Medical/Health Homes and Population Management Workgroup meeting
October 27, 2011
On the call: Denise Levis Hewson, Randall Best, Teresa Piezzo, Mark Massing, John Snow,
Polly Welsh, Marsha Fretwell, Tim Daaleman, Betsey Tilson, Beat Steiner, Laurie Nelson,
Robin Huffman, Dan Mosca, Gerri Smith, Swarna Reddy, Ron Gaskins, Jonathan Fischer,
Amy Whited, Tammy McLean, Elise Bolda, Nidu Menon
A. Introductions
B. Sub Group Organization
a) Adult Care Home /Assisted Living: What’s learned from REACH – Lou Wilson,
Tim Daaleman, Cindy Oakes, Elise Bolda
b) Need Determination – Teresa Piezzo, Marsha Fretwell, Betsy Tilson, Elise Bolda
c) Palliative Care – Jonathan Fischer, Laurie Nelson, (Palliative care coordinators)
Ron Gaskins, Nidu Menon
d) Nursing Home – Denise Levis Hewson, Dr Randall Best, Polly Welsh, Scott
Tenbroeck
Members representing all four workgroups are present at the meeting.
It is good to have folks who are not in any particular workgroup. Within a workgroup
people focus on the details, those who are not in a subgroup can look at the big picture. It is
good to have input to broaden the picture.
The report template was passed around. The purpose of the template was explained- this
document will be used by each sub group to document and report to the large group on the
topics that are being discussed and the recommendations that are being made to the large
workgroup.
Denise thanked everyone’s effort to make this a priority to meet & share your wisdom
C. Sub Group reports
1. Needs Determination – Marsha Fretwell
Minutes from the sub group meeting were distributed.
Background – the dual pop is very diverse, 50% no ADL deficiencies
Purpose of the Subgroup – 1) Develop a process for determining needs of recipients across
the continuum of care 2) Develop tool(s) to aid physicians/providers to: assess needs of
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patients, track progress of patients, and link to eligibility. This tool may replace/enhance
the FL2 Level of Care Determination
Initial thoughts on possible Key Elements for consideration:
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Continuity of Care
Medical and nursing coverage. Engage team of primary care providers
Decrease inappropriate hospitalizations and save hospital days -1) Create financial
incentives for physicians, ‘craving rational systems’, 2) support trusting relationships
between primary care providers and patients
Move off medical model to functional model; Make maximizing patient’s functional
health the overarching goal of new system of care
Anticipation of Need of Resources – Tool that is flexible, functionally based, can be used
at intervals over time with scoring mechanism that can be also related to outcome
measures
What is the patient’s goal or preferences
Importance of linking LTC world
The group is committed to move from a medical model to a functional way of assessing
need.
2. Medical Nursing Home – Randy Best
Minutes from the workgroup were distributed.
The question for this work group is how do you bring a medical home to nursing home
residents? With one of the goals being to improve the quality and continuity of care and
avoid unnecessary hospital stays and Emergency Department (ED) visits.
What are the needs and the solutions? How do you identify the universal elements that
have to be in place, given the differences between rural /urban/ different groups of duals,
different providers’ capacity?
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Medical home model for people who reside in nursing homes – for pediatrics there’s
a well known answer on some of the basic things that’s needed, for example
immunizations.
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In this situation it’s clearly different - some topics are evident - End of life, palliative
care, hospitalizations & readmissions, keeping people out of ERs. We have reps from
Nursing Homes and physicians, who work with NHs as practice, these physicians
have a model of practice whereby they serve nursing home residents exclusively.
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NC model – what supports are needed for creating a medical home for nursing home
residents?
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What’s different for resident in Nursing home vs. ambulatory for pt who goes to the
doctor’s office – where the practice is the owner of the medical home we look to the
individual provider to provide good medical home
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In nursing home – physicians are not going to be employees of the nursing homeThey will be in their own practice. – will be in own practice –facility & practitioners
will each have needs & concerns – physicians may think person can be cared for in
facility with IV but the facility may not think they have the resources to do that. It is
a combination of collaborative roles - a line of control is needed
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In the nursing facility, a full time medical director or physician is not financially
feasible (though calculations are beginning) – facilities that employ NP, Evercare
embedded NP, Dr. Herman/Gonzalez who has physician & NP on site, the Medical
Director’s time in building varies
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In Western & Central NC there is a large presence – group influences NH – a lot of
community physicians are giving up practice – have incentive for treatment in place
– have call number after hours – call me first not 911; Challenge is have to have
leverage to work with administrators– varies with the corporation.
