AOA-OMED Annual Meeting ACOI Presentation GOOD GERIATRICS CARE INCLUDES PREVENTION, AND GET PAID!!!!!!!! October 6-7, 2018

Transcription

1 AOA-OMED Annual Meeting ACOI Presentation GOOD GERIATRICS CARE INCLUDES PREVENTION, AND GET PAID!!!!!!!! October 6-7, 2018 Janice A Knebl, DO, MBA DSWOP Endowed Chair and Professor in Geriatrics Director, Center for Geriatrics Interim Chair, Department of Internal Medicine & Geriatrics Program Director, HRSA WE HAIL Program Fort Worth

2 Disclosures Grant Support HRSA/ Eli Lily/ Roche/Suveen I am a Baby Boomer (one of 78 million) I love everything old! I am a Geriatrician and Palliative Medicine & Hospice Osteopathic Internal Medicine Physician My favorite group are super seniors I believe that progress has been made in geriatrics care and there is hope for the future! I believe every day above ground is a great day!

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4 Objectives Understand the Preventive Care Guidelines for Older Adults Provide examples of good geriatrics care that involves prevention Describe prevention measures included in the initial annual wellness, annual wellness and advanced care planning visits

5 Case #1- Mrs. New Medi Cares A 65-year-old retired schoolteacher and avid AARP member presents to a new osteopathic physician for her Welcome to Medicare Visit. She brings in a list of questions for her new doctor about how to remain healthy and age well. She comes with pages of AARP and Blue Zones recommendations she printed off of the internet. How do you approach this visit? What are your recommendations?

6 Blue Zone Lessons 1. Move naturally 2. Purpose 3. Down shift 4. 80% rule 5. Plant slant 6. Wine 7. Belong 8. Loved ones first 9. Right tribe Power 9 Dan Buettner, Blue Zones, National Geographic

7 Blue Zones Vitality Compass Biological age Overall life expectancy Healthy life expectancy Years gaining/losing because of habits

8 Case #2- Mr. I. B. Well An 83-year-old retired osteopathic physician has been your patient for 10 years and presents for his annual examination. He has a PMHx of HTN, HLD and DJD. How do you approach this visit? What are your recommendations?

9 What is the Annual Wellness Visit (AWV)? Annual preventive health screening Begins 12 months after enrolling in Medicare Welcome to Medicare Visit (first 12 months on Medicare) Initial Annual Wellness Visit (one per lifetime) Subsequent Annual Wellness Visits (annually) Must be provided by a health professional Physician, PA or NP or other licensed practitioner working under the direct supervision of a physician

10 Elements of the AWV Review the Health Risk Assessment (HRA) Obtain patient history: PMH, SH, FH List of current providers/suppliers List of current medications and allergies Patient assessment Height, Weight, BMI, BP Does NOT require a Physical Exam

11 Elements of the AWV Screening and detection of: Depression Cognitive impairment Functional ability and safety, including Hearing impairment Ability to perform ADLs and IADLs Fall risk Home safety

12 AWV Wrap-Up Provide to patient: 1. Written screening schedule-appropriate USPSTF preventive health 2. Risk factors and conditions being addressed or followed the AWV 3. Personalized health advice for health education or lifestyle changes May include community resources

13 Health Risk Assessment

14 Nutrition Screening MINI NUTRITIONAL ASSESSMENT Determine Nutritional Health Nutrition Screening BMI Simplified Nutrition Assessment Questionnaire

15 DETERMINE Checklist 2 I have an illness or condition that made me change the kind and/or amount of food I eat 3 I eat fewer than 2 meals per day 2 I eat few fruits or vegetables or mild products 2 I have 3 or more drinks of beer, liquor or wine almost every day 2 I have tooth or mouth problems that make it hard for me to eat 4 I don t always have enough money to guy the food I need 1 I eat alone most of the time 1 I take 3 or more different prescribed or over the counter drugs a day 2 Without wanting to, I have lost or gained 10 #s in last 6 months 3 I am not always physically able to shop, cook and/or feed myself Total Score: 0-2 Good! 3-5 Moderate nutritional risk 6 or higher High nutritional risk

16 Nutrition Screening Tools Simplified Nutrition Assessment Questionnaire: Can be answered by patients through the mail or while sitting in a waiting room Sensitivity and specificity of 88.2% and 83.5% for identifying those at risk of weight loss Mini-Nutritional Assessment: 18 items, requires administration by a trained professional, short form consists of 6 items Evaluates the risk of malnutrition among frail older adults and to identify those who may benefit from early intervention

