Medical Home Work Group

Medical Home Work Group

December 8, 2011

Participants: Randy Best, Denis Levis, Swarna Reddy, Nick Turkas, Debi Dihoff, Jeannine Schupp, John Snow, Polly Welsh, Betsey Tilson, Katie Warem, UNC Intern, Beat Steiner, Teresa Piezzo, Nidu Menon, Pat Gerney, Elise Bolda

Nursing Home Sub Group Update

Nursing Home Ray graphic – the idea being to raise the level for all homes

·  started with the super home model Tier 5, and anchored on the lower end to engage all nursing homes

·  review of draft nursing home standards listed on the graphic

Tier 1

*  Medication Review

*  Licensed Medical Director and individual attending physicians

*  Attending physicians for residents (intermittent/week)

*  Advanced directives in place

*  Access to dietitian

Tier 2 (+1)

*  Medication Reconciliation (Med. Rec.) by CCNC

*  Explicit attention to psychotropic and anticoagulant/anti-platelet drugs

*  Attending physicians review and act on Med. Rec. recommendations

*  Legal guardian/DMPA identification and acquisition policy in place

*  Standard access to provider portal information/reports

*  Note: All previous expectations carry to higher levels—the list of standards is hierarchical

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Tier 3 (+1,2)

*  Physician presence on site fixed days/times of the week (1-2 days)

*  Facility encourages a reduced number of physicians attending residents

*  Advanced directives/MOST forms (reviewed every 6 months)

*  All transitions have clear communication prior to leaving facility (transition policy in place with transfer form, name, and number of single contact)

*  Oral health care for residents

Tier 4 (+1,2,3)

*  24/7 Call system with trained LTC providers

*  Regular on-site schedule 2-3 days per week

*  Embedded MD/NP

*  Patient wishes/care goals evident in medical records

*  Medication review with risk-benefit assessment

*  Root cause analysis of unplanned ED/hospital admissions

*  Clearly established performance standards

*  Enhanced oral health care

Tier 5 (+1,2,3,4)

*  24/7 call system with consultation

*  Embedded MD serves as Medical Director

*  First page of chart to display MOST form, patient wishes

*  Palliative care goals—prominent and current with evidence of discussion with patient/family/designated care giver

*  Periodic review of med list; e-prescribing, e-reconciliation

·  each tier adds to the standards for previous standards moving up the continuum with the Tier 5 being the most integrated

·  at higher tiers might be some relief in terms of frequency/regulatory relief, reviews and surveys

·  Create incentives to move people as far up the continuum as far as they can reach and not leave anyone out.

Nursing homes doing solid quality improvements would experience shared savings.

·  Comments, suggestions, improvement-- need input from people closer to nursing home world to see what is theoretically possible--need to know what realities are.

·  Create a system where we have support resources available through CCNC networks.

·  How do nursing homes trying to become medical homes avail themselves of the resources available in the networks?

·  How do we tie nursing homes to the 14 networks – some of these resources could be provided by the network – certainly for smaller facilities – in the way practices are tied to a network

Discussion:

·  Why can’t skilled nursing facilities (SNFs) be enrolled now? This is because we will need to do a state plan amendment (SPA).

·  Star rating in NH industry--very controversial--need different language.

·  Okay with criteria—we may find resistance on ranking. Concept can be misleading.

·  Problem with 2 criteria – identification of legal guardian is really, really hard-- can ask—never see some families; easier for nursing home when legal guardian is identified.

·  First page of chart should be “MOST” form (patient’s wishes)—federal regulations cannot require people to complete “MOST” form.

·  Completely consistent with PCP – giving incentives totally makes sense –

·  State--nothing is done in terms of survey. State average for surveys is 15 months and 12 months for the federal government. Nursing homes would love to see NC ask about the use of their resources.

Are there thresholds for information technology for ranking?

·  In patient-centered medical homes, incentives to create tools; hospital affiliates moving ahead-–NH have to fund their own information systems. Concern is that none of it is going to match-up at the end of the day. Over 1/3 of facilities have a pretty good electronic system.

·  UNC has experimented with more direct communication between hospital and NH –real time.

·  Need to add technology/information support to graphic.

Adult Care Home Sub Group Update

·  UNC REACH model sustaining physician/nurse practitioner can be viable to go out to see patients – mini-team Care Management (CM)/Pharmacy/Primary care provide (PCP)/Nurse Practitioner (NP) – have community health system and UNC doing this.

·  Another statewide group that is not as successful – Mike Lancaster to talk with how to engage in a proactive way – primarily behavioral health group – now marketing as primary care

·  A tiered approach – can help this – like the nursing home sub group graphic, only for adult care homes.

·  Good when an outside agency can help influence provider that is not high quality. Having a connection to somebody who can set some standards is good.

·  Good idea to have ICFMR.

Needs Determination Sub Group Update

·  Reviewing existing assessment tools & criteria

·  Functional need groupings (buckets) moving toward a standard protocol for determining needs

·  Matrix – includes cognitive/emotional/physical/available and natural support from highest level of complex care to clinically complex (vent/head injury – to rehab) down to well and elderly. Based on functional needs.

·  Conceptually many assessments out there – can we use the same instrument – can we consolidate so different places use the same form, figure out how scoring assessment puts patient into bucket – bucket determines level of need which in turn establishes level of resources. Identify flexibility in facilities etc.

·  Comprehensive CHA at one end of the spectrum – maybe 1-2 screening questions for PCP, like screening questions for depression or palliative care referral

·  Mechanism – may just be regular way of screening into Case Management (CM).

·  PCP referral uses CRG’s for categories.

·  Use data to identify patients, a little worry that if rely on PCP might miss people with cognitive and short-term memory problems.