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In the case of an embedded N, who is employer – facility or physicians – different
entities have different needs, cost structure, liability?
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Typically PMPM – going to have to be shared between facility & practitioner – got to
align the interests of 2 separate entities trying to do the same thing – different
burdens – may need to have PMP as a floor to cover overhead and separate PMPM to
pay for performance – not all fees for service – some structure that rewards a
practice – profit sharing.
What are minimum items that need to be in place to be a medical home – not
everyone will have the infrastructure –what are the quality metrics to get enhanced
fees? Send ideas to Denise, Randy or Nidu.
There are 400 Nursing Homes in North Carolina.
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Option models that guarantee so many hours in Nursing Facility – would have to
change payment mechanism , our work group will describe the model & options;
what are criteria for Nursing Homes to become medical home – then they have
option of employing or docs on wheels
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Not a huge number of physicians who want to follow residents in NF – perhaps have
medical director and lots of independent [physicians – not sure how many homes
have that from what we hear – some homes had 100 physicians – independently
own, community-established NF – rare will have lots of physicians
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Need to set up what are expectations – that’s the piece we’re trying to look at –
minimum criteria – not every home will have everything.; Post-acute bundling
episodes of care – hospitals post-30 days, hospitals is something else – there may
have an interest in this as well.
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Nursing homes relies mostly on charitable funding to stay viable, tried in 4 county
areas, nursing homes were not receptive – Regulations drive everything; tried
repeatedly to make changes but was not successful.
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Nursing Homes get fined because people get out – this is going to happen even in the
best sites. Regulatory agencies makes everyone fearful – facilities trust the
Associations – national models are very connected by their policies, Administration
will be enthusiastic; they will check with corporate and things get derailed. Nursing
home decides they want to become a medical home – or they don’t
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Might be a way to create a network infrastructure – would be opportunities
pharmaceutical /mental health particularly if don’t have leadership or not many
dual patients – can look at 1s-2s in community and create a network of sorts so
there is accessibility to the services they would otherwise not have.
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Facilities have concerns about regulatory bodies & getting slapped – trying to do the
same thing for physicians. There could be a ‘Center of Excellence’ approach where –
if the site meets criteria as medical home provider – then could be subject of lesser
scrutiny and the regulatory agencies can back off a little; a lesser degree of scrutiny.
There has to be something for the facility also- and the regulatory pull back is the
way to go.
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Agree – as long as we understand that even the best facility can have someone get
out the door; mental health support is a huge carrot as well – behavior management
assistance is very important.
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Cost savings of beds not turning over; the families did not have to hold the bed
because the person had a UTI. Getting volunteers & medical director who have
expertise to lead them; it can work – it is a culture change – are advantages to
Nursing Homes even though they have regulatory restrictions & financial
restrictions
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State kind of regulation can be changed; the federal ones cannot be changed. – may
be carrot around level of external evaluation (1996 – state rules use federal rules as
proxy). The other elephant in the room is the trial attorney – a lot of hospitalization
is the result of everyone being afraid not to send the person to the hospital.
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There is currently Tort reform in the General Assembly
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Any other comments, Send suggestions on criteria & quality ideas and we welcome
participation in the workgroup. Some preliminary work done before the Nov 14th
workgroup.
3. Palliative Care - Jonathan Fischer
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The sub group which originally seemed intended to evaluate the use of palliative
care in medical homes; we evaluated the principles, looking at integrating
palliative care support for duals.
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Good symptom management & support with caregivers. Ideally begins at time of
diagnosis of debilitating diagnosis and continues through to death
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Palliative care needs an Interdisciplinary team – skilled provider, chaplain, nurse
assistants
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Something a physician could think of when first meeting patient – to be sure they
are thinking along the lines of palliative care needs – we agree upon the
“surprise question” would I be surprised if this person died over the next 1 – 1.5
years? . There is evidence to support that question as a global prognostic
question enables physicians to stop in their tracks to discuss goals of care and
attention to palliative care principles.
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Consensus document from CAPC ( Center for the Advancement of Palliative
Care) which identifies a checklist model trigger that can be used in hospitals
primarily, although has utility in other settings – in addition to surprise question
– has other items including like dementia, family discord and other things that
drawn attention to higher need of attention to palliative care
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Different levels of palliative care- Primary Palliative care that we are discussing –
primary provider, and include advance care planning, symptom management,
goals discussions, part of an approach of a provider to a patient’s family.
