Decision Aids for Advance Care Planning: An Overview of the State of the Science

Annals of Internal Medicine

Mary Butler, PhD, MBA; Edward Ratner, MD; Ellen McCreedy, MPH; Nathan Shippee, PhD; and Robert L. Kane, MD

Ann Intern Med. Published online 29 July 2014 doi:10.7326/M14-0644

Advance care planning honors patients' goals and preferences for future care by creating a plan for when illness or injury impedes the ability to think or communicate about health decisions. Fewer than 50% of severely or terminally ill patients have an advance directive in their medical record, and physicians are accurate only about 65% of the time when predicting patient preferences for intensive care. Decision aids can support the advance care planning process by providing a structured approach to informing patients about care options and prompting them to document and communicate their preferences. This review, commissioned as a technical brief by the Agency for Healthcare Research and Quality Effective Health Care Program, provides a broad overview of current use of and research related to decision aids for adult advance care planning. Using interviews of key informants and a search of the gray and published literature from January 1990 to May 2014, the authors found that many decision aids are widely available but are not assessed in the empirical literature. The 16 published studies testing decision aids as interventions for adult advance care planning found that most are proprietary or not publicly available. Some are constructed for the general population, whereas others address disease-specific conditions that have more predictable end-of-life scenarios and, therefore, more discrete choices. New decision aids should be designed that are responsive to diverse philosophical perspectives and flexible enough to change as patients gain experience with their personal illness courses. Future efforts should include further research, training of advance care planning facilitators, dissemination and access, and tapping the potential opportunities that lie in social media or other technologies.

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Advance care planning is a way to inform care choices for a patient who cannot express a preference and a planning tool that helps patients begin to prioritize their treatment goals. The preferences of seriously ill patients for life-sustaining interventions depend on their care goals. Some prioritize living longer to achieve life goals, whereas others may not wish to be kept alive when meaningful recovery or a particular quality of life is no longer possible (1–3). Religious and spiritual values and beliefs also affect goals of care (4–5). Advance care planning helps to honor patient preferences and goals if incapacitating illness or injury prevents adequate communication (6).

Decision aids help patients consider health care options. Such aids for advance care planning support the 3 key components of the process: learning about anticipated conditions and options for care; considering these options; and communicating preferences for future care, either orally or in writing. The most important information a decision aid can provide to a decision maker depends on the patient's current health status and the predictability of illness trajectories (Figure). A healthy person may benefit most from general decision aids focused on choice of health care proxies and goals of care for hypothetical catastrophic situations, such as after loss of function or cognition or terminal illness. For patients with a life-threatening illness, appropriate aids focus on decisions to accept, withhold, or terminate specific treatments. Advance care planning with decision aids takes place in various settings; it is often done outside clinical settings, particularly among healthy older adults. Nonclinical partners in shared decision making may include family members, caregivers, or attorneys or other professionals.

Read more:

http://annals.org/article.aspx?articleid=1891307

New ICD-10 Compliance Date - Final Rule

Centers for Medicare and Medicaid Services has announced a final rule establishing October 1, 2015, as the new ICD-10 compliance date.

The final rule, scheduled to be published in the Federal Register on August 4, implements Section 212 of the Protecting Access to Medicare Act (PAMA) of 2014 which became law on April 1 delaying the ICD-10 implementation deadline from October 1, 2014 to October 1, 2015.

The final rule not only establishes October 1, 2015, as the new ICD-10 compliance date but also requires the continued use of ICD-9-CM through September 30, 2015.

The one-year delay in the ICD-10 code switchover will take a financial toll on the healthcare industry, according to CMS, which estimates the cost to HIPAA covered entities will be $1.1 billion to $6.8 billion. However, the final rule from CMS concludes that a one-year delay--as opposed to a longer delay--will be the “least costly and most fiscally responsible way to implement the requirements of section 212 of PAMA." Because a delay of longer than one year would slow or even stop progress towards ICD-10 implementation, the final rule establishes the “shortest delay permitted by law, which is one year.”

http://www.healthdatamanagement.com/news/Final-Rule-Establishes-New-ICD-10-Compliance-Date-48526-1.html

Medicare, Medicaid, and Children's Health Insurance Programs: Extended Temporary Moratoria on Enrollment of Ambulance Suppliers and Home Health Agencies in Designated Geographic Locations

Action

Extension of temporary moratoria.

Summary

This document announces the extension of temporary moratoria on the enrollment of new ambulance suppliers and home health agencies (HHAs) in specific locations within designated metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse.