17 Medication Review Medication review and reconciliation Medication procurement Assess for knowledge & reliable administration by self or others (Physical & cognitive capabilities) Name of person overseeing home medications Beers Criteria for potentially inappropriate medication use in older adults (ID/Reconsider high risk meds) Assess for nonadherence

18 Depression Screening PHQ-2: Patient Health Questionnaire-2 Over the past 2 weeks how often have you been bothered by any of the following problems? 1. Little Interest or Pleasure in Doing Things? 2. Feeling down, Depressed or Hopeless? Not at all 0 Several days 1 More than half the days 2 Nearly everyday 3 SCORE: 0-6 with 3 for screening purposes Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care. 2003;41:

19 Depression Screening GDS 5: Geriatrics Depression Scale 5 Items 1. Are you basically satisfied with your life? 2. Do you often get bored? 3. Do you often feel helpless? 4. Do you prefer to stay at home rather than going out and doing new things? 5. Do you feel pretty worthless the way you are now? A NO to 1 or a YES to 2-5 each counts as one point. Score of 2 or more is a positive screen Geriatrics At Your Fingertips, 19 th Edition, AGS Publication.

20 Alzheimer s Association: Cognitive Assessment Toolkit Medicare AWV Algorithm for Assessment of Cognition 3 Validated Patient Assessment Tools: GPCOG, MIS and Mini-Cog No nationally recognized screening tool for the detection of cognitive impairment currently 3 Validated Informant Assessment of Patient Tools: Short IQCODE, AD8 and GPCOG Alzheimer s Association Recommendations for Operationalizing the Detection of Cognitive Impairment During the Medical Annual Wellness Visit in a Primary Care Setting. Alzheimer & Dementia 9(2013)

21 Mini-Cog Example

22 AD8 Dementia Screening

23 Cognitive Evaluation Tools Screening tool Areas assessed Time to administer MoCA: Montreal Cognitive Assessment (cutoff point 26) Attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation Who can administer Specificity Sensitivity 10 min Clinician 87% 100% Mini-cog Recall and visuospatial abilities 2-4 min Clinician 89% 76% MMSE: Mini Mental State Exam (cutoff point = 25) Orientation, registration/recall, attention and calculation, and language 10 min Clinician 84% 76% SLUMS: St. Louis University Mental Status exam Orientation, registration/recall, remote memory, visuospatial skills, attention, abstraction, and executive function 7 min Clinician? 98% 98% IQCODE (informant questionnaire for cognitive decline in the elderly) - short Informant based: executive functions, cultural experience 6-10 min Anyone >75% >75% Clock drawing test Visuospatial abilities, executive functions, semantic processing, global and diffuse cognitive abilities 1-2min Clinician 77% 87% General practitioner assessment of cognition (GPCOG) MIS: Memory impairment screen (cutoff point < 5) Similarities with mini-cog, recall, executive function, visuospatial abilities, orientation. 6 min Clinician 86% 85% Subjective memory loss 10 min Clinician 98% 45% AD8 Orientation, recall, executive function, and interest in activities 1-3 min Anyone 86% 85%

24 Cognitive Impairment Detection and Earlier Diagnosis

25 Cognitive Impairment Care Planning Toolkit Alzheimer s Association

26 Alzheimer s Association App The free Alzheimer s Association Alzheimer's Disease Pocket card app puts reliable information and assessment tools at your fingertips. Physicians can find clinical information on the diagnosis and management of Alzheimer's disease and other dementias, utilize interactive tools, and much more.

27 Functional Vision Hearing Recommended Screen Do you have trouble seeing, reading, or watching TV? (with glasses, if used) Do you have difficulty hearing conversation in a quiet room? Unable to hear whisper test 6-12 inches away? Further Assessment if + Screen Vision Testing Snellen Chart Consider referral to optometry or ophthalmology Cerumen check and removal if impacted Consider Audiology referral

28 Functional Assessment Activities of Daily Living

29 Instrumental Activities of Daily Living

30 Fall Risk Assessment Orthostatic Blood Pressure Measurement 4-Stage Balance Test 30 Second Chair Stand Timed Up and Go - TUG