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2nd level, more specialty level- palliative care physician or NP & interdisciplinary
team – more accessible in hospitals with palliative care conduct teams and
through hospice providers, some hospices may have outpatient component.
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The entirety of the continuum of palliative care and the necessary tools and
principles that apply
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We stress the continual review of form has to be stressed – even when MOST
form gets filled out, conditions change over time. There is a need to be an
opportunity particularly, at transition of care or when change in functional
status or symptomatology occurs there is a need to review, reevaluate and revise
those forms.
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Importance of transitions, we want to be sure any system included the
availability of palliative care with in different settings and of some sort of
mechanisms by which patients and families to become aware of the availability
of those services.
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Also look at tools such as the ‘palliative performance scale’ where ambulation,
activity levels, evidence of disease, self- care needs, nutrition intake etc are all
good correlation with that and overall mortality or prognostics periods. Posed
the question that there were different settings of care for duals to engage in
palliative care and we need to prioritize the setting where there is most impact
for palliative care. The consensus was you go where patients are – in hosp, home,
nursing homes.
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In that line the group talked about models tried or underway including having
Palliative care providers work in tandem with specialty clinics (UNC & Duke
marrying a supportive care team to a oncology clinic, or heart failure clinic) or
large practice seeing a lot of dually eligible patients –( thinking about the team
down in Wins-Salem), another model – having hospices provide palliative care
consultants to Nursing Homes and trainings with NH staff, assist in development
of palliative care services in hospitals that don’t already have them.
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There is a challenge with not having enough trained providers with skills in
palliative care. We need to leverage more the skill set that exists in hospices
around the state, try to make it easier through either regulatory reform or
financial incentives to hospitals for providing palliative care before patients are
eligible for the service.
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Several on call had tried outpatient palliative care or in home care with varying
success; some of challenges that were described were financial difficulties which
stems from not being able to narrow down who were the most appropriate
patients for that team to be engaged with. Some of the patients not being truly
home bound, still going out to other providers and were having the palliative
care provider coming to their home, sometimes the palliative care team found
themselves supplanting the PCP, providing too many of the services, over
extending themselves and using too many resources that did not get
reimbursed. New model that are being tried is limiting practice to folks with 1.5
year mortality expectation, with PCP still be involved using Nurse Practitioner
and nurse extenders to talk with family about the consultation prior to Nurse
Practitioner or Physician goes to pts home or Nursing Facility, a more efficient
marrying of resources to the needs.
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Mentioned before with these groups is also the lack of reimbursement for
interdisciplinary care that palliative care providers would like to apply to
patients they see on hospice side, where they have per diem payment. On the
outpatient side, they just have a fee for service, that they are reimbursed for
which rarely comes close to covering the more complete services that palliative
care teams would like to provide for their patients.
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Looking for funding mechanisms that would allow for a greater extent of
services particularly on the outpatient arena
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Models around the country successful – mostly in a FFS model, but in capitated
model (Kaiser, Aetna comprehensive care program. Figuring out how those
hurdles can be overcome to allow greater access to palliative care services
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The key is to hook up with and educating specialty clinics. The specialty clinics
would welcome the presence of the support teams.
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When pts come to family doc we have this conversation but some specialties’
such as nephrologists & cardiologist are not willing to have these conversationsa lot of the time specialty clines would welcome a palliative care consult but then
again someone from oncology was offended that they were being asked to
provide palliative care to a patient whose life has been extended three months
due to a treatment that was being considered successful.
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Among oncologists receptivity varies by type of cancer – ones with palliative
care live longer – The data supports palliative care.
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Palliative care and hospice care a continuum –
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Clinical & social criteria for referral for palliative care – example at UNC all stage
4 lung cancers seen by palliative care team – not waiting for oncologists. From
hospital stand point – driven by quality and overall ranking, affects hospitals
mortality index– look at complexity of patients – are these people more
appropriately designated as palliative care patients?
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Concurrent care exploration – patient who elects hospice they do not have to
forgo curative therapies – that selection or choice is a barrier for
interdisciplinary care that hospices can provide – examples of model around the
county relaxing that and 6 month – getting better outcomes, symptom
improvement, pt satisfaction, without a large expenditure of cost- now possible
for pediatric patients (changes under ACA – though challenges implementing the
changes)
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Ask other sub groups moving forward if there is the need for the presence of a
palliative care expert to seed that conversation in the groups, please let Elise or
Jonathan know to get some additional minds in the group.