Dates

Effective Date: July 29, 2014.

For Further Information Contact

August Nemec, (410) 786-0612.

News media representatives must contact CMS' Public Affairs Office at (202) 690-6145 or email them at press@cms.hhs.gov.

Supplementary Information

I. Background

A. CMS' Imposition of Temporary Enrollment Moratoria

Section 6401(a) of the Affordable Care Act added a new section 1866(j)(7) to the Social Security Act (the Act) to provide the Secretary with authority to impose a temporary moratorium on the enrollment of new Medicare, Medicaid or CHIP providers and suppliers, including categories of providers and suppliers, if the Secretary determines a moratorium is necessary to prevent or combat fraud, waste, or abuse under these programs. For a more detailed explanation of these authorities, please see the July 31, 2013 notice (78 FR 46339) or February 4, 2014 extension and establishment of a temporary moratoria document (hereinafter referred to as the February 4, 2014 moratoria document) (79 FR 6475).

Based on this authority and our regulations at § 424.570, we have implemented two phases of the moratoria to date. In the notice issued on July 31, 2013 (78 FR 46339), we imposed moratoria on the enrollment of home health agencies in Miami-Dade County, Florida and Cook County, Illinois and surrounding counties and on the enrollment of ground ambulance suppliers in the Harris County, Texas area and surrounding counties. Then, in the document published on February 4, 2014 (79 FR 6475), we imposed moratoria on the enrollment of home health agencies in Broward County, Florida, Dallas County, Texas and Wayne County, Michigan and surrounding counties and on the enrollment of ground ambulance suppliers in Philadelphia, PA and surrounding counties.

B. Determination of the Need for Extending a Moratorium

In extending these enrollment moratoria, CMS considered both qualitative and quantitative factors suggesting a high risk of fraud, waste, or abuse. CMS relied on law enforcement's longstanding experience with ongoing and emerging fraud trends and activities through civil, criminal, and administrative investigations and prosecutions. CMS' determination of a high risk of fraud, waste, or abuse in these provider and supplier types within these geographic locations was then confirmed by CMS' data analysis, which relied on factors the agency identified as strong indicators of risk. (For a more detailed explanation of this determination process and of these authorities, see the July 31, 2013 notice (78 FR 46339) or February 4, 2014 moratoria document (79 FR 6475)).

1. CONSULTATION WITH LAW ENFORCEMENT

In consultation with the HHS-OIG and the Department of Justice (DOJ), CMS identified two provider and supplier types in nine geographic locations that warrant a temporary enrollment moratorium. For a more detailed discussion of this consultation process, see the July 31, 2013 notice (78 FR 46339) or February 4, 2014 moratoria document (79 FR 6475).

2. BENEFICIARY ACCESS TO CARE

Beneficiary access to care in Medicare, Medicaid, and CHIP is of critical importance to CMS and its state partners, and CMS carefully evaluated access for the target moratorium locations. Prior to imposing and extending these moratoria, CMS consulted with the appropriate State Medicaid Agencies and with the appropriate State Department of Emergency Medical Services to determine if the moratoria would create an access to care issue for Medicaid and CHIP beneficiaries in the targeted locations and surrounding counties. All of CMS' state partners were supportive of CMS analysis and proposals, and together with CMS, determined that these moratoria will not create access to care issues for Medicaid or CHIP beneficiaries. CMS also reviewed Medicare data for these areas and found there are no current problems with access to HHAs or ground ambulance suppliers.

3. LIFTING A TEMPORARY MORATORIUM

In accordance with § 424.570(b), a temporary enrollment moratorium imposed by CMS will remain in effect for 6 months. (For a more detailed explanation of how CMS can lift a temporary moratorium, see the July 31, 2013 notice (78 FR 46339) or February 4, 2014 moratoria document (79 FR 6475).) If CMS deems it necessary, the moratorium may be extended in 6-month increments. CMS will evaluate whether to extend or lift the moratorium before any subsequent moratorium periods. If one or more of the moratoria announced in this document are extended or lifted, CMS will publish a document to that effect in theFederal Register.

Once a moratorium is lifted, the provider or supplier types that were unable to enroll because of the moratorium will be designated to CMS' high screening level under § 424.518(c)(3)(iii) and § 455.450(e)(2) for 6 months from the date the moratorium was lifted.