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32 Home and Community Safety!! Bike Helmets Driving (seat belts) Driving Safety (55 Alive) Smoke & Monoxide Detectors Fraud Prevention Elder Mistreatment Home Safety

33 Community Evidence-Based Programs for Older Adults Chronic Disease and Medication Management Depression Falls Management Physical Activity Disease Self Management Home Meds Healthy IDEAS PEARLS AMOB Enhance Fitness Fit & Strong Healthy Moves www. acl.gov

34 PREVENTIVE SERVICES COVERED BY MEDICARE PART B Pneumococcal, influenza and hepatitis B vaccines Screening mammography Screening pap smear/pelvic exam Prostate cancer screening Colorectal cancer screening Diabetes outpatient self-management training services Bone mass measurements Screening for glaucoma Medical nutritional therapy for individuals with diabetes or renal disease Cardiovascular screening blood tests Diabetes screening tests

35 Immunization Recommendations Agency Hep B Herpes Zoster Influenza Pneumonia Tetanus AGS 1 at least once in adults who are high risk Once after age 60 in immunocompetent people Once yearly One PCV13 at age 65, followed by one dose of PPSV months later Once every 10 years American Cancer Society 10 Not recommended during cancer treatment Recommended Zostavax and Shingrix Once yearly Recommended both Prevnar and pneumovax Not recommended during cancer treatment CDC 11 Recommended if not previously vaccinated with potential to come into contact with infected individual, lifestyle choices, have DM, HIV+, or chronic liver disease adults 50+ recommended either Zostavax or Shingrix which is given in 2 doses, one dose 2-6 months after initial dose Once yearly Prevnar and Pneumovax recommended for all adults 65+ Once every 10 years Medicare 12 Recommended for those who are at risk of contracting virus Medicare may not cover this service Once yearly, additional vaccines if medically necessary Recommended both Prevnar and pneumovax, one year apart Medicare may not cover this service AAFP 13 3 doses Shingrix is preferred, given in 2 doses. Zostavax given in 1 dose Once yearly 1 dose PCV13, 1 dose PPSV23 one year apart 1 dose TdaP, then Td booster every 10 years

36 Life Expectancy for Men

37 Life Expectancy in Women

38 Prevention/Screening Considerations for Older Adults Older adults should receive preventive health measures from which they are likely to benefit based on their health and remaining life expectancy Clinical condition can be categorized as those with: 10 years of remaining life expectancy 5-10 years of remaining life expectancy Moderate Dementia: 2 10 years of remaining life expectancy End of Life: <2 years of remaining life expectancy

39 Prevention/Screening Considerations for Older Adults Few older adults have been included in RCTs that evaluate screening measures, especially frail older adults; therefore, recommendations are often based on indirect evidence It is important to consider the effect of preventive health measures not only on quantity of life but also on quality of life, satisfaction with life, and in maintaining independence Preventive health recommendations for older adults need to be individualized based on patient health, function, risk of disease, and preference

40 Preventive Tests/Procedures Agency Eye Care Hearing Diabetes Mellitus AGS Yearly screen Yearly screening every 3 years if they are overweight or obese CDC Dilated eye exam with DM every year. Those at risk for glaucoma should have a dilated eye exam every 2 years Hearing screening, full hearing test Screening if patients are overweight, over 45 years of age, family history of DM, sedentary, ever had gestational diabetes Medicare Once yearly Once yearly Once yearly AAFP evidence is insufficient to assess the balance of benefits and harms of screening for impaired visual acuity in older adults Evidence is insufficient of the benefits of screening 50+ of age recommends screening every 3 years in adults aged who are overweight or obese

41 Preventive Tests/Procedures Agency Cholesterol Coronary Artery Disease Blood Pressure AGS Every 5 years, more often in CAD, DM, PAD, Prior stroke Serum CRP at least once, Lipid screening. Recommend against screening with ECG, exercise stress test, or electron beam CT in people with few nor no CAD risk factors Yearly CDC Patients without heart disease screen every 4-6 years. Those with heart disease screen more often Screening if overweight, unhealthy eating, or smoking. Use of EKG, Echocardiogram, Stress test, CXR, Cardiac cath, and coronary angiogram. Lipid testing, b/p and sugar levels Regularly Medicare Once yearly Once every 5 years Once yearly AAFP Screening for men35 and older, screening for women 45 and older Evidence of screening with ECG is insufficient Recommends screening in 18+ also recommends obtaining measurements outside clinical setting before starting treatment

