ADVANCED PRACTICE PROVIDER ROUNDS:

Transcription

1 ADVANCED PRACTICE PROVIDER ROUNDS: UTILIZING CMS CHRONIC CARE MANAGEMENT FOR DIFFICULT CASES APARNA GUPTA, MSN, MBA, RN Senior CRNP, Benedum Geriatric Center, UPMC Chair, UPMC APP Preceptor Academy Director, CE, Pennsylvania State Nurses Association #6 President-Elect, PSNA #6

2 OBJECTIVES OUTLINE PRINCIPLES OF CROSS-CONTINUUM MANAGEMENT OF COMPLEX MEDICAL CASES IDENTIFY THE ROLE OF THE ADVANCED PRACTICE PROVIDER IN IDENTIFYING POLYPHARMACY AND MANAGEMENT OF GERIATRIC PATIENTS WITH COMPLEX CHRONIC MEDICAL CONDITIONS UNDERSTAND THE IMPACT OF CARE COORDINATION AND REIMBURSEMENT IN THE CONTEXT OF CHRONIC CARE MANAGEMENT AND PATIENT COST SHARING, PROJECTION OF NEXT STEPS.

3 THE CASE OF R.S.

4 R.S. EST CARE 3/ YR OLD AA FEMALE, LIVES INDEPENDENTLY IN A HIGH RISE APARTMENT BUILDING PMH INCLUDES T2DM, HTN, HLD, RLS, BREAST CALCIFICATIONS, SLEEP APNEA, DEPRESSION MOOD IMPAIRMENTS IMPACT FUNCTION AND QUALITY OF LIFE FAMILY HISTORY SIGNIFICANT FOR HTN IN BOTH PARENTS, AND BREAST CANCER IN MOTHER PERFORMS HER OWN ADLS. ASSIST WITH IADLS IS QUESTIONABLE (SHE SAYS SHE DOES HER OWN COOKING AND GROCERY WITH FOOD STAMPS). INDEPENDENT WITH AMBULATION. I DON T NEED AGING HELP LIKE THOSE OTHER OLD PEOPLE

5 R.S. IP, 6/5/2015 POST FALL, R MEDIAL MALLEOLAR FX DX INFILTRATING DUCTAL CARCINOMA ER+, PR+, 8/17/2015 IP 10/1/2015 LEFT TOTAL MASTECTOMY IP 11/2/15 CC LEFT INCISION DRAINAGE, DC TO SNF, AMA TO NIECE S HOUSE, THEN TO HER OWN APARTMENT SUBOPTIMAL SOCIAL SUPPORT IP 1/29/16 CONFUSED, AV HALLUCINATIONS, DC TO SHORT TERM REHAB APS REFERRED BY AAA 1/2016

6 THE COCKTAIL LIST FOR R.S. KLONOPIN 1 MG BID METOPROLOL 50 MG BID DIOVAN 40 MG QDAY FUROSEMIDE 20 MG QDAY POTASSIUM CHLORIDE 20 MEQ QDAY METFORMIN 500 MG QDAY SERTRALINE 50 MG QDAY OXYBUTYNIN 5 MG 2-3 TIMES Q DAY OSCAL 1 TAB TID MULTIVITAMIN 1 TAB QDAY RISPERDAL 0.25 MG AT BEDTIME PRN ACETAMINOPHEN 325 MG Q6 HRS PRN ASA 81 MG QDAY DILITIAZEM 120 MG QDAY HYDRALAZINE 100MG BID CLONIDINE 0.1 MG /24HR PATCH X 7 DAYS

7 THE BACKGROUND ON CHRONIC CARE Multiple chronic conditions among Medicare fee-for-service beneficiaries, 2010

8 THE BACKGROUND ON CHRONIC CARE Chronic Conditions as leading causes of death,

9 CHRONIC CARE AROUND THE WORLD

10 LEADING CHRONIC CARE TODAY CENTERS FOR MEDICARE AND MEDICAID SERVICES INSTITUTE OF MEDICINE, 2001 CROSSING THE QUALITY CHASM: A NEW HEALTH SYSTEM FOR THE 21 ST CENTURY INSTITUTE FOR HEALTHCARE IMPROVEMENT ROBERT WOOD JOHNSON FOUNDATION THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY THE JOINT COMMISSION

11 ARE WE ANY CLOSER TO THE TRIPLE AIM?

12 WHAT IS CHRONIC CARE MANAGEMENT What is the contextual definition?

13 CHALLENGES IN GERIATRIC CARE TODAY Lack of Care Coordination Polypharmacy Patients Inadequately Trained Medication Reconciliation Physical and Mental Impairments Lack of Active Follow Up Gaps in Transitions Geriatric syndromes

14 EXISTING MODELS OF CARE DELIVERY IMPROVING CHRONIC ILLNESS THE CHRONIC CARE MODEL GRACE GERIATRIC RESOURCES FOR ASSESSMENT AND CARE OF ELDERS PATIENT CENTERED MEDICAL HOME PROGRAM FOR ALL INCLUSIVE CARE OF THE ELDERLY TRANSITIONAL CARE MODELS GEM MODEL CMS ACCOUNTABLE HEALTH COMMUNITIES AND MANY MORE.

