TRANSITIONAL AND EXTENDEDCARE MEDICINE CHRISTINE WELLER DO CMD

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TRANSITIONAL AND EXTENDED-CARE MEDICINE CHRISTINE WELLER, DO, CMD WELLER HEALTH TRANSITIONS, LLC FAMILY PRACTICE

TRANSITIONAL AND EXTENDED-CARE MEDICINE CHRISTINE WELLER, DO, CMD WELLER HEALTH TRANSITIONS, LLC FAMILY PRACTICE REVIEW & REUNION FEBRUARY 12, 2017

OBJECTIVES • To learn more about PA/LTC (nursing home) facilities and what services they

OBJECTIVES • To learn more about PA/LTC (nursing home) facilities and what services they provide, what medical care is available and how to help your patient's as the transition back into your care. • To better understand the role of a SNFist/SNFologist/Transitionalist and Medical Director in the PA/LTC setting. • To more efficiently and effectively evaluate a patient returning from a hospital or PA/LTC setting in order to prevent high risk issues that would lead to a readmission and get paid for doing so. • To appropriately discuss end-of life care including hospice care with your patients and get paid for doing so. • To have a resource for advanced care planning in order to discuss the importance of having a living will, power of attorney and a code status designated before hospital admission.

QUESTION 1: WHAT IS THE MOST FREQUENT CAUSE OF HOSPITAL READMISSION WITHIN 30 DAYS

QUESTION 1: WHAT IS THE MOST FREQUENT CAUSE OF HOSPITAL READMISSION WITHIN 30 DAYS OF HOSPITAL DISCHARGE? 20% 20% 20% A. B. C. D. E. A. Acute renal failure B. COPD exacerbation C. CHF Exacerbation D. Sepsis E. Medication error 10

QUESTION 2: WHAT IS THE MOST EFFECTIVE INTERVENTION A TRANSITIONALIST OR PCP CAN PERFORM

QUESTION 2: WHAT IS THE MOST EFFECTIVE INTERVENTION A TRANSITIONALIST OR PCP CAN PERFORM TO PREVENT A HOSPITAL READMISSION UPON INITIAL EVALUATION? A. Reconcile medication list with patient and/or family and call previous facility to talk directly with physician, NP or PA. B. Discuss and encourage of advanced care planning forms including living will, POA, DNR status and hospice need if appropriate. C. Ensure appropriate labs, testing, specialist follow-up, durable medical equipment, home health care and family/community support is in place to fulfill patient's healthcare needs in the home. D. All of the above. 25% 25% A. B. C. D. 10

FREQUENTLY USED ABBREVIATIONS • PA/LTC-Post-Acute and Long-Term Care • AL-Assited-Living • ECF-Extended Care Facility

FREQUENTLY USED ABBREVIATIONS • PA/LTC-Post-Acute and Long-Term Care • AL-Assited-Living • ECF-Extended Care Facility • SNF- Skilled Nursing Facility • LTACH-Long-Term Acute Care Hospital • NP- Nurse Practitioner • PA- Physician Assistant • NPP-Non-Physician Provider (NP or PA-a provider who can write orders) • CMD-Certified Medical Director • AMDA-American Medical Director's Association-The Society for Post-Acute and Long-Term Care

WHAT IS TRANSITIONAL CARE MEDICINE • The coordination of all aspects medical care involved

WHAT IS TRANSITIONAL CARE MEDICINE • The coordination of all aspects medical care involved in a patient's transfer from one clinical setting to another. • Such health-care settings include sub-acute and post-acute facilities, long-term care facilities, hospice service settings, patient's home, primary and specialty offices and the hospital. • A comprehensive plan of care, an interdisciplinary team, and clinicians well- trained in sub-acute and chronic care, who understand the medically complex patient's current clinical status, history, goals, preferences is required to effectively direct such transitions safely and effectively 1.

MY TRANSITION TO TRANSITIONAL MEDICINE • 12 years office-based family medicine • 6 years

MY TRANSITION TO TRANSITIONAL MEDICINE • 12 years office-based family medicine • 6 years as a SNFist, SNFologist, Transitionalist or, just plain, "nursing home doc"

POST-ACUTE AND LONG-TERM CARE VENUES • Assisted-living (AL) –provides services focused on maintaining resident

POST-ACUTE AND LONG-TERM CARE VENUES • Assisted-living (AL) –provides services focused on maintaining resident independence in a supervised setting. Many assisted living residents live in communities with apartments and amenities such as group dining and medication assistance. Assisted-living is not regulated by the federal government. • Long-term care (LTC) – traditionally provided in nursing homes, providing patients who can no longer be cared for at home or in assisted-living with support for both daily living activities and complex medical problems. Long-term care is regulated by the federal government.

