Paying for Dementia Care. Mary Ann Forciea MD Clinical Professor of Medicine Division of Geriatric Medicine University of Pennsylvania Health System

Transcription

1 Paying for Dementia Care Mary Ann Forciea MD Clinical Professor of Medicine Division of Geriatric Medicine University of Pennsylvania Health System

2 Audience: Possible concerns about dementia care in my site Time required to meet needs of patient/caregiver Availability of interprofessional team care in my site Unfamiliarity with Medicare/Medicaid/insurers special programs Unfamiliarity with local support available to patients and caregivers

3 Provider Questions How often should I see my patients with dementia? Is the patient or the caregiver the real focus of the visit? When in the course of the disease does this change? How does my responsibility for prevention change for my patients with dementia?

4 Goals of this seminar Increased awareness of financial challenges during the course of a dementia illness Increased awareness of newer models of payment and quality assessment Gain-sharing programs Medicare HMOs Quality measures: incentives/penalties Sites of care Individual practitioners

5 Dementia care is Expensive System costs Hospitalizations/ED visits Institutional stays Hospice stays Patient/family costs Home care support Caregiver stress Much of this cost is hidden

6 Projected Total and Per-Person Annual Monetary Costs of Dementia in the United States, in 2010 Dollars. Hurd MD et al. N Engl J Med 2013;368:

7 Task 1 Estimates of Costs of Care Write down your estimate of annual cost of care for a patient/family with moderate dementia Including: Medicare spending Cost sharing Caregiving support

8 How much is the annual cost of care for a patient with dementia? Office care Co pays, transport, attendant, meds Home care Attendant Pay Missed wages of family caregivers Home modification NH care Self pay Medicaid issues Hospice

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10 Yearly Cost per Person Attributed to Dementia, in 2010 Dollars. Hurd MD et al. N Engl J Med 2013;368:

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12 Selected Recent Studies of the Dementia Epidemic. Larson EB et al. N Engl J Med DOI: /NEJMp

13 How can health care professionals help? Better attention to the primary care needs of the patient with a dementing illness will improve: Quality of life of patients Quality of life of caregivers Cost Decreased hospital/er use End of life care much of health care for dementia patients is reactive and unsystematic, rather than proactive and planned Odenheimer

14 Models to influence primary care Reimbursement (time) Medicare coding Hierarchical Condition Coding (CMS) New models Group visits Medical Homes System Integrations (ACOs) Quality Improvement/Performance Measures

15 Coding changes Hierarchical Condition Codes developed for the Medicare Advantage Program Plans Adjust payment for disease severity CMS Fee-for-service applications Cumulative risk score of Medicare costs Based on coding, with most complex codes higher valued Code carefully, capturing patient complexity

16 Model systems Medical Homes Vision of integrated sites of care for the chronically ill Outcomes emerging Independence at Home CMS Demonstration Project on integrated care for homebound elderly Gain-sharing program Both incorporate Performance Measurement to ensure quality of practice

17 Challenges: Quality Measures Definition of quality care National Specialty societies neutral entities (non profit consortia) Local: experts/teams of leaders Source of data Evidence base Expert opinion Ease of data collection

18 Quality measures for dementia care Clinical care items which should be offered to all patients within a disease category Quality assessment indicators Payers: Medicare, private insurers Certifiers: Joint commission, Medicare, State Departments of Health, Practitioner certification agencies Systems Facilities Individual practitioners

19 Impact on practice Resource for individual practitioner Good linkage to EMR Guide for facility/system for resource allocation Behavior change Pay for performance Incentives Penalties

20 Task : Quality Measure for Dementia Care Form groups with neighbors in the audience You have been named to your health system s IP quality assurance panel as a representative of your discipline. You are working with a mini-team to plan a quality audit of a group of primary care practices For a medical office caring for a patient who has been diagnosed already with dementia, Agree on 3 clinical services/care items which should be documented in the chart in a 12 month period

21 List: Debrief

22 PCQI (AMA) Quality Measure: Dementia Care AMA convened a workgroup panel ( , final report Oct 2011): MDs (neurology, psychiatry, geriatrics, primary care), Nursing, Rehab Med Review of existing guidelines and supporting data bases of information Series of meetings to define/refine

