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Advisory Council April 2019 Meeting Presentation: View from the Clinic

Monday, April 29, 2019

Printer Friendly Version in PDF Format (4 PDF pages)


Person Centered Care Planning: A View from the Clinic

Soo Borson MD
Dementia Care Research and Consulting
Professor Emerita, University of Washington School of Medicine
Affiliate Professor, School of Nursing

Person Centered Care for Dementia: Principles and Process

  • Person > disease(s)
  • Key friends and family
  • Clinician roles = consultant, technician, container of uncertainty
    • Eliciting concerns, understanding, priorities
    • Advising from evidence + judgment
    • Integrating complexity
    • Negotiating goals
    • Evaluating goal attainment
    • Adjusting and revising
    • Anticipating and counseling
    • Mitigating risk

Person-Centered Dementia Care: 5 Domains

Pie chart: Cognition; (1)Mental and (2)emotional health; (1)Physical health; (1)Key friends and family; (1)Social determinants.
Modified from Borson & Chodosh, Clin Geri Med 30; 395-420 (2014)

CMS Cognitive Impairment Care Planning Code 1.0 -- Alzheimer's Association Workgroup

  • Interprofessional collaboration
  • Goals
    • Explain in plain language - purpose and elements of CPT 99483
    • Encourage uptake in primary care
      • Illustrate simple ways to meet required 9 elements
    • Identify gaps -- the evidence of collective experience
    • Anticipate potential barriers to use

Borson, Chodosh, Cordell et al. Alz Dementia 13: 1168-1173 (2017)

Key innovations

  • Acknowledges complexity (9 elements)
  • Explicitly includes caregivers
  • Requires written, shared care plan
  • Offers good value for providers and health systems
  • Allows combination with other select codes -- reflects realities of 'care on the ground'...and the phone...and when patient is not present...and...

CPT 99483 vs. Person-Centered Care Planning

Pie chart: Cognition/function--History, objective measure, staging, impact on function, Ability to make own decisions; (1)Mental and (2)emotional health--Neuropsychiatric symptoms, Potential causes/care; (1)Physical health, risks--Safety, Med reconciliation, Advance care plan, Treatment and prognosis; (1)Key friends and family--Willingness/ability to care, Stress, depression, cognitive impairment, frailty, knowledge and skills; (1)Social determinants--Resources, access, continuity of care.

Person-Centered Care Planning 2.0: Putting It into Practice

  • What providers need in order to change their practice
  • Person-centered measures, e.g. Managing Your Loved One's Health
  • Payment incentives for comprehensive dementia care (already in CPC+ models of primary care)
  • Systems of care
    • Dementia care teams - adapting local resources
    • Standardized documentation and care plan templates
    • Electronic accountability and referral tools
    • Population and outcome research management