II. Extension of Home Health and Ambulance Moratoria—Geographic Locations

As noted earlier, we previously imposed moratoria on the enrollment of new HHAs in Broward county, Miami-Dade and Monroe and their surrounding counties in Florida, the Illinois counties of Cook, DuPage, Kane, Lake, McHenry, and Will, the Michigan counties of Macomb, Monroe, Oakland Washtenaw, and Wayne and the Texas counties of Brazoria, Chambers, Collin, Fort Bend, Galveston, Dallas, Harris, Liberty, Denton, Ellis, Kauffman, Montgomery, Rockwall, Tarrant, and Waller. Further, we previously imposed moratoria on the enrollment of new ground ambulance suppliers in the Texas Counties of Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery, and Waller and the Pennsylvania counties of Bucks, Delaware, Montgomery; and Philadelphia and the New Jersey counties of Burlington, Camden, and Gloucester. These moratoria became effective upon publication in theFederal Registerof a notice on July 31, 2013 (78 FR 46340)and a moratoria document on February 4, 2014 (79 FR 6475).

In accordance with § 424.570(b), CMS may deem it necessary to extend previously-imposed moratoria in 6-month increments. Under its authority at § 424.570(b), CMS is extending the temporary moratoria on the Medicare enrollment of HHAs and ground ambulance suppliers in the geographic locations discussed herein. Under regulations at § 455.470 and § 457.990, these moratoria also apply to the enrollment of HHAs and ground ambulance suppliers in Medicaid and CHIP. Under § 424.570(b), CMS is required to publish a document in theFederal Registerannouncing any extension of a moratorium, and this extension of moratoria document fulfills that requirement.

CMS consulted with both the HHS-OIG and DOJ regarding the extension of the moratoria on new HHAs and ground ambulance suppliers in all of the moratoria counties, and both HHS-OIG and DOJ agree that a significant potential for fraud, waste, and abuse continues to exist in these geographic areas. The circumstances warranting the imposition of the moratoria have not yet abated, and CMS has determined that the moratoria are still needed as we monitor the indicators and continue with administrative actions such as payment suspensions and revocations of provider/supplier numbers. (For more information regarding the monitored indicators, see section I.B. of the February 4, 2014 moratoria document (79 FR 6475).)

Based upon CMS' consultation with the relevant State Medicaid Agencies, CMS has concluded that extending these moratoria will not create an access to care issue for Medicaid or CHIP beneficiaries in the affected counties at this time. CMS also reviewed Medicare data for these areas and found there are no current problems with access to HHAs or ground ambulance suppliers. Nevertheless, the agency will continue to monitor these locations to ensure that no access to care issues arise in the future.

Based upon our consultation with law enforcement and consideration of the factors and activities described previously, CMS has determined that the temporary enrollment moratoria should be extended for an additional 6 months.

III. Summary of the Moratoria Locations

CMS is executing its authority under sections 1866(j)(7), 1902(kk)(4), and 2107(e)(1)(D) of the Act to extend these moratoria in the following counties for these providers and suppliers:

Table 1—HHA Moratoria

State	City/metro area	Counties
FL	Fort Lauderdale	Broward.
FL	Miami	Monroe.
		Dade.
IL	Chicago	Cook.
		DuPage.
		Kane.
		Lake.
		McHenry.
		Will.
MI	Detroit	Macomb.
		Monroe.
		Oakland.
		Washtenaw.
		Wayne.
TX	Dallas	Collin.
		Dallas.
		Denton.
		Ellis.
		Kaufman.
		Rockwall.
		Tarrant.
TX	Houston	Brazoria.
		Chambers.
		Fort Bend.
		Galveston.
		Harris.
		Liberty.
		Montgomery.
		Waller.

Table 2—Part B Ambulance Moratoria

State	City/metro area	Counties
PA/NJ	Philadelphia	Bucks.
		Burlington (NJ).
		Camden (NJ).
		Delaware.
		Gloucester (NJ).
		Montgomery.
		Philadelphia.
TX	Houston	Brazoria.
		Chambers.
		Fort Bend.
		Galveston.
		Harris.
		Liberty.
		Montgomery.
		Waller.

IV. Collection of Information Requirements

This document does not impose information collection and recordkeeping requirements. Consequently, it need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 35).

V. Regulatory Impact Statement

CMS has examined the impact of this document as required by Executive Order 12866 on Regulatory Planning and Review (September 30, 1993), Executive Order 13563 on Improving Regulation and Regulatory Review (January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, section 202 of the Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2)).

