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Journal features Commonwealth Medicine physician leader
By Jennifer Rosinski
UMass Medical School Communications
June 05, 2014
The care coordination of an AIDS patient and his HIV-positive wife managed by UMass Medical School’s Judith Steinberg, MD, MPH, is a textbook example of success using the patient-centered medical home (PCMH) model, according to a cover story in the most recent issue of Medical Economics.
Dr. Steinberg (at right), clinical associate professor of medicine and deputy chief medical officer for UMass Medical School’s Commonwealth Medicine division, said that it was critical to have a behavioral health specialist immediately begin counseling the couple following their diagnosis.
That coordination would not have existed if Steinberg’s practice was not a medical home, one of 44 participants in the multi-payer Massachusetts Patient-Centered Medical Home Initiative (MA-PCMHI) sponsored by the Massachusetts Office of Health and Human Services.
“When I describe the patient-centered medical home to practices, providers, or to anyone—all of us are patients at one point or another—I like to say it’s really the way we, as patients, would like to see our care delivered,” Steinberg told Medical Economics.
“It makes such perfect sense that our care is focused on us as an entire individual, not as individual diseases or organ systems. That our care is well-coordinated and communicated across many settings and there’s an attention to quality and we are all partners in our care.”
The article, “Patient-centered medical home: Making care coordination work for your practice,” also included insight from Christine Johnson, PhD, PCMH quality improvement and transformation director at Commonwealth Medicine. She described how a physician reluctant to use care managers grew to appreciate them after they assisted in handling a complicated post-hospitalization patient. The physician said it was like “going from baggage to first class,” Johnson said.
Commonwealth Medicine is leading the development of the patient-centered medical home model and helping practices turn it into a reality. Led by Steinberg, Commonwealth Medicine has partnered with Bailit Health Purchasing LLC on MA-PCMHI. The three-year multi-payer demonstration concluded on March 31, 2014 and is in the analysis stage. Early results show 43 of 44 practices received National Committee for Quality Assurance PCMH recognition. Statistically significant improvement was shown in 11 of 22 clinical quality measures, including chronic disease management, prevention and care coordination. A complete evaluation and report is expected in the fall of 2014.
The Centers for Medicare and Medicaid Services’ claims acceptance rates approached the average for normal claims, and participants were able to test the impact of errors in claim reports during the process.
The Centers for Medicare and Medicaid Services’ initial testing of updated medical diagnosis codes that will be required at health care payers and providers next year proved to be successful, according to Niall Brennan, the acting director of CMS Offices of Enterprise Management.
The updated codes, ICD-10, replace ICD-9 to bring the U.S. up to speed with other industrialized countries and allow for more specific patient diagnoses.
After several delays, the implementation of ICD-10 will be required by Oct. 1, 2015.
All entities covered by the Health Insurance Portability and Accountability Act must implement the new codes to create consistency between the health care system in the United States and other industrialized countries.
Brennan, in a CMS blog post, said testers submitted more than 127,000 claims with ICD-10 codes to the Medicare Fee-for-service (FFS) claims systems and received electronic acknowledgments confirming their claims were accepted.
There were approximately 2,600 participating providers, suppliers, billing companies and clearinghouses during the week of testing, according to Brennan.
The largest testing group was from clearinghouses, which submit claims on behalf of health care providers, Brennan said. They submitted 50 percent of all the test claims.
In the U.S., CMS accepted 89 percent of the test claims, with some regions reporting acceptance rates as high as 99 percent, according to Brennan. Medicare FFS claims system did not present any issues during the testing process. Normal claims acceptance rates average between 95 and 98 percent.
“This testing week allowed an opportunity for testers and CMS alike to learn valuable lessons about ICD-10 claims processing,” Brennan said. “In many cases, testers intentionally included such errors in their claims to make sure that the claim would be rejected, a process often referred to as negative testing.”
In the near future, the Department of Health and Human Services expects to release an interim final rule that will include a new compliance date requiring the use of ICD-10 beginning Oct. 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9- through Sept. 30, 2015.
CMS will be releasing details about plans to conduct end-to-end testing in 2015, according to Brennan.
Who is using your patient portal? What is the health
literacy of your population? Has your organization reaped the incredible
benefits of actively engaged patients? If not, the time to act is now!
Patients who have more knowledge, skill, and confidence in
managing their health, and who are more adept at navigation and using the
health care system, appear to incur lower costs.
