Advisory Council May 2021 Meeting Presentation: Value Based Care

05/03/2021

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

Monday, May 3, 2021

Printer Friendly Version in PDF Format (6 PDF pages)

 

Working Toward Value Based Primary Care for Dementia

Soo Borson MD
Professor of Clinical Family Medicine, University of Southern California
Professor Emerita of Psychiatry and Behavioral Sciences, University of Washington
Co-Lead, BOLD Public Health Center of Excellence on Early Detection of Dementia

Figure 1. US Geriatric Specialist Workforce v. Persons with Dementia

Line chart comparing Geriatric Medicine, Geriatric Psychiatry, and Persons with Dementia.
Borson S, Chodosh J. Clin Geri Med 2014; 30: 395-420.
No reliable figures for cognitive neurologists

The Scope OF Primary Care

  • Health promotion
  • Prevention -- primary, secondary, tertiary
  • Health maintenance
  • Counseling and patient education
  • Provider is a personal physician/advanced practitioner (ARNP, PA)
  • Patient advocacy with health care system: coordination, cost-effectiveness
  • Sustained relationship -- long-term patient-provider partnership
  • https://www.aafp.org/about/policies/all/primary-care.html

Primary Care Providers

  • 85% of first diagnoses, 80% of care
  • Under-detection
  • Late diagnosis
  • Inequities in detection
  • Dx often 'NOS'
  • Broad care model
  • Low uptake of CMS dementia care benefits

Yang et al. J Am Med Dir Assoc 2016; Drabo et al. Alzheimer's Dement 2019

Memory Disorder Specialists (neurology, geriatrics, psychiatry)

  • 15% of first diagnoses, <10% of care
  • More standardized assessment
  • Mainly earlier stages
  • Larger health disparities
  • Narrow disease-focused care model
  • No specific role or relationship with primary care
  • More 99483 coding

Yang et al. J Am Med Dir Assoc 2016; Drabo et al. Alzheimer's Dement 2019

To Improve Dementia Outcomes, Leverage the Power of Primary Care

  • Dementia as a Brain Disease
    • Focus on etiology
    • Biological mechanisms
    • Pharmacotherapy
    • Address presenting problem
    • "Diagnose and adios"
  • Dementia as a Chronic Condition
    • Focus on the person and the total mix
      • Multidomain assessment, what matters most, managing uncertainty, staying the course
    • Organizing principle of care
      • Psychosocial and functional impact
      • Health outcomes
      • Health systems

Uptake of Medicare Benefits that Can Enable Better Dementia Care

VISIT TYPE FIRST DATA YEAR MOST RECENT DATA YEAR
Annual Wellness Visit (older adults) 8% (2011) 32% (2018)
Cognitive Assessment and Care Planning (PLWD) <0.05% (2017) 0.96% (2019)
Chronic Care Management (PLWD) n/a 6.7% (2019)
2021 MEDICARE ADVANTAGE 'DEMENTIA INCENTIVE' -- HCC adjustment
Jacobson et al, Health Aff 2020; Hargraves, Health Care Cost Institute; Zissimopoulos et al in prep; Reddy et al. Ann Fam Med 2020

Impact of Primary Care Continuity on Acute Care Utilization in Dementia

OUTCOME RISK RATIO p value NNT TO PREVENT ONE EVENT
Hospitalization 1+ 0.90 <0.001 29
30-day readmission 1+ 0.81 <0.001 97
ACSC hospitalization 1+ 0.87 <0.002 87
Emergency dept visit 1+ 0.92 <0.001 23
Godard-Sebillotte et al, JAGS 2021. N=22,033 people living with dementia and 2+ primary care visits; Quebec primary care administrative data. Year 1 baseline (high vs low PC continuity), Year 2 outcome.

PRIMARY CARE PROVIDERS WANT TO CARE FOR PEOPLE LIVING WITH DEMENTIA AND THEIR FAMILIES

"I think that we are it… When it comes to dementia specifically…we are there from the beginning to the end, or we can be, or when it comes to someone's life, we are there from the beginning to the end. I have the training to deliver babies. I can be there when someone takes their first breath as a human being, and I have the training to take care of someone at the end of life, too, and then for every breath in between, we are here. I think when it comes to people's family systems and the life course that someone takes, I think that we are uniquely positioned to take care of people with dementia, to be the medical provider. Who else is better suited to do that? At the same time, we definitely don't have the resources, the culture, societally, or the systems and structures in place with reimbursement and funding to do it well.

With thanks and credit to Dr. Alissa Bernstein Sideman for sharing her work [supported in part by the National Institute on Aging (K01AG059840) and the California State Alzheimer's Disease program (19-10615)].

Primary care practices: embrace strengths, fix weaknesses

  • Strengths: relationship-based, located in patients' own communities, prioritize access to health care, and maintain a range of specialty and institutional consultative and referral relationships for specific care needs
  • Targets for improvement
    • Team-based care: Physicians/advanced practice providers + other health professionals
    • More face-to-face/personal contact, more continuity, lower documentation burden/screen time,
    • Safe simplification of assessments and management interventions
    • Incentives to implement existing CMS benefits -- traditional Medicare vs Medicare Advantage plans
    • Relevant education/training that demystifies dementia, builds on unique strengths of primary care

MANAGING DEMENTIA IN PRIMARY CARE: FIVE DOMAINS OF HEALTH

  • CONTINUOUS CARE MANAGEMENT
    • COGNITIVE HEALTH
    • EMOTIONAL/BEHAVIORAL HEALTH
    • PHYSICAL HEALTH AND FUNCTION
    • CARE PARTNER CAPACITY, NEEDS
    • HEALTH RELATED SOCIAL NEEDS

CAN WE IMAGINE 'NO-CRISIS' CARE?

PRIMARY CARE OF DEMENTIA: GAPS IN RESEARCH AND POLICY

  • RESEARCH
    1. Define outcome goals and value for primary vs specialty care of dementia
    2. Test prevailing assumptions: e.g. do all patients really need neuroimaging?
    3. How can specialty providers best support primary care?
    4. What payment models best address critical barriers to implementing better care?
  • POLICY
    1. Engage primary care leaders as co-designers of dementia care goals/content/benefits
    2. Expand the value discussion beyond dollars: solve the dementia care quality measure problem
    3. Invest in practice-based dementia research network
    4. Sponsor collaboration between Alzheimer's Disease Research Centers and Geriatric Workforce Enhancement Programs

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