Executive Orders 12866 and 13563 direct agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major regulatory actions with economically significant effects ($100 million or more in any 1 year). This document will prevent the enrollment of new home health providers and ambulance suppliers in Medicare, and new home health providers and ambulance suppliers in Medicaid and CHIP. Though savings may accrue by denying enrollments, the monetary amount cannot be quantified. After the imposition of the moratoria on July 30, 2013, 231 HHAs and 7 ambulance companies in all geographic areas affected by the moratoria had their applications denied. We have found the number of applications that are denied after 60 days declines dramatically, as most providers and suppliers will not submit applications during the moratoria period. Therefore, this document does not reach the economic threshold and thus is not considered a major action.

The RFA requires agencies to analyze options for regulatory relief of small entities. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and small governmental jurisdictions. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $7.0 million to $35.5 million in any one year. Individuals and states are not included in the definition of a small entity. CMS is not preparing an analysis for the RFA because it has determined, and the Secretary certifies, that this document will not have a significanteconomic impact on a substantial number of small entities.

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis if an action may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 604 of the RFA. For purposes of section 1102(b) of the Act, CMS defines a small rural hospital as a hospital that is located outside of a Metropolitan Statistical Area for Medicare payment regulations and has fewer than 100 beds. CMS is not preparing an analysis for section 1102(b) of the Act because it has determined, and the Secretary certifies, that this document will not have a significant impact on the operations of a substantial number of small rural hospitals.

Section 202 of the Unfunded Mandates Reform Act of 1995 also requires that agencies assess anticipated costs and benefits before issuing any regulatory action whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. In 2014, that threshold is approximately $141 million. This document will have no consequential effect on state, local, or tribal governments or on the private sector.

Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed regulatory action (and subsequent final action) that imposes substantial direct requirement costs on state and local governments, preempts state law, or otherwise has Federalism implications. Since this document does not impose any costs on state or local governments, the requirements of Executive Order 13132 are not applicable.

In accordance with the provisions of Executive Order 12866, the Office of Management and Budget reviewed this document.

Authority

Sections 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh) and 44 U.S.C. Chapter 35; Sec. 1103 of the Social Security Act (42 U.S.C. 1302).

Dated: July 2, 2014.

Marilyn Tavenner,

Administrator, Centers for Medicare & Medicaid Services.

[FR Doc. 2014-18174 Filed 7-29-14; 4:15 pm]

BILLING CODE 4120-01-P

http://www.regulations.gov/#!documentDetail;D=CMS_FRDOC_0001-1525

Study Finds Pediatric Telemedicine Improves Patient Outcomes

Following a comprehensive study of 1,000 pediatric telemedicine consultations available throughout Latin America, researchers at Children’s Hospital of Pittsburgh discovered physicians there were highly satisfied with the services and believed they had improved patient outcomes.

The study, covered in Healthcare IT News, showcased Children’s multi-center experience in telemedicine at three hospitals in Colombia and one in Mexico from July 2011 to June 2013.

Children’s physicians provided 1,040 consultations for 476 patients, with a real-time intervention taking place in 23% of those encounters. In 6% of the tele-consultations, a different diagnosis was suggested based on the interpretation of cardiac or imaging studies.

Relevant patient data was provided in a secure database and telemedicine hardware was used for real-time consultations.

We’re told that a CICU physician from Children’s participated in all encounters.

Based on anonymous surveys of physicians participating at the international centers, 96% of respondents reported being satisfied or highly satisfied with the telemedicine service, while 58% rated the promptness and time dedicated by the tele-intensivists as very high. Physicians reported that they sometimes changed their clinical practice in relation to the telemedicine encounters, with changes in surgical management noted most frequently.

“Now we know that the physicians we assist internationally consider this technology to be useful for patient outcomes and education. We will continue to expand access to the world’s best healthcare for children around the world,” said lead investigator Ricardo A. Muñoz, M.D.

The study is available for review here.

http://mhealthwatch.com/study-finds-pediatric-telemedicine-improves-patient-outcomes-23702/

The Latest Stage 2 Meaningful Use Attestation Data: Shocking Yet Anticipated

by Naomi Levinthal and Anantachai (Tony) PanjamapiromTuesday, July 29, 2014

TOPIC ALERT:

• Meaningful Use

Click on topic to receive periodic emails.

At the July 10 Health IT Policy Committee meeting, CMS and the Office of the National Coordinator for Health IT reported the latest Stage 2 attestation numbers: 972 eligible professionals (EPs) and 10 eligible hospitals (EHs) through July 1.

