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Advisory Council April 2014 Meeting Presentation: Clinical Services Update

Tuesday, April 29, 2014

Clinical Services Update

Shari M. Ling M.D.
Deputy Chief Medical Officer
Centers for Medicare & Medicaid Services (CMS)
Center for Clinical Standards & Quality

Road Map

  • Innovative Models
  • Care Transitions
  • Patient and Family Engagement Campaign
  • Workforce Education
  • Technical Solutions

Implementation Milestones

February 2013 September 2014 July 2015
Patient and Family Engagement Campaign (PFEC) (12-18 months)
  • Implement and evaluate new care models to support effective care transitions for people with AD
  • Independent evaluation starting during 2014
  • Program goal is to identify an initial small number of the projects for potential expansion by December 2015
  • Patient and Family Engagement Campaign: Submit Final Report (July 30, 2014)
  • Evaluate the effectiveness of medical home models for people with AD
  • Evaluate the effectiveness of the Independence at Home Demonstration
  • Explore the effects of new payment models on AD care and costs
  • Consider test of new payment or deliver model to promote the quality of AD care while reducing costs

Health Care Innovation AwardsRound 2

  • In May 2013, the Innovation Center announced a 2nd round of Health Care Innovation Awards, specifically soliciting proposals in 4 specific categories of care:
    • One of the four categories, “improve care for populations with specialized needs,” designates proposals that target care for persons with AD as a priority population for funding.
    • Awards are expected to be announced by the Spring/Summer 2014.

Care Transitions: National Inpatient and Alzheimer’s/DementiaAnnual Admissions per 1,000 Beneficiaries

  Start Date     End Date   Eligible
Inpatient Hospitalizations Alzheimer's/Dementia
  Admissions     Admissions per  
1,000 Benes
  Admissions     Admissions per  
1,000 Benes
01/01/2009 12/31/2009 34,943,557 11,073,504 316.90 2,784,616 79.69
01/01/2010 12/31/2010 35,482,297 11,100,183 312.84 2,761,930 77.84
01/01/2011 12/31/2011 36,022,892 11,042,902 306.55 2,653,296 73.66
01/01/2012 12/31/2012 36,685,228 10,699,398 291.65 2,116,603 57.70

Alzheimer’s Events 2009 - 2013

Admissions Re-Admissions
Line Graph Line Graph

Patient & Family Engagement Campaign (PFEC)

  • Focus: The QIO shall design its PFEC work to target behaviors among beneficiaries that address Care for Individuals Diagnosed with Dementia
    • Generate processes designed to increase awareness and engagement by providing decisive tools, so patients and families make better decisions related to health care services they receive;
    • Enable patients, their families, care givers and the public in general to interact among themselves and obtain information related to health care services they receive related to Dementia / Alzheimer’s Disease.

PFEC -- Dementia/Alzheimer’s

  • Five (5) QIOs are involved with PFEC targeting clinical diagnosis of dementia/Alzheimer’s disease
  • Participating QIOs
    • California (HSAG)
    • Kentucky (HCE)
    • Michigan (MPRO)
    • Missouri (Primaris)
    • New York (IPRO)
  • The QIOs have established their tactics for achieving success
  • End: July 2014

Persons Impacted

State/QIO # Directly Reached   # Indirectly Reached  
California (HSAG) 1250 n/a
Kentucky (HCE) 630 n/a
Michigan (MPRO) 560 n/a
Missouri (Primaris)   339 29,704
New York (IPRO)   160 (80 beneficiaries w/ 80 graduate caregivers)   882

Lessons Learned

  • Beneficiaries are receptive to using technology and knowledge to actively engage in their healthcare;
  • For some of the target audience the QIOs have learned that Hispanic communities have providers of care but many have English as a second language and are located in a high crime area;
  • Identified that many have limited knowledge of dementia-care best practices, resources; and that many may be unaware, due to recent diagnosis of dementia or Alzheimer’s disease, of evidence-based practices for quality of life practices;
  • Learned that dementia-care resources exist, but beneficiaries have limited understanding of how helpful these resource can be to caregivers;
  • Recognized that beneficiaries and families require education regarding the need, and ability, of being responsible for their healthcare decisions;
  • Acknowledged that care is poorly coordinated between hospitals and community resources;

Health Resources and Services Administration (HRSA) ADRD Activities

  • Reviewing 45 Geriatric Education Centers applications for continued funding for ADRD education and training
  • Writing statement of work for contract for unified curricula
  • GEC grantees are working with the National Task Group on Intellectual Disabilities and Dementia Practices to develop an ADRD curricula focused on individuals with intellectual disabilities
  • HRSA geriatrics grantees are currently participating in monthly conference calls with representatives of other Federal agencies to learn about those agencies’ dementia programs.
  • Partnering with ACL to provide training to the ADRC network

Technical Solutions in the Clinical Environment

  • Physicians and hospitals are eligible for incentive payments for their meaningful use of certified EHR technology. As of April 2013:
    • more than 291,000 professionals, representing more than 50% of the nation’s eligible professionals, received EHR incentive payments; and
    • over 3,800 hospitals, representing about 80 % of eligible hospitals (including Critical Access Hospitals) received EHR incentive payments1.
  • Certified EHR technology must use certain specified health IT standards.
  • Health IT standards support health information exchange and reuse.
  1. Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information: A Report to Congress. Prepared by: ONC. June 2013. 

Clinical Workflowin Caring for Persons with ADRD

  • Detection
  • Diagnosis
  • Care Planning

Opportunities to Apply Health IT Solutions to Clinical Workflow: Some Examples

  • Detection
    • Detection Workflow: Primary Care Providers may detect cognitive impairment using 1 of 8 Brief Cognitive Tools recommended by CMS and NIH
    • Example of HIT Activity: Identify health IT content standards needed for items in the Brief Cognitive Tools to enable interoperable exchange and re-use of this information in EHRs/health IT applications .
  • Diagnosis
    • Diagnosis Workflow: Primary Care Providers or Specialists may make a diagnosis of ADRD by conducting a dementia work-up: history, cognitive exam, and laboratory
    • Example of HIT Activity: Identify health IT content and exchange standards needed for a dementia work-up to enable:
      • bi-directional and interoperable exchange of consultation requests and results between PCP and specialist, and
      • re-use of dementia work-up information.
  • Care Planning
    • Care Planning Workflow: Care planning for persons diagnosed with ADRD would:
      • engage individual/family members/other care team members; and
      • address: all health concerns; individual/family member/caregiver preferences, availability and needed supports; I&R to community supports; and need for advance care planning.
    • Example of HIT Activity: Identify and fill gaps in Health IT standards to allow for the interoperable exchange of care plans and content needed on behalf of persons with ADRD.