Tuesday, September 27, 2011
Opportunities and Gaps
P.L. 111 - 148, Patient Protection and Affordable Care Act
Sec. 4103: Medicare Coverage of Annual Wellness Visit Providing a Personalized Prevention Plan
- “Detection of any cognitive impairment” is specifically listed as an element in the law.
- Required as part of the AWV by the Centers for Medicare and Medicaid Services (CMS) Medicare.
- Effective 01/2011
Detection of Any Cognitive Impairment
P.L. 111-148, Sec. 4103
- Assessment of an individual’s cognitive function by direct observation, with due consideration of information obtained by way of patient report, concerns raised by family members, friends, caretakers, or others.
- Public commenters noted that this definition was vague and suggested adding a standardized screening tool.
Courtesy of Joseph Chin, M.D.
CMS, Office of Clinical Standards & Quality
- How should we detect any cognitive impairment?
- Is there an evidence-based assessment tool that could be used during the annual wellness visit?
- sensitive and specific (to limit over-diagnosis)
- applicable to Medicare beneficiary population
- no cost
- time to administer
- Are there recommendations on referrals and follow-up of individuals identified with cognitive impairment?
- inappropriate and/or ineffective treatments
Evaluation of Cognitive Screening Instruments
- “Detection of cognitive impairment” provision effective 1/2011
- February 23, 2011, NIH hosted a meeting with CMS and other federal agencies to discuss the new legislation and cognitive screening.
- On April 4, second meeting held with professional organizations and federal agencies to determine next steps.
- NIH recently completed a comprehensive review of over 140 published cognitive screening instruments.
- Next meeting (10/31/2011) scheduled to review instruments and make recommendations.
ADRD Federal Agencies
Research Planning, Priority Setting, and Evaluation
- Processes ensure that research programs and priorities are established, evaluated, and support the most promising research.
- Agencies’ processes include:
- Established peer-review/external expert reviews of research programs and funding opportunities
- Participation in and sponsorship of research and state of the science conferences
|NIH State-of-the-Science Conference
Preventing Alzheimer's Disease and Cognitive Decline
|April 26-28, 2010
Scientific Knowledge Gaps
- Firm conclusions cannot be drawn about the association of any modifiable risk factor with cognitive decline or Alzheimer’s disease.
- Evidence is insufficient to support the use of pharmaceutical agents or dietary supplements to prevent cognitive decline or Alzheimer’s disease.
- No “highly reliable consensus-based diagnostic criteria for cognitive decline, mild cognitive impairment and Alzheimer’s,” and available criteria at clinician level are not “uniformly applied,” has been addressed.
Federally Funded Clinical Trials
- Over 40 active clinical trials (pilot and large scale) testing wide range of interventions
- to prevent,
- to slow, or treat AD and/or MCI,
- to improve care delivery and patient/caregiver outcomes.
- Primary Prevention: of the 10 primary prevention trials, 2 are NIA-funded cognitive/AD measure add-ons to large NIH primary prevention trials that address a variety of other primary outcomes.
ADRD FY 2011 Translational Research
Department of Veterans' Affairs
- HX-11-014, Targeted Solicitation for Research Projects on Caregiver Programs and Practice to Improve Care Delivery for Veterans; Release date – March 31, 2011
- HX-11-013, Targeted Solicitation for Research Projects on Customizing Long Term Care Programs and Practice to Meet Veterans’ Needs in the 21st Century; Release date – March 31, 2011
Administration on Aging and National Institute on Aging Collaborations
- PA-11-123, Translational Research to Help Older Adults Maintain their Health and Independence in the Community (R01); Release date- February 16, 2011
- PA-11-124, Translational Research to Help Older Adults Maintain their Health and Independence in the Community (R21), Release date- February 16, 2011
|Supported by the National Institute on Aging and the
National Institute on Nursing Research
Promoting Adoption of REACH Interventions
- The Department of Veterans Affairs has implemented “REACH-VA” through its home health agencies
- Administration on Aging has used REACH in its Funding Opportunity Announcements as a model for its caregiving demonstration projects
- REACH-Hong Kong
AoA New Research Programs for 2011
- “Accelerating Integrated, Evidence-Based, and Sustainable Service Systems for Older Adults, Individuals with Disabilities and Family Caregivers”
- “Creating Dementia Capable, Sustainable Service Systems For Persons With Dementia And Their Family Caregivers.”
To develop and operate integrated long-term service and support systems that are dementia capable.
To ensure that older adults, individuals with disabilities and family caregivers have clear and ready access to a sustainable, integrated system that offers a comprehensive set of high quality, evidence-based services that can help them remain independent and healthy in the community.
Dominantly Inherited Alzheimer Network (DIAN)
Sites: Washington Univ, B&W/MGH/Brown Univ, Columbia Univ, Indiana Univ, UCLA, ION/UCL, Astralian Consortium
- Establish an international registry of mutation carriers and non-carriers from families with early onset AD
- Compare carriers and non-carriers to determine the chronology and order of imaging and biomarker changes that predict symptomatic AD
- Compare the clinical and pathological phenotypes of dominantly inherited AD with those of Late-Onset AD (LOAD) Study
- Maintain a publicly available resource of data and biospecimens
|Alzheimer's Disease Neuroimaging Initiative Public-Private Partnership|
|Alzheimer's Disease (AD) Translational Research Initiative: From Drug Discovery to Clinical Trials|
NIA-Alzheimer's Association Project to Redefine Diagnostic Criteria for Alzheimer's Disease
- To better define the natural history of Alzheimer's disease from asymptomatic stages to full blown dementia
- To attempt to relate the clinical symptoms, as they emerge, to the underlying pathophysiology
- To use present knowledge to better diagnose the disease
- To define a research agenda that will help to extend our knowledge to better reach these goals
Identifying Gaps & Opportunities
- Potential for achieving program goals
- Service or project is supported by evidence
- Need not be specific to Alzheimer’s disease
Direct Clinical Services
- Effective early clinical recognition
- Initiating diagnostic testing early
- Appropriate clinical management
Home & Community-based
- Case management services
- Personal Care/Unskilled Care and Respite Care
- Identifying & mitigating unsafe behaviors
- home safety
- Mobilizing health care benefits (e.g. hospice)
- Securing health care agents and care planning
Education and Outreach for Patients, Families and Providers
- Health care provider training to enrich workforce skills
- Management options
- Case management to improve access and utilization of resources
- Patients and Families
Opportunities and Gaps: Preliminary
- More information about individuals’ and caregivers’ use of services
- Dementia capable service systems
- Needs of special populations
- Training needs
- Outreach to individuals and caregivers
|Gaps and Opportunities: Examples|