Nearly the entire industry is amazed by the paltry attestation volume so far. However, the Stage 2 bar is very challenging to reach, and from our previous research, we anticipated such a dramatically slow attestation trend. Last year, we conducted interviews with more than 100 hospitals in integrated delivery networks across the country to assess their levels of Stage 2 readiness. We evaluated interviewee responses on a four-point scale and converted the values to percentages, with 100% being "Process not yet evaluated for Stage 2," and 0% being "No gaps remaining to remediate." The top-two Stage 2 core objectives for which hospitals were least prepared one year ago was Transition of Care (TOC) and View, Download and Transmit (VDT) (see Figure 1).

 

Preparing for Transitions of Care and View, Download and Transmit

The TOC and VDT objectives have subtle yet important nuances that can prolong planning and incur additional efforts. The TOC objective requires providers to meet three measures that track the transmission of a summary of care record to the next setting of care:

• The first measure allows providers to use any method to deliver the summary of care record (including patient delivery);
• The second measure requires electronic transmission; and
• The third measure is a "yes or no" attestation that a provider has exchanged at least one summary of care record with another user on a different electronic health record system than their own.

In our study, these hospitals had not yet assessed the available, specific transmission options for TOC's Measure 2, in which a summary of care document must be electronically transmitted for more than 10% of the patient transitions or referrals.

VDT has two measures. The first is to make certain required information available on a patient portal or personal health record within four business days for EPs and 36-hours post-discharge for EHs, with a more than 50% performance threshold. The second VDT measure tracks patients' access of the portal or PHR and requires that more than 5% of the patients view, download or transmit their health information. Last year, we found most hospitals had yet to validate whether all required data elements can be made available within 36 hours for VDT Measure 1. Additionally, these hospitals were in the early implementation phases of their portal or PHR rollouts and had yet to develop a patient engagement initiative.

Based on our experiences with multiple hospitals around the country preparing for Stage 2 attestation, TOC and VDT objectives prove to be the most taxing from both technology and workflow perspectives. The trends we identified last year are confirmed within the preliminary attestation data ONC released based on 474 EPs and 8 EHs that attested by the end of May. We analyzed this new data set with a specific focus on these two most challenging objectives.

Transitions of Care Stage 2 Attestation Trends Show High Level of EP Exclusions

The data show that 77% of EPs did not reach sufficient referral volumes and thus met the exclusion criteria for all of the objective's measures. By removing one of the most difficult objectives from these EPs' lists, that likely made Stage 2 much easier to achieve, resulting in the high number of attestations compared with hospitals.

The story is different for hospitals, which do not have any exclusion criteria. It is impossible to derive statistical significance from a pool of only eight EH attestations; however, their data provide some interesting observations. Only two hospitals reported a performance rate greater than or equal to 25% for TOC's Measure 2 (the required threshold for electronic transmission of a summary of care record is more than 10%). However, the reported performance rates are much higher for TOC's Measure 1, which does not require electronic transmission and can rely on patients to deliver the summary of care record. For that measure, six of the hospitals achieved between 75% and 85% performance. We anticipate that EP exclusion rates will continue for 2014 Stage 2 attestations and that EHs will continue to perform at the margin for the TOC's Measure 2.

EPs Fare Better With VDT Than EHs

Eighty-one percent of EPs performed in the highest range (i.e., 90% to 100%) for the first VDT measure (making information available to patients within specified timeframes for greater than 50% of patients), whereas EH data show a more varied performance. More than half of the EPs met the second VDT measure (the percentage of patients who viewed, downloaded or transmitted their information) within the 5% to 30% range. However, for all eight EHs, the performance was right at the margin (5% to 10%).

New portal implementations will affect both EP and EH performance, but we expected EPs to fare better than EHs for the second VDT measure for several reasons. The patient portal implementation continued well into 2014 for the majority of our hospital members. Although we have not tracked portal implementation trends for EPs, we assume many practices are rolling out a tightly-integrated portal also designed by their primary EHR vendor. Those portal set-ups may lend implementation benefits for EPs, as opposed to EHs that may experience integration challenges when they deploy a third party portal (e.g., 37% of our interview chose a third-party portal vendor).

In addition, patient engagement may be easier to realize in a provider's office because of the more frequent patient interaction, compared with the acute care setting. For example, EPs can encourage patients to use the portal pre-encounter by setting up an appointment on the portal, whereas for the inpatient domain, admission is condition-dependent and not usually based on "choice" or a patient's schedule. Furthermore, patients seen in the ambulatory setting are generally more "well" than those admitted to the hospital or seen in the emergency department, and that difference in the patient population condition may also make it easier for the EPs to educate patients on the benefits of the portal and encourage its use.