15 CMS CHRONIC CARE MANAGEMENT IN CALENDAR YEAR (CY) 2015, CMS WILL BEGIN MAKING SEPARATE PAYMENT UNDER THE MEDICARE PHYSICIAN FEE SCHEDULE (PFS) FOR CHRONIC CARE MANAGEMENT (CCM) SERVICES UNDER CURRENT PROCEDURE TERMINOLOGY (CPT) CODE CCM SERVICES ARE NON-FACE-TO-FACE CARE MANAGEMENT/COORDINATION SERVICES FOR CERTAIN MEDICARE BENEFICIARIES HAVING MULTIPLE (TWO OR MORE) CHRONIC CONDITIONS.

16 CMS CHRONIC CARE MANAGEMENT IN CASE YOU MISSED IT, HERE IS THE RECAP: CMS REIMBURSEMENT IS AVAILABLE FOR CARE COORDINATION SERVICES PROVIDED TO PATIENTS WITH 2 OR MORE EXISTING CHRONIC CONDITIONS, EXPECTED TO LAST AT LEAST 12 MONTHS OR UNTIL DEATH OF THE PATIENT AT LEAST 20 MINUTES OF NON FACE TO FACE CARE COORDINATION, ON A MONTHLY BASIS REIMBURSEMENT ESTIMATED $ 42.60/ PER PATIENT/ PER CALENDAR MONTH REQUIRES PATIENT CONSENT AND THE REIMBURSEMENT IS SUBJECT TO PATIENT COST SHARING THIS IS WHERE THE STORY GETS INTERESTING.

17 CMS CHRONIC CARE MANAGEMENT COMPREHENSIVE CARE PLAN FOR ALL HEALTH ISSUES STRUCTURED DATA AND RECORDING EHR AND OTHER ELECTRONIC TECHNOLOGY REQUIREMENTS, ACCESS TO CARE CANNOT BE BILLED DURING THE SAME SERVICE REQUIREMENTS AS CPT CODES , CODES G0181/G0182, OR CPT CODES ; OTHER RESTRICTIONS (SPONSORED PROGRAMS, DEMONSTRATION PROJECT)

18 CCM - A MEDICAL HOME EXPERIENCE CARE COORDINATION IS PRE EXISTING WITHIN THE FRAMEWORK OF MEDICAL HOME TARGETED PILOT WITH PATIENT PANELS OF THREE PHYSICIANS IN TWO OUTPATIENT GERIATRICS CLINICS HIGH RISK PATIENTS SELECTED WITH AT LEAST 2 OR > CHRONIC CONDITIONS SATISFYING CRITERIA COORDINATED BY CRNP / PCP -> WEEKLY INTERDISCIPLINARY TEAM MEETINGS

19 CCM - A MEDICAL HOME EXPERIENCE KEY ROLE OF PRACTICE BASED CASE MANAGER. COMPREHENSIVE CARE PLANS CREATED AND REVISED DURING / AFTER TEAM MEETINGS ABILITY FOR COST SHARING CONSIDERED PRIOR TO CONSENT CONSENT FOR CCM SERVICES OBTAINED DURING PCP OFFICE VISIT - GOALS OF CARE, SHARED CARE PLAN TO BE PROVIDED TO PATIENT.

20 THE BUSINESS CASE FOR CCM INCREASED NET REVENUE WHEN AUXILIARY STAFF DELIVERED MOST SERVICES NET REVENUE LOSS IF PHYSICIANS PROVIDE CCM SERVICES, CASE FOR TEAM BASED CARE 20% CCM COPAYMENT IMPACTS ENROLMENT BREAK-EVEN THRESHOLD FOR CCM SERVICES PROVIDED BY RN- 131 PATIENTS LPN 76 MEDICARE PATIENTS (BASU ET AL MEDICARE CHRONIC CARE MANAGEMENT PAYMENTS AND FINANCIAL RETURNS TO PRIMARY CARE PRACTICES: A MODELING STUDY. ANNALS OF INTERNAL MEDICINE,163(8), )

21 BACK TO R.S. COMPLEX CARE WHERE TO START?

22 PRIORITIES FOR CARE GOALS OF CARE AND / OR ADVANCED CARE PLANNING : ONGOING / LEEWAY / FAMILY INVOLVEMENT MEDICATION AND CARE PLAN ADHERENCE LIFESTYLE ROLE FOR MOTIVATIONAL INTERVIEWING PSYCHOSOCIAL MENTAL HEALTH SUPPORT