POST-ACUTE AND LONG-TERM CARE VENUES • Skilled nursing facility care (SNF) – care ordered

POST-ACUTE AND LONG-TERM CARE VENUES • Skilled nursing facility care (SNF) – care ordered by a physician, delivered by skilled nursing or therapy staff, and paid for by Medicare part A for a fixed period of time (up to 100 days). Skilled care takes place in a nursing home, and may or may not be the same as post-acute care. • Long-term acute care hospital (LTACH)– a facility, either freestanding or within a hospital setting, specializing in treating extremely medically complex patients requiring extended hospitalization usually greater than 25 days with access to care including mechanical ventilation.

OTHER LEVELS OF CARE COMMONLY UTILIZED DURING OR AFTER PA/LTC CARE HEALTH STAYS •

OTHER LEVELS OF CARE COMMONLY UTILIZED DURING OR AFTER PA/LTC CARE HEALTH STAYS • Home Health Care (HHC)- healthcare services that can be given in one's home for an illness or injury. This may include wound care, IV or nutrition therapy, injections, lab work, nurse monitoring of serious illness and unstable health status, patient and caregiver education stuff, physical and occupational speech therapy and assistance with ADLs and light housekeeping. • Palliative care – focuses on managing chronic conditions of a patient with the goal of providing comfort and the highest quality of life possible. This little of care maybe appropriate as a preemptive's service to patients who are not yet qualify for hospice care. It is reimbursed and regulated by the federal government. • Hospice care – focused on providing comfort and pain control versus extending one's life for patients expected to live six months or less. This level of care maybe provided in an inpatient setting, long-term care settings or in a patient's private residence. Regulated by the federal government.

THE NEED FOR PA/LTC PROVIDERS AND WORKERS • PA/LTC patients are a unique and

THE NEED FOR PA/LTC PROVIDERS AND WORKERS • PA/LTC patients are a unique and vulnerable population, often experiencing multiple comorbidities, cognitive impairment and difficult your choices. • About 1/5 of the US population will be 65 or older by the year 2030. • More than half of adults age 65 and older have three or more medical problems. • The 85+ population is projected to increase from 5. 7 million in 2011 to 14, 100, 000 in 2040. • 12 million people receive long-term care services.

THE NEED FOR PA/LTC PROVIDERS AND WORKERS • In 2015, Medicare reimbursed claims for

THE NEED FOR PA/LTC PROVIDERS AND WORKERS • In 2015, Medicare reimbursed claims for 5. 6 million beneficiaries. • It is estimated that we will need 1. 2 million long-term care workers by the end of 2020, requiring creation of 347, 000 new jobs. • The post-acute and long-term care population requires professionals train specifically to the setting. • PA/LTC facilities are the most highly regulated healthcare setting and second highest regulated US industry, preceded only by nuclear power plant regulation.

READMISSIONS COST A LOT OF MONEY In 2011, there were about 3. 3 million

READMISSIONS COST A LOT OF MONEY In 2011, there were about 3. 3 million US readmissions within 30 days of discharge contributing to about $41 billion in hospital costs(4). 55% of those readmissions and 58. 2% of those costs were accounted for Medicare beneficiaries (4). The top five conditions associated with Medicare readmissions in 2011 were: 1. CHF 2. Septicemia 3. Pneumonia 4. COPD 5. Cardiac Dysrhythmias

WHY ARE PATIENTS RE-ADMITTED? • Patients read knitted to the hospital in less than

WHY ARE PATIENTS RE-ADMITTED? • Patients read knitted to the hospital in less than eight days will usually attributed to the original condition that caused her hospital stay(5). • Those returning closer to 30 days typically related to not receiving the proper follow-up care and developing a different illness or complication(5). • No PCP or access to needed resources after discharge. • Type of insurance. • Literacy and education level.

WHY IS THIS IMPORTANT • Hospitals receive cuts to their Medicare payments when readmissions

WHY IS THIS IMPORTANT • Hospitals receive cuts to their Medicare payments when readmissions are higher than expected for certain diagnoses. 6.