According to the Robert Wood Johnson Foundation, people who
are actively engaged in their health care are more likely to stay healthy,
while those who lack the skills and confidence to manage their own care often
require more of it and incur up to 21
percent higher health care costs.
Utilization of patient portals is also a key exercise for
satisfying Meaningful Use (MU) requirements.
Now patients must participate in order for the EP to meet Meaningful Use Stage 2.
Consider these new measures for 2014:
More
than 5% of patients must send secure messages to their EP
More
than 5% of patients must access their health information online (via a
patient portal)
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Josh Valdez took an executive level job in April 2010
expecting to improve medical services at two Puerto Rican Medicare Advantage
health plans owned by a subsidiary of New Jersey company: Aveta Inc.
But a few months after coming on board, the former
government health official claims, he discovered that the plans — MMM
Healthcare and PMC Medicare Choice — had been cheating Medicare out of hundreds
of millions of dollars for years,according
to a whistleblower lawsuit he filed in federal court.
Valdez accuses the health plans of “rampant fraud,” alleging
they overcharged Medicare $300 million to $350 million a year from 2007 through
2010. He claims that Aveta Chief Executive Officer Richard Shinto fired him “in
retaliation for his outspoken opposition to these illegal practices.” Valdez
filed the lawsuit in Santa Ana, California, in April 2011, but it remained
under court seal until February of this year. The case is pending.
In a May 23 statement to the Center for Public Integrity,
the health plans called Valdez a “former disgruntled employee” and added that
the company “categorically denies the allegations in the former employee’s
lawsuit and is highly confident that it will prevail in the case.”
Valdez is a veteran health care executive and consultant who
headed the California regional office of the U.S. Department of Health and
Human Services from 2001 through 2003 under President George W. Bush. He also
was a health policy adviser to Republican Mitt Romney during the 2012
presidential race.
Valdez said in court papers that he served as president of
MSO of Puerto Rico, also owned by a subsidiary of Aveta, for eight months until
his dismissal in December 2010. MSO worked with local doctors to coordinate
coverage for some 230,000 elderly and disabled people then enrolled in those
two Aveta-related Medicare Advantage health plans. In a press release touting
his hire, Aveta said Valdez would enhance medical care while “effectively
managing healthcare costs.”
Aveta’s Puerto Rico health plans and MSO are now operated by
InnovaCare Health Solutions, according to the firm’s website. InnovoCare has
the same Fort Lee, N.J. office and phone number as Aveta. Several members of
the Aveta board, including founding principal investor Daniel E. Straus, have
been affiliated with both companies. Innovacare general counsel Christopher J.
Joyce declined to discuss the corporate structure.
Straus, a prominent investor in several health-care
businesses, also has worked with hedge funds and as a New York City real estate
developer. Joyce said Straus would have no comment.
The whistleblower suit is significant not only for the
magnitude of overbilling it alleges. It also raises questions about federal
oversight of billing practices by health plans that contract with the
government to cover nearly 16 million Americans, at a cost expected to top $150
billion this year.
The federal government paid the two Puerto Rico plans a
total of between $1 billion and $1.8 billion annually from January 2007 through
December 2010, according to the suit. Up to $350 million a year was for bills
that were “improperly inflated,” according to Valdez.
Valdez argues that the health plans sought out chronically
ill patients, who command the highest Medicare payment rates, but overcharged
for them by manipulating a billing formula known as a “risk score.” Medicare
sets risk scores for all patients based on medical data submitted by the health
plans that indicates how sick patients are. Sicker patients mean higher rates.
These scores “were false or fraudulent because they were
based on diagnosis codes that were not substantiated by the medical records or
by the medical conditions of the Medicare beneficiaries served by the plans,”
the suit states.
Valdez said he was told by top executive Shinto in May 2010
that an internal audit of medical records had confirmed that two-thirds of
patient risk scores could not be supported.
According to Valdez, the audit results were discussed at
several executive-level meetings, including some at which top brass talked
about setting up a reserve fund in case federal officials should conduct their
own review and demand refunds.
At a July 2010 meeting, Penelope Kokkinides, Aveta’s chief
operating officer, allegedly said the company would be “screwed” if it was
audited by the federal Centers for Medicare and Medicaid Services, especially
if the review reached back to 2007. She said overcharges had been “particularly
egregious” that year, as the suit paraphrased her alleged remarks.