While CMS acknowledged in its Stage 2 final rule that patient portal use will largely be outside the provider's control, we conclude that patient engagement requirements are harder on EHs than EPs and are likely a significant contributing factor to the early differences in the current Stage 2 attestation volumes.

ONC and CMS' reports to the Policy Committee on Aug. 6 will tell us more about the Stage 2 providers meeting this new bar of meaningful use. Undoubtedly, the attestation volume will increase and with it, perhaps, greater insights into these measures that were the most difficult.

http://www.ihealthbeat.org/perspectives/2014/the-latest-stage-2-meaningful-use-attestation-data-shocking-yet-anticipated

Telemedicine may ease chronic pain

Telecare may ease chronic pain

A telemedicine program using automated phone calls or the Internet to monitor symptoms and tailor drug treatment might help patients with chronic pain improve their condition, a new study found.

Researchers at Indiana University School of Medicine randomly assigned 250 patients with chronic musculoskeletal pain to receive either telecare or standard care from their primary care doctor at a Veterans Administration medical center. Patients in the telecare group reported their pain levels through an interactive voice-recorded call or online, and their answers guided adjustments to their medications, based on an algorithm.

After one year, the telecare patients were nearly twice as likely to report a 30 percent improvement in their pain compared with those who received standard care, and they were more likely to report feeling satisfied with their treatment. Those who received standard care were almost twice as likely to report feeling worse pain after six months compared with the telecare group.

BOTTOM LINE: A program using phone calls or the Internet to monitor symptoms and tailor care might help patients with chronic pain improve their condition.

CAUTIONS: Participants consisted of veterans from a single medical center so the findings may not apply to a wider group. The study relied on self-reports of pain, which may not be accurate.

WHERE TO FIND IT: Journal of the American Medical Association, July 16

http://www.bostonglobe.com/lifestyle/health-wellness/2014/07/20/telemedicine-may-ease-chronic-pain/IENXEzLQJnfkzwY1ZXXw4L/story.html

Five essentials for building the patient-centered medical home

Author Name Jennifer Bresnick   |   Date July 28, 2014 

The patient-centered medical home (PCMH) is becoming one of the most coveted recognitions for healthcare providers in urgent need of better ways to manage population health, close care gaps, and reduce wasteful spending.  As evidence of the model’s effectiveness mounts in conjunction with the shift towards accountable care reimbursement models, what are some of the most critical building blocks for the medical home, and how can providers begin their journey towards developing a system of data-driven, patient-centered care?

Roadmap to success

Providers can operate under the PCMH model without being officially recognized as such, but organizations such as NCQA and the American Academy of Family Physicians (AAFP) offer roadmaps and planning tools to guide providers towards the principles of PCMH operations.  Providers may also wish to bring in consultants that will examine their operations, workflows, and clinical health IT infrastructure maturity while making suggestions about the next steps towards developing strong relationships with patients and partner organizations.

Providers should be aware, however, that moving to the PCMH model does require significant investment in both time and resources, warns Michael Meucci, Director of Transformation and Improvement at Arcadia Healthcare Solutions.  “The medical home is a really resource-intensive model,” he says.  “You go from having a physician who has a one-on-one relationship to a patient to a team-based model where a team has a relationship with the patient.”

Strong leadership and staff commitment

The most important key for success is a strong commitment to that overall transformation, a clear leadership structure that engages all levels of staff, and effective communication within the organization as changes are being made.  “When we look at some of our most successful transformations, we see strong leadership buy-in,” Meucci says.  “[One client] built a steering committee that was made up of representation from the executive leadership team, practice leadership, medical leadership, and technology leadership.  It was really every functional area of that organization that was represented on this team.”

“One of the comments that we heard from [our client organization’s staff] was that they were excited to be asked questions about their patients and their care, because historically they had just been given edicts in terms of what they needed to do, and then they were expected to go do it without question,” adds LuAnn Kimker, RN MSN, CPHIMS, PCMH CCE, Director of Clinical Quality Improvement at Arcadia Healthcare Solutions.

In health systems with multiple locations, the PCMH model can help to standardize workflow and clinical tasks throughout the organization, leading to a reduction in potentially harmful variations and an increase in overall quality, communication, and adherence to the organization’s goals.