 • HEALTH CARE AND SUPPORT PROVIDED IN ECF'S & SNF'S • • Administrator

• HEALTH CARE AND SUPPORT PROVIDED IN ECF'S & SNF'S • • Administrator Director of nursing Medical director Attending physicians Nurse practitioners Physician assistants Wound consultants- DO, MD, NP, PA • • Speech therapists Respiratory therapists Dietitians and dietary managers Social workers and assistants Registered nurses Licensed practical nurses Hospice nurses

HEALTH CARE AND SUPPORT PROVIDED IN ECF'S & SNF'S • Consultant pharmacist • Consultant

HEALTH CARE AND SUPPORT PROVIDED IN ECF'S & SNF'S • Consultant pharmacist • Consultant orthopedist or physiatrist • Consultant psychiatrist and psychologist • Consulting dentist • Consultant optometrist • Physical therapists • Occupational therapists • • Nursing assistants/aides Chaplain Activities director and assistants Housekeeping and maintenance Admissions coordinators Financial officers and support Human Resources

ANCILLARY AND THERAPEUTIC SERVICES AVAILABLE IN ECF'S AND SNF'S • On-site lab services –stat

ANCILLARY AND THERAPEUTIC SERVICES AVAILABLE IN ECF'S AND SNF'S • On-site lab services –stat 3 hour or reg 8 hour • On-site radiology services • X-ray • Venous, arterial, carotid, abdominal US • EKG and echo • PICC line placement • IM Medications • Automated External Defibrillator • Oxygen administration-NC, mask, concentrator • Tracheostomy care and weaning* • Advanced Respiratory Therapy Services* • High-flow* • Percussion vests* • Tracheal/nasopharyngeal suction*

ANCILLARY AND THERAPEUTIC SERVICES AVAILABLE IN ECF'S AND SNF'S • IV fluids and antibiotics

ANCILLARY AND THERAPEUTIC SERVICES AVAILABLE IN ECF'S AND SNF'S • IV fluids and antibiotics (and IV Lasix*) • Life Vest Management* • Clysis- Subcutaneous fluid resuscitation* • Hemodialysis* and Peritoneal dialysis* • Wound vac management • TPN-Total parenteral nutrition* • Nebulizer administration-Duoneb, albuterol, N-acetylcysteine • Ventilator management*(Very few SNFs) • BIPAP and CPAP • Overnight sleep studies* • Palliative and Hospice in-house care • Advanced/focused dementia intervention* *Available in select facilities

SERVICES NOT PERFORMED IN THE ECF & SNF SETTING • ACLS medication administration •

SERVICES NOT PERFORMED IN THE ECF & SNF SETTING • ACLS medication administration • Continuous cardiac monitoring

SNF-SKILLED CARE REIMBURSEMENT • Medicare Part A • Facility is paid a per diem

SNF-SKILLED CARE REIMBURSEMENT • Medicare Part A • Facility is paid a per diem rate based on DRGs and RUG scores which determine payment. • All meds, labs, testing, food, activity costs, overhead, maintenance and therapy reimbursement come out of that per diem rate. • So having expensive resting done like CT scans and stress tests before patients arrive is ideal. Those tests are usually paid for while the patient is in hospital.

WHAT I DO AS A TRANSITIONALIST Evaluate new admissions from hospital/home/other facilities Reconcile medication

WHAT I DO AS A TRANSITIONALIST Evaluate new admissions from hospital/home/other facilities Reconcile medication lists Collaborate with NPs and PAs Work with interdisciplinary team Educate families and help them make decisions Assist as Medical Director in making facility and resident policies and addressing regulatory issues that frequently arise. • Coordinate with hospital and community physicians regarding patients receive and send out/home. • Participate in hospital meetings to exchange feedback in order to maximize the goals of each institution. • • •

WORKING AS AN INTERDISCIPLINARY TEAM • Tremendous clinical care coordination is required in order

WORKING AS AN INTERDISCIPLINARY TEAM • Tremendous clinical care coordination is required in order to achieve beneficial outcomes. • From the dietitians to the nursing aides, input on patient status is highly valued and individual employees are respected for their contribution to the overall care of the resident. • Nursing facilities are the root of the patient-centered model which has been in place in this environment for years before it his the primary care venue.