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In the Palliative care work group we will be looking at palliative care supports
across multiple settings and various models of delivery of care. Invite other
people to participate.
4. Adult Care Homes- Tim Daaleman
Background Information
Request to please contribute to this group; this group is just getting started.
A view into the landscape of Adult care Home, considerable heterogeneity of these
sites adds to the complexity of the issue.
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Heterogeneous population: older adults/geriatric with cognitive impairment;
younger and middle age with chronic mental illness (e.g., schizophrenia)
Non-licensed sites, not under regulation s, with variation in size, training of support
staff, and administrative structure, may have a licensed RN comes in once a week to
pass out meds
Care can involve:
o Post acute care services that do not require skilled (i.e., nursing care), short
term assisted living
o Custodial care (e.g., medication administration), for people with mental
health issues
o Geriatric patients, adds another layer of complexity
o Challenge of looking at care staff within each site.
Some models that are out there for adult care homes include:
Continuing Care Retirement Communities (CCRC): This is a longitudinal model
that people buy-in at the onset of moving from independent living to assisted living.
These are folks at the upper higher end of the dually eligible; there are physicians
who staff assisted living facilities who will staff adult care homes, the challenge is
how you begin to implement any quality improvement efforts or culture change in
these sites because of the lack of any regulations.
Recently there is a Villages Project that began in Beacon Hill in Boston, older adults
who want to remain in the community and need an array of services. Currently the
model is a member services organization, i.e. you pay a fee into this large group that
is a 501C3- and you get services from getting your gutter cleaned to getting some
personal services. There is a meeting going on in Chapel Hill with people who are
very interested in this model.
The next is the Home Care Program, people talk about sort of REACH, there are
multiple different physician and NP based programs that are out there. Most of them
are largely independent or not tied to medical homes. Tying it to the medical health
care systems like Rex, UNC and Duke has been a little bit of a challenge.
What we have come up with in REACH is to integrate home care programs to health
programs mostly within UNC and other health care systems. Different functions,
informatics, quality improvement, risk assessment, identifies or stratifies high risk
patients.
Reimbursement rates are very poor; BU, Hopkins has infrastructure or benefactor
to make this a viable model – vs. shared saving model; REACH cost – looked at how
to we begin to capture everything this person does, one guy doing home-based trip
fee.
With Adult Care Homes the network will probably be key –they don’t have licensed
staff, bring medical home to them – physician, PCP, NPs, pharmacists, bringing the
medical homes to them. The networks will start giving PMPM to support the model.
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We met with provider in Moncure to look at doing this. We were encouraging the
provider to go out to several of these sites; this is an attractive model. Need to align
the incentives – in terms of cost savings there is a great opportunity here
The other piece is also to tying into LME – substantial amount of savings available
here.
May be suggesting a change in reimbursement through PMPM, with 2 or 3 contracts
– how do you tie in medical home and they have LME– integrating those three and
how do you distribute the PMPM?
With our network – challenge is level of employees, rate of turnover – literacy rate is
lower than people can imagine – how do you sustain care standards within these
sites?
Model of bringing in Adult Care Homes has a lot of potential; Lou Wilson who had
shoulder surgery, is one of the co-leads, very excited about opportunity to bring
more clinical support into ACH but it has to be a cost containment approach
In MH community we would like to see funding that would allow people to live
independently with supports in home in community, and not be forced to move into
a home. Duke did this in subsidized housing; the model can go with patient. The
behavioral workgroup has that on its radar as well as the Continuum of care
workgroup.
Where is home care in hospice? Integral part of adult care home; I don’t see it with
this oversight group. How does home care and hospice interplay here?
Denise – outside of dual eligible population, CCNC has a work group trying to
integrate more in the community medical home model, Ginger Parrish & Teresa
Piezzo co-chairing that effort, very much a part of community model. Is hospice very
distinct from palliative care, it has its place in hospice but integral in adult care
homes.
Next meetings:
Nov 4th Adult care Homes
Nov 7th Need Determination
Nov 14th Nursing Homes
TBD Palliative care
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Large Medical Homes Work Group meeting: Dec 8, Thursday 9-11.00 am
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