Kokkinides estimated the liability to the government was as
high as 20 percent of its total Medicare payment, or about $350 million a year,
Valdez alleges. Kokkinides would not comment on the suit.
During his tenure there, Valdez said, company officials gave
no indication they would “notify CMS of the problem or return the improperly
obtained funds to the government,” according to the suit. CMS regulations not
only require Medicare Advantage plans to attest that risk data they present for
payment are accurate but also obligate them to return any overpayments they
discover.
Still, CMS largely trusts the nation’s 700 Medicare
Advantage plans to report risk scores accurately and honestly — and conducts
only a smattering of yearly audits. There’s no indication that CMS officials
reviewed the risk scores for the two Puerto Rican plans. In its 2012 annual
financial report to insurance officials in Puerto Rico, MMM Healthcare stated
that it had not been subject to a CMS payment audit.
However, in late March of 2011, Valdez said he took his
allegations to the U.S. Attorney’s Office for the central district of
California, which has since launched an investigation. That investigation “has
not been completed,” government lawyers wrote in a January 2014 court filing.
Valdez blamed the faulty risk scores on errors in “medical
status visit” forms filled out by the plans’ doctors. The visits were done to
help identify “high risk” members and maximize payments for them. Doctors
participated in a profit sharing arrangement that paid them 50 percent to 60
percent of surplus money that came in from Medicare as a result of the annual
visits, according to the suit.
The lawsuit alleges that company officials failed to take
“corrective measures to delete or filter out” inaccurate codes, although they
knew the doctors had an incentive to inflate them.
In July 2010, executives decided to hold onto millions of
dollars in these payments to the doctors in case CMS auditors required the
company to repay money, according to the suit.
That concern didn’t dissuade company officials from
borrowing $100 million, which was used to pay a dividend to investors, “the
largest of whom was founder and Chairman Daniel E. Straus,” according to the
suit. Valdez said he objected to paying the dividend while the potential
liability to the government “remained unaddressed.”
Data can help improve care coordination and health outcomes for Medicare beneficiaries
With more than 2,000 entrepreneurs, investors, data scientists, researchers, policy experts, government employees and more in attendance, the Department of Health and Human Services (HHS) is releasing new data and launching new initiatives at the annual Health Datapalooza conference in Washington, D.C.
Today, the Centers for Medicare Medicaid Services (CMS) is releasing its first annual update to the Medicare hospital charge data, or information comparing the average amount a hospital bills for services that may be provided in connection with a similar inpatient stay or outpatient visit. CMS is also releasing a suite of other data products and tools aimed to increase transparency about Medicare payments. The data trove on CMS’s website now includes inpatient and outpatient hospital charge data for 2012, and new interactive dashboards for the CMS Chronic Conditions Data Warehouse and geographic variation data. Also today, the Food and Drug Administration (FDA) will launch a new open data initiative. And before the end of the conference, the Office of the National Coordinator for Health Information Technology (ONC) will announce the winners of two data challenges.
“The release of these data sets furthers the administration’s efforts to increase transparency and support data-driven decision making which is essential for health care transformation,” said HHS Secretary Kathleen Sebelius.
“These public data resources provide a better understanding of Medicare utilization, the burden of chronic conditions among beneficiaries and the implications for our health care system and how this varies by where beneficiaries are located,” said Bryan Sivak, HHS chief technology officer. “This information can be used to improve care coordination and health outcomes for Medicare beneficiaries nationwide, and we are looking forward to seeing what the community will do with these releases. Additionally, the openFDA initiative being launched today will for the first time enable a new generation of consumer facing and research applications to embed relevant and timely data in machine-readable, API-based formats."
2012 Inpatient and Outpatient Hospital Charge Data
The data posted today on the CMS website provide the first annual update of the hospital inpatient and outpatient data released by the agency last spring. The data include information comparing the average charges for services that may be provided in connection with the 100 most common Medicare inpatient stays at over 3,000 hospitals in all 50 states and Washington, D.C. Hospitals determine what they will charge for items and services provided to patients and these “charges” are the amount the hospital generally bills for those items or services.
With two years of data now available, researchers can begin to look at trends in hospital charges. For example, average charges for medical back problems increased nine percent from $23,000 to $25,000, but the total number of discharges decreased by nearly 7,000 from 2011 to 2012.
In April, ONC launched a challenge – the Code-a-Palooza challenge – calling on developers to create tools that will help patients use the Medicare data to make health care choices. Fifty-six innovators submitted proposals and 10 finalists are presenting their applications during Datapalooza. The winning products will be announced before the end of the conference.