23 Final Measures 10 measures of quality care in 3 domains: Dementia subtyping and staging Assessment and management of behavioral symptoms Caregiver education, assessment, assistance Data available through chart audits Evidence base to support items Guidelines, Systemic Reviews

24 Measure set: Domain 1 dementia staging (Measures 1, 2, 3) 1: Patients with dementia who were staged: Mild, mod, severe MMSE ( or mini Cog), Montreal Cognitive Assessment (MoCA) scale Fast Scale 2: Cognition assessed and/or reviewed annually 3: Functional status assessment annually

25 FAST scale grading FAST SCALE ADMINISTRATION The FAST scale is a functional scale designed to evaluate patients at the more moderate-severe stages of dementia when the MMSE no longer can reflect changes in a meaningful clinical way. In the early stages the patient may be able to participate in the FAST administration but usually the information should be collected from a caregiver or, in the case of nursing home care, the nursing home staff. The FAST scale has seven stages: 1 which is normal adult 2 which is normal older adult 3 which is early dementia 4 which is mild dementia 5 which is moderate dementia 6 which is moderately severe dementia 7 which is severe dementia

26 Fast: instructions FAST stage 1 is the normal adult with no cognitive decline. FAST stage 2 is the normal older adult with very mild memory loss. (MCI) Stage 3 is early dementia. Here memory loss becomes apparent to co-workers and family. The patient may be unable to remember names of persons just introduced to them. Stage 4 is mild dementia. Persons in this stage may have difficulty with finances, counting money, and travel to new locations. Memory loss increases. The person's knowledge of current and recent events decreases. ( early IADL issues) Stage 5 is moderate dementia. In this stage, the person needs more help to survive. They do not need assistance with toileting or eating, but do need help choosing clothing. The person displays increased difficulty with serial subtraction. The patient may not know the date and year or where they live. However, they do know who they are and the names of their family and friends(severe IADL issues). Stage 6 is moderately severe dementia. The person may begin to forget the names of family members or friends. The person requires more assistance with activities of daily living, such as bathing, toileting, and eating. Patients in this stage may develop delusions, hallucinations, or obsessions. Patients show increased anxiety and may become violent. The person in this stage begins to sleep during the day and stay awake at night (ADL Issues). Stage 7 is severe dementia. In this stage, all speech is lost. Patients lose urinary and bowel control. They lose the ability to walk. Most become bedridden and die of sepsis or pneumonia.

27 FAST sub staging 7a. Speech ability limited to the use of a single intelligible word in an average day 7b. Ambulatory ability lost (cannot walk without personal assistance). 7c. Ability to sit up without assistance lost (e.g., the individual 7d. will fall over if there are no lateral rests [arms] on the chair). e. Loss of the ability to smile.

28 Dementia Quality Measure Domain 2: Behavioral symptoms 4. Assessment for neuropsychiatric symptoms 5. Intervention for neuropsychiatric symptoms 6. Screened for depression

29 Dementia Quality Measure Domain 3 - Caregiving 7. Caregivers or patients counseled for safety 8. Counseling/assessment of driving risk 9. End of life counseling: Goals of care documentation Proxy identification/review (within 2 yrs. of diagnosis) 10. Caregivers Education Sources of additional support

30 Safety Counseling Wandering ID bracelets Kitchen Safety Guns

31 Driving risk Trail making office based tests Referral to Driving Assessment Centers Private pay Road test in patient s vehicle Practitioner liability

32 Goals of Care Documentation Advance Directives stage of disease 5 wishes Transfer wishes (Do not Hospitalize) Health Care Proxies Facility forms POLST

33 Mitchell et al Caregiver education

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35 Summary Patients with dementia and their families/caregivers have a long journey to travel Dementia care elements should not be overshadowed by acute or comorbid illness care Performance (quality) measures may be a tool to influence care And hopefully reward quality practice

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37 Audience Reason for Interest Job-related Practitioner Nurse Social Work Administrator Other Personal Caregiver Family member

38 Task 3 You are asked to design a QI project for your site related to dementia care Which performance measure would you choose to focus on in your own practice site? Debrief in your mini group Big debrief