NATIONAL PLAN TO ADDRESS ALZHEIMER'S DISEASE: 2017 UPDATE. Strategy 2.F: Ensure that People with Alzheimer's Disease and Related Dementias Experience Safe and Effective Transitions between Care Settings and Systems

09/01/2017

Preventable Hospitalizations. CDC worked with partners to conduct a review of interventions related to dementia and decreasing preventable hospitalizations, as well as a systematic review of caregiver interventions. The findings from this review will help to inform the current state of evidence-based strategies and interventions related to the Healthy People topic area "Dementias, including Alzheimer's disease" and its objective "To reduce the proportion of preventable hospitalizations in persons with diagnosed Alzheimer's disease and other dementias." A publication that described the results is available.

For more information, see:

________________________________________

Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. The first phase of the Initiative ended in 2016 and has shown reductions in avoidable hospitalizations. A recent Health Affairs article details results from 2015 evaluation and final results are expected in the fall of 2017. In 2016, Phase Two of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents launched which provides enhanced payments to participating nursing facilities for the treatment of the six most common conditions associated with potentially avoidable hospitalizations: pneumonia, congestive heart failure, chronic obstructive pulmonary disease/asthma, skin infections, dehydration, and urinary tract infections. Additionally, this model includes payments to practitioners in nursing facilities that are similar to the payments they would receive for treating patients in hospitals. Practitioners also will be paid for engaging in multi-disciplinary care coordination and caregiver engagement. The Initiative is taking place in nearly 260 nursing facilities across seven states, Alabama, Colorado, Indiana, Missouri, Nevada, New York, and Pennsylvania.

For more information, see:

________________________________________

Nursing Home Compare Improvements. In July 2016, nursing homes were required to submit daily staffing data that is traceable to an auditable source. CMS is collecting the staffing data now and plans to have new staffing measures derived from it on Nursing Home Compare (NHC) in early 2018.

For more information, see:

________________________________________

Improved Care Planning for Medicare Beneficiaries. In 2013, CMS began paying separately under the Medicare Physician Fee Schedule for transitional care management services for the transition of Medicare beneficiaries back into the community following discharges from certain settings. In 2015 CMS began paying separately under the Medicare Physician Fee Schedule for chronic care management (CCM) services for beneficiaries with multiple chronic conditions. In 2017, CMS began separate Medicare Physician Fee Schedule payment for additional care management services, including payment for: complex CCM for Medicare patients with multiple chronic conditions; behavioral health integration services including services furnished using the "psychiatric Collaborative Care Model"; and cognitive and functional assessment and care planning for beneficiaries with cognitive impairment (e.g., AD/ADRD). The latter, billed under code G0505 for 2017, must be furnished by a physician or other appropriate billing practitioner (e.g., nurse practitioner or physician assistant). The service includes a cognition-focused evaluation, including a pertinent history and examination; medical decision making of moderate or high complexity; functional assessment (for example, ADLs), including decision making capacity; use of standardized instruments to stage dementia; medication reconciliation and review for high-risk medications; evaluation for neuropsychiatric and behavioral symptoms (including depression), including use of standardized instruments; evaluation of safety (for example, home safety), including motor vehicle operation, if applicable; identification of caregivers, caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks; advance care planning and addressing palliative care needs, if applicable and consistent with beneficiary preference; creation of a care plan, including initial plans to address any neuropsychiatric symptoms (NPS) and referral to community resources as needed (for example, adult day programs, or support groups); and care plan shared with the beneficiary or caregiver with initial education and support.

________________________________________