Chronic Conditions Warehouse and Dashboard
CMS recently released new and updated information on chronic conditions among Medicare fee-for-service beneficiaries, including:
Geographic data summarized to national, state, county, and hospital referral regions levels for the years 2008-2012;
Data for examining disparities among specific Medicare populations, such as beneficiaries with disabilities, dual-eligible beneficiaries, and race/ethnic groups;
Data on prevalence, utilization of select Medicare services, and Medicare spending;
Interactive dashboards that provide customizable information about Medicare beneficiaries with chronic conditions at state, county, and hospital referral regions levels for 2012; and
Chartbooks and maps.
These public data resources support the HHS Initiative on Multiple Chronic Conditions by providing researchers and policymakers a better understanding of the burden of chronic conditions among beneficiaries and the implications for our health care system.
Geographic Variation Dashboard
The Geographic Variation Dashboards present Medicare fee-for-service per-capita spending at the state and county levels in interactive formats. CMS calculated the spending figures in these dashboards using standardized dollars that remove the effects of the geographic adjustments that Medicare makes for many of its payment rates. The dashboards include total standardized per capita spending, as well as standardized per capita spending by type of service. Users can select the indicator and year they want to display. Users can also compare data for a given state or county to the national average. All of the information presented in the dashboards is also available for download from the Geographic Variation Public Use File.
Research Cohort Estimate Tool
CMS also released a new tool that will help researchers and other stakeholders estimate the number of Medicare beneficiaries with certain demographic profiles or health conditions. This tool can assist a variety of stakeholders interested in specific figures on Medicare enrollment. Researchers can also use this tool to estimate the size of their proposed research cohort and the cost of requesting CMS data to support their study.
Digital Privacy Notice Challenge
ONC, with the HHS Office of Civil Rights, will be awarding the winner of the Digital Privacy Notice Challenge during the conference. The winning products will help consumers get notices of privacy practices from their health care providers or health plans directly in their personal health records or from their providers’ patient portals.
OpenFDA
The FDA’s new initiative, openFDA, is designed to facilitate easier access to large, important public health datasets collected by the agency. OpenFDA will make FDA’s publicly available data accessible in a structured, computer readable format that will make it possible for technology specialists, such as mobile application creators, web developers, data visualization artists and researchers to quickly search, query, or pull massive amounts of information on an as needed basis. The initiative is the result of extensive research to identify FDA’s publicly available datasets that are often in demand, but traditionally difficult to use. Based on this research, openFDA is beginning with a pilot program involving millions of reports of drug adverse events and medication errors submitted to the FDA from 2004 to 2013. The pilot will later be expanded to include the FDA’s databases on product recalls and product labeling.
Providers, suppliers, billing companies and clearinghouses can submit ICD-10 acknowledgement test claims anytime up to the new planned October 1, 2015 ICD-10 implementation date. However, the Centers for Medicare and Medicaid Services is advising stakeholders to delay this front-end testing until after October 6, 2014, when Medicare is scheduled to update its systems.
A May 30 announcement from Niall Brennan, acting director of the CMS Offices of Enterprise Management, recommended that submitters contact their local Medicare Administrative Contractor for additional information about ICD-10 acknowledgment testing, which will allow providers, suppliers, billing companies and clearinghouses the opportunity to determine whether CMS will be able to accept their claims with ICD-10 codes.
In March, Brennan said that CMS successfully conducted a week of ICD-10 testing for more than 127,000 claims that were submitted with ICD-10 codes to the Medicare Fee-for-service claims systems and which received electronic acknowledgements confirming that their claims were accepted. He reported that about 2,600 participating providers, suppliers, billing companies and clearinghouses participated in the test week--representing about five percent of all submitters--and that this testing did not identify any issues with the Medicare FFS claims systems.
Brennan also informed stakeholders that CMS will be conducting end-to-end ICD-10 testing in 2015. "Details about this testing will be released soon," he said. In May, CMS canceled limited end-to-end testing that had been scheduled for late July, when CMS planned to give a small sample group of providers the opportunity to participate in end-to-end testing with Medicare Administrative Contractors and the Common Electronic Data Interchange contractor.
The Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date requiring the use of ICD-10 beginning October 1, 2015. The rule will require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. Last week, CMS announced that the partial code freeze for ICD-9-CM and ICD-10 will continue through October 1, 2015.