42 Cancer Screening Considerations

43 Cancer Screening Considerations Agency Breast Prostate Cervical/PAP Smear AGS every 2 y in women aged Women over 70 should continue w/reasonable life expectancy Recommend against performing screening with prostate cancer with PSA and/or digital rectal examination Against screening in women 65+ who have had adequate prior screening/hysterectomy for benign disease American Cancer Society Every other year, patient can choose to have a screening every year. Continue as long as woman is in good health and expected to live 10 more years or longer. PSA screening for men 50+ every 2 years for a PSA less than 2.5ng/mL, every 1 year for PSA 2.5ng/mL or higher Screen every 5 years unless 65+ with regular screenings for the past 10 years and as long as they have not had any serious precancers found in the last 20 years. Women with hysterectomy should stop screening unless procedure was done as a pre-cancer treatment. CDC Mammogram every 2 years for women ages should consider having PSA's done. Men over 70 should not be screened routinely Pap screening should continue in women over 65, every 3-5 years for the next 20 years of their life, screening not recommended if they had a total hysterectomy Medicare Yearly screening in patients over 40 years of age Annual exam, either PSA or digital rectal exam for all males 50 years and older Annually for High Risk and Abnormal Pap within past 3 years. Every 2 years for women with normal risk AAFP Biennial screening for ages Not recommend routine PSA's in men 55 and older. Testing is based on patient's decision. Recommends against screening for 65+ who have had adequate prior screenings and are not otherwise high risk for cervical cancer, also in women who have had total hysterectomies. Otherwise screening every 5 years for at risk patients. MD Anderson Yearly clinical breast exam and mammogram 45+ patient's decision for PSA testing, repeat testing based upon results. 85+ not recommended for screenings No additional screening tests if no unusual results in the past 10 years. High risk women should be screened every 3 years

44 Cancer Screening Considerations Agency Skin Lung Colon AGS Yearly Yearly low dose CT Scan for ages with 30 pack/year smoking and currently smoke or have quit in the past 15 years Every 10 y for colonoscopy in adults aged *negative in average-risk individuals. Yearly FOBT and FIT. American Cancer Society No guidelines for early detection. Routine self examination. Yearly low dose CT scans for patients and are current smokers or have quit in the last 15 years or have a 30 pack/year history Start regular screenings at 45 through 75. Ages screening decision based on life expectancy, overall health, and previous screening history. Over 85 should no longer be screened. CDC Neither for or against total body examination to find skin cancers early Yearly screening for Cease screenings: at age 81, has not smoked in 15 years, or if health problems make unable to have surgery for removal if cancer is found FOBT Yearly. Flex Sig every 5 years or 10 years with yearly FIT. C- Scope every 10 years Medicare Examination by patient Yearly low dose CT Scan for ages Asymptomatic patients and patients with a 30 year smoking history or patients quit smoking in the past 15 years FOBT Yearly. Screening C-Scope every 10 years (unless high risk, then every 2-5 years). Flex Sig every 48 months. Screening Barium Enema every 48 months (high risk every 24 months) AAFP evidence is insufficient to assess the balance of benefits and harms of routine exam. Patient's should perform yearly self exams. Low dose CT Scans yearly for ages who have had 30pack/year smoking history or who have quit smoking in the last 15 years. Cease screening once a patient has not smoked for 15 years or has developed health problems that would limit removal if cancer is found Routine screenings from years can be patient's decision to be screened. Screening is not recommended for patients 85+ MD Anderso 6 Screenings only recommended for individuals with increased risk. Patients to do regular self examinations Low dose CT scans yearly for ages if a current smoker or have a 30 pack/year history 50 and older C-Scope every 10 years, more often if high risk. FOBT every year.

45 How Do We Stop Cancer Screening? Cancer screening saves lives by finding asymptomatic lesions Potential to be lethal many years in the future if allowed to grow For colon and breast cancer about 10 years from screening detection to lethality Harms accrue immediately Benefit/Risk ratio strongly related to life expectancy Choosing Wisely recommends colon & breast screening only in elders with 10 years from screening detection to lethality But rates of cancer screening remain high in older persons with limited life expectancy with likelihood of harm Schoenborn et al. JAMA Internal Medicine 2017.