“The PCMH model really standardizes things across health centers,” said Carol Mensch, MSN RN-BC, Performance Improvement Coordinator at ChesPenn Health Services. “As a community health center, it really changes things to emphasize the patient-centered aspect of care.  If we hadn’t gone the PCMH direction, the Healthy People goals we follow might have pushed us towards those population health features, as well.  But having [the PCMH structure] helps us focus and channel some of our areas of need.”

An underlying technical infrastructure

While EHR adopters can succeed with many of the PCMH principles without an additional outlay in technological infrastructure, clinical analytics and population health management tools can expand a provider’s capabilities to conduct risk assessments, stratify patients, preempt non-adherence, and prevent 30-day readmissions that often come with a hefty financial penalty.  Many of the most technologically savvy organizations in the nation have invested heavily in predictive analytics and data warehousing.

“We are using real-time algorithms within and outside of the EHR to look at risk, and predict and inform clinical and operational pathways,” says Steve Hess, CIO, University of Colorado Health, one of this year’s “Most Wired” hospitals. “While still early, we are starting to see patterns related to how our patients are interacting with our system and the reimbursement impact of those changes. It is important that our systems are set up to provide the complete patient picture and to ensure that the patient is getting the appropriate care in the appropriate setting at the right time.”

Effective patient engagement tools

In addition to in-house analytics, providers must invest in patient engagement if the PCMH is to be successful.  Helping patients manage their chronic diseases, show up for screenings and other primary care services, and access their health information to improve literacy and encourage healthy choices are key features of the PCMH, and health IT tools are available to help.  The patient portal is a pillar of Stage 2 meaningful use, and is a wildly popular feature with patients.

“We recently started a system-wide patient engagement education that includes media, TV, and print, encouraging patients to talk to their providers about using our portal,” explains Catholic Health Partners CMIO Stephen Beck, MD, FACP, FHIMSS. “The intent is to educate patients and continue to educate our providers as we realize there is some economy in the use of our patient portal.”

“Collaboration across the community is going to be a very positive outcome from this work,” he added. “Some communities are well connected right now with HIEs and other interaction at the community level, but most are still very competitive. By nature of making it easier to share information about patient care and improving continuity, I hope the patient will be the winner relative to meaningful use and HIE integration.”

Community stakeholder buy-in

Those community connections provide the foundation for a truly effective PCMH.  Primary care providers can no longer work in isolation, sending patients out to specialists but rarely receiving feedback on the results.  By working together as a “medical neighborhood” instead of individual organizations spending money and man-hours faxing documents back and forth, both providers and patients can reap significant benefits.  Patients may not always understand their responsibilities when it comes to coordinating their care, and hospitals waste millions every year on inefficient communications, lengthy transitions, and waiting for information from colleagues.

“It is important for all health care professionals involved in patient care to have a solid understanding of the role of the patient and family in articulating needs and developing a care plan,” says AAFP. “PCMH integration enables warm handoffs at the moment the patient or family is ready and, thus reduces stigma, improves adherence and augments access to support groups, parenting programs and other medical neighborhood services.”

http://healthitanalytics.com/2014/07/28/five-essentials-for-building-the-patient-centered-medical-home/

Medicare Program; Evaluation Criteria and Standards for Beneficiary and Family Centered Care Quality Improvement Organization Contract

A Notice by the Centers for Medicare & Medicaid Services on 07/28/2014

This notice with comment period describes the general criteria we intend to use to evaluate the effectiveness and efficiency of Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) that will enter into contracts with CMS under the 11th Statement of Work (SOW) in May 2014 titled, “Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) Contract” (HHSM-500-2014-RFP-BFCC-QIO). This contract allows for a transition period from the incumbent QIOs to the successor QIOs. The activities for the BFCC-QIO SOW begin August 1, 2014. The evaluation of a BFCC-QIO's performance related to the SOW will be based on evaluation criteria specified for the tasks set forth in Attachment J-10 of the BFCC-QIOs' SOW contract.

DATES

Effective Date: August 1, 2014 to July 31, 2019.

Comment Date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on August 27, 2014.

 Background

Section 1153(h)(2) of the Social Security Act (the Act) requires the Secretary of the Department of Health and Human Services to publish in the Federal Register the general criteria and standards that will be used to evaluate the effective and efficient performance of contract obligations by the Quality Improvement Organizations (QIOs) and to provide the opportunity for public comment with respect to these criteria and standards. This notice describes the general criteria that will be used to evaluate the performance of Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) under the 11th Statement of Work (SOW) contract beginning August 1, 2014.