This notice sets out a
summary of the use and burden associated with the following information
collections. More detailed information can be found in each collection’s
supporting statement and associated materials (see ADDRESSES).
CMS–10340 Collection of Encounter Data From
Medicare Advantage Organizations, Section 1876 Cost HMOS/CMPS, Section 1833
Health Care Prepayment Plans (HCPPS), and Pace Organizations
CMS–10380 Reporting Requirements for Grants to
States for Rate Review Cycle I, Cycle II, Cycle III, and Cycle IV and Effective
Rate Review Program Under the Paperwork Reduction Act (PRA) (44 U.S.C.
3501–3520), federal agencies must obtain approval from the Office of Management
and Budget (OMB) for each collection of information they conduct or sponsor.
The term ‘‘collection
of information’’ is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and
includes agency requests or requirements that members of the public submit
reports, keep records, or provide information to a third party.
Section 3506(c)(2)(A)
of the PRA requires federal agencies to publish a 60-day notice in the Federal
Register concerning each proposed collection of information, including each
proposed extension or reinstatement of an existing collection of information,
before submitting the collection to OMB for approval. To comply with this requirement,
CMS is publishing this notice.
Information Collection
1. Type of Information Collection
Request:
Extension of a
currently approved collection; Title of Information Collection: Collection of
Encounter Data from Medicare Advantage Organizations, Section 1876 Cost HMOS/CMPS,
Section 1833 Health Care Prepayment Plans (HCPPS), and Pace Organizations;
Use:
CMS collects encounter
data or data on each item or service delivered to enrollees of Medicare
Advantage (MA) plans offered by MA organizations. MA organizations currently
obtain this data from providers. CMS collects this information using standard
transaction forms and code sets.
CMS will use the data for determining risk
adjustment factors for payment, updating the risk adjustment model, calculating
Medicare DSH percentages, Medicare coverage purposes, and quality review and improvement
activities.
The data is also used to verify the accuracy and
validity of the costs claimed on cost reports.
For PACE organizations, encounter data would serve
the same purpose it does related to the MA program and would be submitted in a
similar manner.
Form Number: CMS–10340
(OCN: 0938– 1152); Frequency: Weekly; Affected Public: Private sector (business
or other for-profits); Number of Respondents: 683; Total Annual Responses: 516,493,635;
Total Annual Hours: 34,433 (For policy questions regarding this collection
contact Michael Massimini at 410–786–1566).
2. Type of Information Collection
Request: Revision of a
currently approved collection; Title of Information Collection: Reporting Requirements
for Grants to States for Rate Review Cycle I, Cycle II, Cycle III, and Cycle IV
and Effective Rate Review Program; Use: Under the section 1003 of the Affordable
Care Act (ACA) (section 2794 of the Public Health Service Act), the Secretary,
in conjunction with the states and territories, is required to establish a
process for the annual review, beginning with the 2010 plan year, of
unreasonable increases in premiums for health insurance coverage.
Section 2794(c)
requires the Secretary to establish the Rate Review Grant Program to assist
states to implement this provision. In
addition, section 2794(c) requires the Rate Review Grant Program to assist
states in the establishment and enhancement of ‘‘Data Centers’’ that collect,
analyze, and disseminate health care pricing data to the public.
Concurrent with this
information collection request, HHS released Cycle IV of the Rate Review
Grants, ‘‘Grants to States to Support
Health Insurance Rate Review and Increase Transparency in the Pricing of Medical
Services.’’
The purpose of Cycle IV of the Rate Review Grant Program is to
continue the rate review successes of Cycles I, II, and III, as well as to
provide greater support to Data Centers, thereby enhancing medical pricing
transparency. States and territories that apply for funds are required to
complete the grant application.
States and territories that are awarded funds
under this funding opportunity are required to provide the Secretary with rate
review data, four quarterly reports, and one annual report per year until the
end of the grant period detailing the state’s progression towards a more
comprehensive and effective rate review process. A final report is due at the
end of the grant period.
This information
collection is required for effective monitoring of grantees and to fulfill
statutory requirements under section 2794(b)(1)(A) of the ACA that requires grantees,
as a condition of receiving a grant authorized under section 2794(c), to report
to the Secretary information about premium increases.
