Members of the interprofessional geriatrics care team
    • Direct service workers
  • Each of the modules that constitute the curriculum can be accessed at

QUESTIONS?


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