23 THE COCKTAIL LIST FOR R.S. ANTIHYPERTENSIVE DRUGS HYPOGLYCEMIC AGENTS CARDIAC MEDICATIONS, ANTIPLATELET AGENTS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS ANTICHOLINERGIC MEDICATIONS SSRI DIURETICS SEDATIVE-HYPNOTIC, ANTIPSYCHOTIC AND ANXIOLYTIC DRUGS

24 POLYPHARMACY AND THE ELDERLY BEER S LIST - CRITERIA FOR POTENTIALLY INAPPROPRIATE MEDICATION USE IN OLDER PERSONS INDEPENDENT OF DIAGNOSES OR CONDITIONS DRUG-DISEASE / SYNDROME INTERACTION DRUGS TO BE USED WITH CAUTION AMERICAN GERIATRIC SOCIETY 2015 UPDATED BEERS CRITERIA FOR POTENTIALLY INAPPROPRIATE MEDICATION USE IN OLDER ADULTS. J AM GERIATR SOC NOV;63(11): DOI: /JGS

25 WHAT IS POTENTIALLY INAPPROPRIATE PRESCRIBING? START/ STOPP CRITERIA VALIDATED RELIABLE SYSTEMS-BASED CRITERIA FOR POTENTIALLY INAPPROPRIATE PRESCRIBING DESIGNED TO HIGHLIGHT INAPPROPRIATE PRESCRIBING AND PREVENT ADVERSE DRUG EVENTS START (SCREENING TOOLS TO ALERT RIGHT TREATMENT) 22 RULES ALERTING PROVIDERS TO COMMON INSTANCES OF PRESCRIBING OMISSION STOPP (SCREENING TOOL OF OLDER PERSONS POTENTIALLY INAPPROPRIATE PRESCRIPTIONS) 65 RULES RELATING TO COMMON AND INAPPROPRIATE PRESCRIBING IN THE ELDERLY POPULATION O'MAHONY, D., O'SULLIVAN, D., BYRNE, S., O'CONNOR, M. N., RYAN, C., & GALLAGHER, P. (2014). STOPP/START CRITERIA FOR POTENTIALLY INAPPROPRIATE PRESCRIBING IN OLDER PEOPLE: VERSION 2. AGE AND AGEING, AFU145.

26 CASE OF R.S WAS SHE TAKING HER MEDICATIONS AND HOW OFTEN? WHAT DOES THE MEDICATION LIST LOOK LIKE NOW? WERE ANY MEDICATIONS DE PRESCRIBED AND WHY?

27 R.S. DE PRESCRIBED METOPROLOL 50 MG BID CITALOPRAM 20 MG QDAY OXYBUTYNIN 5 MG BID OSCAL 1 TAB TID ACETAMINOPHEN 500 MG BID ASA 81 MG QDAY

28 THE CASE OF R.S. POLST COMPLETED 10/6/2015, MULTIPLE GOALS OF CARE DISCUSSIONS WITH PATIENT AND FAMILY BY PCP AND CARE TEAM PREVENTIVE CARE HIGHLIGHTED WITH MULTIPLE NO SHOW AND VISIT CANCELLATIONS, MULTIPLE PHONE CONTACT ATTEMPTS TO WITH PATIENT AND FAMILY FAMILY DOES NOT RESPOND TO OUTREACH EFFORTS ROBUST, CROSS CONTINUUM CARE COORDINATION - APS REFERRED BY AAA,1/2016 IS R.S. A PART OF THE CCM INITIATIVE??

29 LESSONS LEARNED CHALLENGES CHANGE IN PRACTICE- INTEGRATE TIME SPENT (REQUIRES DOCUMENTATION) MAINTAIN PATIENT REGISTRY NUANCES IN REIMBURSEMENT REQUIREMENTS COST SHARING - BARRIERS FACED BY PATIENT POPULATION

30 LESSONS LEARNED OPPORTUNITIES CAPITATED PLANS, SNP, FFS TRUE CARE COORDINATION IN REAL TIME, ACROSS DISCIPLINES COMING TOGETHER OF IDEAS AND SHARE CONCERNS WITHIN THE TEAM SHARED DECISION MAKING AND TRANSPARENCY OF CARE PLANS GOALS OF CARE DISCUSSIONS CARE CAN BE PATIENT CENTERED!

31 PARADIGM SHIFT THE MOVE TO VALUE BASED CARE PATIENT - CENTERED, GOAL DRIVEN CARE, SHARED DECISION MAKING ADDRESS GERIATRIC SYNDROMES TRANSPARENCY IN CARE, CLOSE THE GAPS ACROSS TRANSITIONS RECOGNITION OF CARE COORDINATION EFFORTS FOR REIMBURSEMENT THE PATH TO ALTERNATIVE PAYMENT MODELS FOR CHRONIC CARE IN MCC POPULATION HEALTH MANAGEMENT???

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