On May 23, 2011, CMS
published a final rule with comment period (76 FR 29964) to implement the
annual review of unreasonable increases in premiums for health insurance
coverage called for by section 2794. Under the regulation, if CMS determines
that a state has an Effective Rate Review Program in a given market, using the
criteria set forth in the rule, CMS will adopt that state’s determinations
regarding whether rate increases in that market are unreasonable, provided that
the state reports its final determinations to CMS and explains the bases of its
determinations.
The final
rule titled ‘‘Patient Protection and Affordable Care Act; Health Insurance
Market Rules; Rate Review’’ (78 FR 13406, February 27, 2013) amends the standards
under the Effective Rate Review Program. Currently, CMS relies on publicly available information and annual
calls with individual states to obtain the information needed to evaluate
whether a state has begun to or continues to satisfy the Effective Rate Review Program
criteria. CMS is proposing to instead
collect the information in writing from all states that would like to request
effective status.
Form Number: CMS–10380
(OCN: 0938–1121); Frequency: Annually and On occasion; Affected Public: Public
Sector and State and Territory Governments; Number of Respondents: 50; Total
Annual Responses: 553; Total Annual Hours: 20,951. (For policy questions
regarding this collection contact Susie Lorden at 301–492–4162.)
Dated: May 28, 2014.
Martique Jones, Deputy Director,
Regulations Development Group, Office of Strategic Operations and Regulatory
Affairs.
MORE than 7,650 NHS Wales staff have completed the first level of the national learning programme Improving Quality Together, according to new figures.
The scheme, which provides staff, contractors, managers and board members with skills that will help them improve the care delivered to patients, has been completed at the first level by 7,654 people in the past 15 months.
There are three levels to the programme, launched in March 2013, and it is led by 1,000 Lives Improvement, which is part of Public Health Wales.
Staff complete the bronze level through a series of online modules, with the silver level providing an opportunity to develop and implement improvement projects. The gold level is establishing a network of improvement coaches and there is additional training for board members.
Dr Alan Willson, director of 1,000 Lives Improvement, said: "Improving Quality Together is providing staff with the knowledge and expertise to continue improving our services, so that they are the safest and most efficient they can be.
"We are already seeing the benefits of staff speaking a common language of improvement as they work towards the same goals - improved patient experience and outcomes."
"We are delighted that so many NHS Wales staff have completed at least the bronze level of Improving Quality Together and are looking forward to even more colleagues signing up to the learning programme."
In Aneurin Bevan University Health Board, cleaner operating theatres have lead to safer care under the scheme.
Nurse Helen Dinham used the skills she learnt to reduce surgical site infections, by improving the standard practice of cleaning in orthopaedic theatres in the health board.
Improving Quality Together helped her team address the obstacles that were preventing the correct level of cleaning taking place, such as standardising equipment and amended policies.
The outcome of the project was 100% compliance with the cleaning requirements, meaning infection risks were reduced and patients would recover more quickly.
She said: "Reaching our target was very good for staff morale and has reassured patients that the quality of care and the standard of cleanliness in orthopaedic theatres is excellent."
In ABMU Health Board, they looked at improving patient flow and communication on hospital wards.
Reducing delays in a patient's journey and improving communication on hospital wards are just two of the key benefits gained from Jo Rowland's silver project in the Princess of Wales Hospital, Bridgend.
The assistant head of physiotherapy used her Improving Quality Together training to implement daily ward rounds to discuss each patient and find out the next step needed.
Reporting back findings on a daily basis has increased efficiency and resulted in reduced lengths of stay in hospital and improved patient flow through the wards.
It has also provided a consistent approach, which has improved communication between staff, patients and their families.
Meanwhile, Cardiff and Vale University Health Board has improved access to dental services for patients in prison Head of primary care service delivery Rhian Blake used her silver training to improve access to dental services for patients at Her Majesty's Prison in Cardiff. In the past 18 months the profile of the prison population had changed significantly, with more individuals on remand and shorter sentences.
As a result, many patients had incomplete dental treatment, or didn't receive the required treatment in a timely fashion.
Rhian used the programme's methodology to analyse the problem and find solutions, which included the immediate allocation of appointments when needed, and a quicker triage process. The changes led to a reduction in complaints and fewer missed appointments.
Palliative care teams help help terminally ill patients live as good a life as possible until the end.
Rebecca Roberts had never heard of palliative care two years ago when her boyfriend, "Papa" Joe Funes, begain suffering multiple organ failure. But by the end of Papa Joe's life, she was devoted to the medical process.