46 How Do We Stop Cancer Screening? Context crucial Context of trusting physician-patient relationship critical Most likely to be receptive if recommendation is personalized Health status vs life expectancy Agreement that poor health status or functional are good reasons not to screen Antagonism to avoiding screening based on limited life expectancy Don t recommend cancer screening if patient unlikely to live 10 years - That s like hitting you over the head with a hammer.it s too harsh 2017 Schoenborn et al. JAMA Internal Medicine.

47 How Do We Stop Cancer Screening? Don t say You will not live long enough to benefit from this test Do say This test will not help you live longer Patients wanted to discuss health care that could help them live longer or better When patients have your conditions and need help for day to day activities, this test can cause more harm than benefit It sounds like the doctor considered my personal issues and decided that I should not have the test Schoenborn et al. JAMA Internal Medicine. 2017

48 How Do We Stop Cancer Screening? Bottom Line Patients open to being told they should not have cancer screening Needs to come from a physician they have a relationship and trust Many patients don t get the relationship between life expectancy and cancer screening benefits But they do seem to understand that poor health and functional status may make the screening unwise May help to note counter context of types of health care that might help Schoeborn et al. JAMA Internal Medicine. 2017

49 American Heart Association & American Academy of Sports Medicine Recommendations: Aerobic Activity Resistance Activity Stretching/Flexibility Activity Balance Activity

50 Case #3 Ms. Deana R. Wishes An 86-year-old retired nurse presents for her routine clinic visit and wants to discuss her future care if she has a medical emergency or a change in her health that would affect her decisionmaking capacity. She has HTN, GERD and Osteoporosis. She lives independently and performs all of her own ADLs and IADLs. How would you approach her request at this visit?

51 Advance Care Planning Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (list separately in addition to code for primary procedure)

52 Advance Care Planning (ACP) A Physician's Guide to Talking About End-of-Life Care NCBI.NLM.NIH.gov/PMC/Articles/PMC (1) Initiating discussion (2) Clarifying prognosis (3) Identifying end-of-life goals (4) Developing a treatment plan Frequently asked questions about ACP: CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician Fee Schedule/Downloads/FAQ-Advance-Care-Plannin.pdf

53 The Conversation Project The Conversation Project is dedicated to helping people talk about their wishes for end-of-life care. The Conversation Project works in collaboration with the Institute for Healthcare Improvement, a not-forprofit organization that is a leader in health and health care improvement worldwide.

54 PREPARE: Advanced Care Planning Tool Step 1: Choose a medical decision maker Step 2: Decide what matters most in life Step 3: Choose flexibility for your decision maker Step 4: Tell others about your medical wishes Step 5: Ask doctors the right questions PREPARE, a free, patient facing Advanced Care Planning Tool increases advanced directive documentation. Sudore et al, JAMA Int Med 2017 Aug;177(8)

55 Active Ageing the process of OPTIMIZING opportunities for health, participation and security in order to enhance quality of life as people age WHO (2012)

56 E-Learning Modules Reynolds IGET-IT Program and NBOME Learning Platform Performance improvement modules for practicing physicians and residents Free CME Available online at ilearn.nbome.org Fall risk education & assessment Elder mistreatment Medication management ACP

57 Welcome to Medicare Visit Annual Wellness Visit

58 Geriatrics Resources NIA- AGS- HRSA GWEP- UNTHSC Center for Geriatrics

59 Questions Effective January 1, 2016, the Centers for Medicare & Medicaid Services (CMS) pays for voluntary Advance Care Planning (ACP) under the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS). Which of the following is TRUE regarding the ACP: A. ACP can only occur once annually B. Medicare pays for ACP as a separate Part B service when it is medically necessary C. Medicare pays for ACP only as part of an Annual Wellness Visit D. ACP can only be utilized when the patient has cancer, heart disease and/or a neurologic disorder

60 Questions Which of the following is NOT included as a routine part of a Medicare Annual Wellness Visit? A. Height, weight and blood pressure B. EKG C. Detection of any cognitive impairment D. Updating the medication list

61 Questions A yearly Medicare Wellness Visit (called the Annual Wellness Visit) includes ALL the following EXCEPT: A. Review of medical and family history B. Detection of cognitive impairment C. ACP D. Blood pressure measurement E. Digital rectal exam

62 Questions Which of the following immunizations are NOT recommended for ALL older adults over the age of 65? A. Influenza vaccine B. Td booster every 10 years C. Varicella Zoster vaccine D. Hepatitis B vaccine E. Pneumonia PCV13 vaccine

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