WORKING WITH NPS AND PAS • In skilled and long-term care, NPPs are the

WORKING WITH NPS AND PAS • In skilled and long-term care, NPPs are the "glue" that holds patients care and facility morale together. • NPPs are difficult to find for this setting as they must be well-versed in pharmacology, sub-acute care and life threatening change of condition, and internal medicine. They must multitask well and work well with the interdisciplinary team. Many come with an intensive or critical care background. • Many facilities have one NP that works 5 days/week and know the patient population well.

TRANSITIONAL CARE MANAGEMENT • The services are required during the beneficiary's transition to community

TRANSITIONAL CARE MANAGEMENT • The services are required during the beneficiary's transition to community setting following particular kinds of discharges • The healthcare professional accepts care of the beneficiary postdischarge from the facility setting without a gap • The healthcare professional takes responsibility for the beneficiary's care • The beneficiary has medical and /or psychosocial problems that require moderate or high complexity medical decision-making • The 30 day TCM. Begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.

TCM SETTINGS ARE FOR JUST FOLLOWING THE BENEFICIARIES DISCHARGE FROM ONE OF THE FOLLOWING

TCM SETTINGS ARE FOR JUST FOLLOWING THE BENEFICIARIES DISCHARGE FROM ONE OF THE FOLLOWING INPATIENT HOSPITAL SETTINGS • Inpatient acute care hospitals • Inpatient psychiatric hospital • Long-term care hospital • Skilled nursing facility • Inpatient rehabilitation facility • Hospital outpatient observation or partial hospitalization • Partial hospitalization at a community mental health center

TCM QUALIFYING HOME SETTINGS TO WHICH THE PATIENT RETURNS FROM DISCHARGE • His or

TCM QUALIFYING HOME SETTINGS TO WHICH THE PATIENT RETURNS FROM DISCHARGE • His or her home • His or her domiciliary • A rest home • Assisted living

TRANSITIONAL CARE MANAGEMENT CODES CPT 99495 CPT 99496 • Transitional care management services with

TRANSITIONAL CARE MANAGEMENT CODES CPT 99495 CPT 99496 • Transitional care management services with moderate medical decision complexity and face to face visit within 14 days of discharge. • Transitional care management services with high medical decision complexity and face-to-face visit within 7 days of discharge. • $158. 47 • $224. 33

TCM REQUIRED TASKS –THERE ARE FOUR - 1 • 1. An interactive contact: •

TCM REQUIRED TASKS –THERE ARE FOUR - 1 • 1. An interactive contact: • You must make an interactive contact within two days after discharge from one of the above facilities. • Contact maybe by telephone, email or face-to-face. • Two attempts at contact with appropriate documentation of the efforts are considered sufficient. However, Medicare expects that you will continue your contact attempts until successful.

TCM REQUIRED TASKS - 2 • Non face-to-face services: • By physician or NPP-obtain

TCM REQUIRED TASKS - 2 • Non face-to-face services: • By physician or NPP-obtain and review discharge information, review need for follow up on pending diagnostic tests and treatments, interact with other healthcare professionals as needed, provided education to the beneficiary on our family/caregiver, establish a reestablish referrals and arrange for needed Community resources, assist in scheduling required follow up with community providers and services. • By your licensed clinical staff under the direction of a physician or NPP-communicate with agencies and community services the beneficiary uses, provided education to the beneficiary and or caregiver to support self-management, independent living and activities of daily living, assess and support treatment regime adherence and medication management, identify available community and health resources, assist the beneficiary and or family in assessing needed care and services.

TCM REQUIRED TASKS – 3 • Face to face visit within certain time frames:

TCM REQUIRED TASKS – 3 • Face to face visit within certain time frames: • 7 days if high medical decision complexity • 14 days with moderate medical decision complexity • Medical decision-making complexity depends on the following: • Number of possible diagnoses and or the number of management options that must be considered. • Amount and or complexity of medical records, diagnostic tests and/ or other information that must be obtained, reviewed analyzed. • Risk of significant complications, and look at it he and /or mortality as well as comorbidities associated with the patient's presenting symptoms, diagnostic procedures and /or the possible management options.