Dr. Matthew Katics, director of palliative medicine services at Salinas Valley Memorial Hospital, defines palliative care as a specialty that provides patients total care while they are enduring an often fatal illness. By definition, palliative care can treat non-terminal patients, but the lion's share of care is done during the patients final weeks or months of life.
"Total care cuts to the heart of palliative care," Katics said. "We move away from treating a disease and toward treating a person. Palliative care is not synonymous with hospice."
Palliative care is often confused with hospice, but they are not the same. Hospice allows terminally ill patients to return home to spend their final days in familiar surroundings and made comfortable. The goal of palliative medicine is to improve the quality of life for the patient, terminal or not. Palliative care is a multi-pronged approach, using physicians, psychosocial workers to treat mood, nurses skilled in this type of care, and members of the clergy and other spiritual leaders.
"Palliative care is a medical specialty directed at those with life-limiting chronic disease," said Dr. John Hausdorff, medical director of the palliative care team at the Community Hospital of the Monterey Peninsula. "It focuses on providing relief from the symptoms, pain, and distress of illness, whatever the diagnosis."
Katics used an example of a patient entering the hospital for a hip replacement. The patient has suffered excruciating pain for many years and is now addicted to opiates. After the surgery, a palliative care team – the doctor, nurses and a psychosocial care worker – will help the patient explore alternative treatments for long-term pain management to get them to the point of functional recovery.
Or a patient could come into the hospital with difficulty breathing and suffering from chronic obstructive pulmonary diseases. The emergency room stabalized the patient's breathing, but what about when he goes home? Then what? The palliative care team will review his medicines, talk with him, and even evaluate him for any mood disorders. COPD is a fatal disease that can take years to kill.
"We want you living as good as you can, feeling as good as you can, for the time you have," Katics said.
Papa Joe begins a journey
It was the summer of 1994 when Roberts received a call informing her that her boyfriend was en route in an ambulance from King City to Salinas with a massive head injury. When she arrived at SVMH, she didn't recognize him, she said. His head was massively swollen and his skin was the color of slate.
Thursday afternoon Roberts and Katics sat under the shade in a patio at the hospital, catching each other up on their lives since Papa Joe died two years ago.
That 1994 summer, Papa Joe was found on the ground at the base of a grandstand in a park in King City. One side of his head was horribly malformed from an impact – from what, exactly, was never established. It could have been the result of an altercation with what Roberts calls "Joe's acquaintances." But a neurosurgeon told Roberts that the pattern and severity of the injury was not consistent with a blow from a club or cane. The damage was far greater.
Nearly 20 years later, a good many in King City harbor far more nefarious believes – that Papa Joe might have been beaten, then climbed to the top of the stands to lick his wounds. It was there that Joe, who had minor run-ins with King City Police before, was tossed off the grandstand where he sustained the violent injuries to his head. Other, less dramatic, scenarios feed the rumor mill in the farming and ranching community in the deep southern part of Monterey County.
Initially no police report was written up, but when SVMH required one to proceed with treatment, Roberts said the response was, "You mean that son of a bitch is still alive?" A broadly worded report was written, where it remains an open case because it is now a homicide.
Meanwhile Joe remained in a coma, and doctors were telling Roberts he didn't have a chance of survival. But with Roberts fighting every effort to disconnect him from life support, Papa Joe continued to live. First minor moves, a hand squeeze, then one day he opened his eyes and tried to talk. A doctor came in removed the breathing tube and Joe talked with a raspy, tired voice. He also answered all the doctor's questions, who then determined he was alert and oriented. He went home, extremely disabled.
A fall re-injured the original head trauma, and the result was stroke-like symptoms. Back in the hospital he began to retain water and his kidneys began to fail. Joe was now being treated by the palliative care team and they stabilized him. That was when Roberts met Katics for the first time. Her experience with doctors was not good. In the early days she had face-to-face confrontations with a doctor who was determined to unplug his live support. Katics and his team were different.
"He's one of a kind," Roberts said. "After all those years of posturing and the sighs aimed at me, all my distrust melted away."
Katics' approach to Papa Joe
Often the gravely ill patient is the only one doctors must contend with. When families are in the mix, each member sometimes has wildly different views of the best care for their sick loved one. The facts that all must keep in mind as they approach their last days is that medical science is allowing people to live longer, but not better. Diseases that would have killed a generation ago can be contained for years. But what does the patient want?
"Is giving them more days better or just prolonging the suffering?" Katics asked. "People are complex and they have a desire to know."