·  TREO data – CRGs

Palliative Care Sub Group Update

Trying to define mechanisms to improve access to palliative care and ways to enable patients to receive palliative care in their homes.

·  In-home palliative care discontinued by some providers because not financially feasible.

Hospice and nursing homes discussion

·  Considerations around who gets payment

·  Palliative care can be provided in NF – same thing can be done in NF

·  May need to have it in standards for hospice on continuum.

·  Concurrent care vs all money goes to hospice – instead have medical home, where NH might buy services from hospice – payment go to medical home and then medical home decides what to buy –

·  one responsible entity to determine how to use limited funds available.

Outpatient approach is being tried and has been well received. The agency that gets paid controls the patient care; when hospice is paid, hospice gains control of care plan.

What are elements of care a patient needs?

·  Nursing homes sometimes acting as gatekeeper for hospice; many patients die before a referral is made.

·  Hospice is a reimbursement structure. Create enough resources to provide palliative care to facilities; facilities will have their own resources to provide the care and have hospice-like payment.

For NH/Medical home to meets palliative care criteria

·  Staff will need pain medicine dosage information/training.

·  Hospice nursing in homes different skill set than NH support.

·  One distinction of hospice is bereavement support one year post death

·  100 out of 2500 pts on hospice 2-4 years out – many were in skilled facilities; that’s also a complaint of NH; should not work that way; hospice keeps them on and on.

All hospices should be palliative care, not all palliative care is hospice. Hospice is a payment methodology for end of life care rather than a model of health care.

Expectations for the work groups

Core leadership group is beginning to look at over-arching concepts.

·  Asking for recommendations from work groups for the overall conceptual strategic framework (graphic example) and

·  Low-hanging fruit or areas where there is need for more immediate or prompt change.

·  There are two deliverables due to CMS under this grant: 1) strategic framework and 2) implementation plan.

·  Must determine how resources will be used differently and how to make those changes.

·  Look at aspects of current process that need changed or provides an opportunity for sooner shared savings—global picture and practical reality of steps and changes.

·  Three years to make the changes.

·  Hope to have input from the groups by January 15 at the latest.

·  Consistently agreed that we are going on a medical home infrastructure for all dual eligibles.

What’s missing:

More impaired dual eligibles potentially coming into the system because of this initiative and impaired people in their homes with more intensive needs are an area that is not being covered.

Other thoughts

·  Need to have some flexibility in this model to provide 24/7 community coverage such as community paramedics or advanced paramedics who could go visit in home – do some intervention, treat in place rather than ED.

·  Have to have the flexibility to support that kind of infrastructure--docs on wheels SWAT.

·  NH – can start IV – injuries that involve bones (not head injury) if fracture if there was an alternative to ER. The concern is the damage done waiting (psychotropics, catheter) cheaper to go do urgent care that accepts and then if you have to take patient to hospital, then go to hospital.

Medicaid is a special group – only pop with increasing ED visits – they are complicated patients – system not set up so well—patients have to be more organized to go to doctor.

CCNC networks could be helpful, for example

·  transportation taxi vouchers

·  cell phones versus call ambulance call

·  Install grab bar in shower.

·  Networks need flexibility and the ability to pay for things – not just reimbursable-- a fund to help people stay safely in home.

·  Dropping some of restrictions around high risk people 22 visit limit

·  Waive Tier 5 medication co-pays, other ways to get everything on the table. Global PMPM for certain high risk individuals—need more wrap around supports. Policy change can be requested.

·  Different PMPM for different Populations – tiers or buckets with needs determination

·  Chronic pain, behavioral health, hard for anyone individual to deal with – need a team, their costs are so high – don’t have to wait long to see cost impact – can show something within months.

·  Constantly moving from doctor to doctors-–needs some resources and support to make it palatable--need to incent docs to take them.

·  Involuntary commitment not possible for NH.

Increase access to ventilators in NC-–will require real change

·  Barriers are regulatory – physical plant requirement, must be dedicated unit – if unit dedicated to vent – transfer discharge rules apply –patient has to return to vent unit so NH has to hold unpaid.

·  Allow facilities to retrofit rooms so that vent patients can be put throughout the facility;

·  the other piece is the psychological support needed.

·  most patients are stabilized enough – maybe we don’t need pulmonologist – out in county there is none – look at how stable they are by the time they are place in the NH.

·  Entrapment of unit, and the discharge reg. Psychological help is huge, not weaning people

·  Example: Patient in acute care for months – sometimes ventilators and dialysis – got to take them to dialysis & ventilators/tracheotomies & transportation.

·  Identify that and becomes a PMPM – doesn’t seem to be any answers for it.

·  Need infrastructure for certain group of patients with complicated needs--sometimes sent out of state. This is the time to ask to try to get the resources.

Mobile crisis should be able to help – should be able to go to different places

·  The ED wait times for psych patients report out

·  Mobile groups are very limited – owner is on board of one – geriatric specialty varies

·  Communications about behavioral problem from the beginning and not being surprised by it.

·  Common ED – schizophrenic hearing voices is a clear acute care problem – may require meds, psych consult, involve. Involuntary Commitment – all ED can do to meet need.

·  Just as common, people come in with dementia & behavioral issues, they can’t be managed and are dangerous to staff & other residents (are generally elderly and somewhat frail) – ED has same problem as NH—if medicate get critized, if restraints are used, get criticized. OIG with anti-psychotics – can’t tie up, can’t lock them up,

Next steps

Sub groups aim to get some infrastructure descriptions in place – to meet scope of sub group to Elise and Nidu by Friday, January 13; may have to meet before that.

NH will be revising this schematic and get out to all work groups– will submit it with revisions that are received by email.

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