TCM REQUIRED TASKS – 4 • Billing for TCM • At a minimum, document

TCM REQUIRED TASKS – 4 • Billing for TCM • At a minimum, document in the medical record • Date beneficiary was discharged • Direct contact with the beneficiary and /or caregiver • Date you finish the face-to-face visit • Complexity of medical decision-making – moderate or high https: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional. Care-Management-Services-Fact-Sheet-ICN 908628. pdf

ADVANCED CARE PLANNING CODES 2016 • CPT 99497 $85. 99 1 st 30 minutes

ADVANCED CARE PLANNING CODES 2016 • CPT 99497 $85. 99 1 st 30 minutes • CPT 99498. $74. 88 Additional 30 minutes • As of January 1, 2016, CMS reimburses for advanced care planning consultation as a part of the welcome to Medicare visit or separately, on any occasion. The service is to include early conversations between patients and the practitioners, both before and in this progresses and during the course of treatment, to decide on the type of care that is right for them.

ADVANCED CARE PLANNING CODES 2016 • Advanced care planning including the explanation and a

ADVANCED CARE PLANNING CODES 2016 • Advanced care planning including the explanation and a discussion of advanced directive's such as standard forms (with completion of such forms, when performed) by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family members and or surrogate. • There are no specific performance standards, special training, or quality measures a provider must satisfy to bill for ACP • ACP maybe furnished and billed separately on the same day as an evaluating and management visit.

ADVANCED CARE PLANNING CODES 2016 • ACP may be billed on other occasions beyond

ADVANCED CARE PLANNING CODES 2016 • ACP may be billed on other occasions beyond the initial consultation, however it is expected that the code status would change on those occasions. • ACP is subject to cost sharing requirements, unless furnished in conjunction with the "Welcome to Medicare" visit or an annual wellness visit. • Presently, ACP is not reimbursable if furnished via Telehealth. • ACP maybe furnished "incident to" subject to direct supervision.

ADVANCED CARE PLANNING CODES 2016 • https: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNProducts/Downloads/Advance. Care. Planning. pdf

ADVANCED CARE PLANNING CODES 2016 • https: //www. cms. gov/Outreach-and-Education/Medicare-Learning. Network-MLN/MLNProducts/Downloads/Advance. Care. Planning. pdf • http: //www. e-mds. com/advance-care-planning-2016 -medicarephysician-fee-schedule

PROFESSIONAL COURTESY AND MALPRACTICE RISK REDUCTION • As providers evaluate patients during the transitions

PROFESSIONAL COURTESY AND MALPRACTICE RISK REDUCTION • As providers evaluate patients during the transitions from various settings, it is easy to pass judgment on what might have taken place during their care there. • As we were all taught in medical or graduate school, being professional to your colleagues is extremely important. Trying to understand the situation by gathering facts and helping the patient to understand their health issues will yield the best overall results for all parties. • Neutral commentary when the full picture is not understood is imperative to reduction of unnecessary malpractice liability, patient dissatisfaction and consumer confidence in the medical industry. • If in doubt, call your patient's previous provider to get the facts.

REFERENCES • 1. American Medical Directors Association-The Society for Post-Acute and Long-Term Care-Clinical Practice

REFERENCES • 1. American Medical Directors Association-The Society for Post-Acute and Long-Term Care-Clinical Practice Guideline "Transitions of Care in the Long-Term Care Continuum" Columbia, MD: AMDA 2010 • 2. US Department of Health and human services – Centers for Medicare and Medicaid services: transitional care management services; • 3. "Hospital Readmissions by Addressing the Causes. " Center for Medicare Advocacy. T. Edelman. April 18, 2016. Online resource. • 4. "AHRQ: The conditions that cause the most readmissions. " Hines RT all. , AHRQ brief, April 2014; Herman, Becker's Hospital Review, 4/18/14. • 5. "Closer look at what causes readmissions". Jess White. Healthcare Business and Technology. June 15, 2015.

RESOURCES • https: //powerofattorney. com/wp-content/uploads/2013/07/ohio-durable-power-of-attorney-form. pdf • https: //powerofattorney. com/wp-content/uploads/2013/07/ohio-medical-power-of-attorney-form. pdf • https: //www.

RESOURCES • https: //powerofattorney. com/wp-content/uploads/2013/07/ohio-durable-power-of-attorney-form. pdf • https: //powerofattorney. com/wp-content/uploads/2013/07/ohio-medical-power-of-attorney-form. pdf • https: //www. doyourownwill. com/download/living-will/ohlw. pdf • https: //www. odh. ohio. gov/pdf/forms/dnrfrm. pdf • https: //www. hospiceofcincinnati. org/downloads/Ohio. MOLSTv 7. pdf • https: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNProducts/Downloads/Advance. Care. Planning. pdf • https: //www. cms. gov/Outreach-and-Education/Medicare-Learning-Network. MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN 908628. pdf