Provisions of the Notice With Comment Period

The purpose of the BFCC-QIO contract is to improve healthcare services for Medicare beneficiaries through BFCC performance of numerous statutory and regulatory review functions, including, but not limited to the following:

• Quality of care reviews, including beneficiary complaint reviews and general quality of care reviews;
• Beneficiary appeals of hospital discharges and terminations of service decisions, commonly referred to as Grijalva, BIPA, andWeichardt appeals.
• Medical necessity reviews;
• Appropriateness of setting reviews;
• Diagnosis Related Group (DRG) reviews;
• Readmission reviews;
• Reviews under Emergency Medical Treatment and Active Labor Act (EMTALA);
• Sanctions; and
• Monitoring of Physician Acknowledgement Statements under section 1156(a) of the Act and our regulations at 42 CFR 412.46.

The BFCC-QIO contract also imposes other BFCC-QIO responsibilities: Coordinating and collaborating with other QIOs; developing and making recommendations to promote responsiveness to beneficiary and family needs; providing opportunities for listening to and addressing beneficiary and family concerns; and providing resources for beneficiaries and caregivers in decision making. These QIO beneficiary and family centered efforts align with the National Quality Strategy, which encourages patient and family engagement. (See the BFCC-QIO Statement of Work, Solicitation Number: HHSM-500-2014-RFP-BFCC-QIO, which was posted on December 5, 2013 and is available at https://www.fbo.gov/index?s=opportunity&mode=form&id=6a3acf7d9bd34efb1268e120a13b22e8.)

Evaluation of the Tasks

We will conduct monitoring activities throughout the course of the contract and will act upon findings as necessary. Information used for these monitoring purposes includes but is not limited to:Show citation box

• Deliverables submitted by the BFCC-QIO to CMS in accordance with the Section F “Deliverables or Performance.”
• Provider/facility surveys and/or productivity measures, including cost benefit analysis.
• Data for measures indicated in Attachments J-4 and J-10 of the BFCC-QIO SOW.
• Data from the BFCC-QIO's Internal Quality Control Program.
• Other data submitted by BFCC-QIOs as required by CMS.
• Additional information gathered by email, telephone, video or in-person visits.

BFCC-QIOs must cooperate with the Contracting Officer Representative (COR) on all our monitoring processes and address any concerns identified by the COR. We will take appropriate contract action (for example, providing warning for the need for adjustment, instituting a formal correction plan, terminating an activity, or recommending early termination of a contract because of failure to meet contract timelines or performance as specified in the contract). This means that the BFCC-QIO must comply with the Contract, Tasks, Schedules of Deliverables, Evaluation Measures Tables, and any subsequent modifications (including Health Care Quality Improvement System and Transmission of Policy Memorandums) issued by CMS.

Additionally, there will be multiple periods of more formal evaluation under this contract. The first evaluation will occur at the end of the 12th month of the contract. Subsequent evaluations will occur at the end of the 24, 36, 48 and 54th month of the contract. The evaluations will be based on the most recent data available to us. The performance results of the evaluation at each evaluation period (that is, 12, 24, 36, 48 and 54th months) will be used, in addition to ongoing monitoring activities, to determine the BFCC-QIO's performance on the overall contract.

The BFCC-QIO measures for the 11th SOW are as follows:

• Quality of Review: Inter-Rater Reliability.
• 4-day Data Entry Compliance.
• Timeliness of Beneficiary Complaints and Other Quality of Care Reviews.
• Timeliness of Discharge/Service Termination Reviews.
• Timeliness of EMTALA and Higher Weighted Diagnosis-Related Group Reviews.
• Complainant Agreement to Complete Survey.
• Beneficiary Experience with Quality of Care Complaints.
• Beneficiary Experience with Appeal Reviews.

Annual and 54th Month Evaluation

Annual and 54th month evaluation criteria are specifically defined in Attachment J-10, “Annual and 54th Month Evaluation Criteria Measures Table,” of the BFCC-QIO SOW; the criteria for evaluating each deliverable are identified in Section F (“Deliverables or Performance”) of the 11th SOW. Further, the Contracting Officer will use the Contractor Performance Assessment Reporting System (CPARS) criteria in performing evaluations: Quality, Schedule/Timeliness, Cost/Price Control, Business Relations, Management, and Small Business. Performance on the evaluation criteria defined in Attachment J-10 will be considered for assessment of the Quality sub-factor for the CPARS assessment.

Read More: https://federalregister.gov/a/2014-17625