When there is family involved, there are emotions and confusion. There are many paths a patient can elect to follow, but Katics and his team ensure none of the decisions are made in ignorance.
"Each path is OK as long as you are doing it with your eyes open," he said. "Part of my job is to get to clarity for the patient and family."
The sooner a patient teams with a palliative care unit the better the outcome, whatever that may be. The ideal time would be at the point of diagnosis of a serious disease, said Christine Short, director of Nursing Support Services and coordinator of the palliative medicine service at CHOMP.
"If palliative care starts at an early stage, such as upon a serious diagnosis, a thoughtful conversation can occur with the patient about what matters most and is most important to them," she said. "Our priority is to respect patients' wishes and interests, and to make sure they understand their situation well enough to make informed decisions."
In one case at CHOMP, a woman with long-term gastrointestinal issues had several surgeries and had difficulty managing ongoing pain and nausea. After dealing with the immediate medical issues, the palliative care team met with her and her husband.
The team asked her to think about the future – what interventions she wanted and who would speak for her if she couldn't. A social worker – part of any palliative care team – stepped in and helped the couple with an advanced healthcare directive, which provides instructions to medical teams for future care. Both SVMH and CHOMP palliative care teams strongly advise everyone to pick up an advanced directive from their primary physician, fill it out, have their doctor keep a copy, have the hospital file another copy, and keep a copy for you.
"Giving the couple the advanced directive prompted them to talk with their friends to arrive at clear directions to any future physician caring for them," CHOMP's Hausdorff said.
Papa Joe's goodbye
When Roberts decided there was nothing more doctors could do for her love, she made the decision to take him home. But she was surprised that there was one more thing Katics could do for them. Joe's breathing was distressed and he needed a breathing bag in the ambulance on the way home. But paramedics weren't allowed to use an ambu bag, as they are called, per ambulance company policy.
"So Dr. Katics jumped in the back of the ambulance and bagged Joe all the way home," Roberts said. "And then at home, he helped me set up all the supplies I would need to care for Joe."
His two daughters, his mother, and his grand-kids sat around his bed. He looked at Roberts with raised eyebrows in that "I'm sorry" expression, closed his eyes and died.
On Thursday, Roberts and Katics sat on the patio, at times holding hands as they talked about Joe.
Fighting back tears, Roberts told Katics that she loved Papa Joe. "We were talking and had a whole plan to move away, start a new life, and then two days later, boom, that happened."
Katics took that in for a moment, squeezed her hand and softly told her: You advocated for him, and you fought the fight that was right for him."
With mounting evidence that cancer research and biomedical discovery are slowing even as a 45% increase in cancer cases is projected by 2030, the National Patient Advocate Foundation (NPAF) – a national non-profit organization providing the patient’s voice in improving access to quality cancer care – just released a blueprint to accelerate the delivery of promising new treatments to patients and launched a new grassroots movement called Project Innovation to drive action.
Issued as a call to action, the new white paper – Securing the Future of Innovation in Cancer Treatment – is the result of consultation with biomedical researchers, medical innovators, patient advocates, clinicians and policymakers and offers a roadmap for addressing the pervasive obstacles slowing the pace of cancer discovery. Among the barriers cited are a nearly 20% drop in government-funded basic research since 2010 and a steady decline in venture capital investment in biotechnology since 2007.
Also impeding progress are logistical, bureaucratic, institutional and regulatory obstacles that add years to scientific discovery and drug development, such as added steps and inefficiencies in the clinical trials process, duplicative and conflicting standards, auditing mandates, increasing regulatory requirements and delays in review decisions. As a result, it takes nine or more years from discovery to approval for a new cancer therapy compared to an average time of two years for HIV drugs. Further, because drug development is an uncertain process, a 2010 Tufts University study puts the cost of developing one innovative cancer drug at upwards of $1 billion.
“This report represents a wakeup call for all Americans and is intended to spark a national movement to make cancer innovation a national priority,” said Nancy Davenport-Ennis, NPAF’s founder and chairman. “Cancer kills 1,600 Americans every day and this number will only increase in the years ahead unless we commit as a nation to hasten the pace of medical discovery. It is time to put cancer innovation on the national agenda and press for solutions that will save lives instead of continuing a one-sided conversation on the cost of treatment.”
Project Innovation to spearhead a national dialogue on cancer innovation
To turn these findings into practice, NPAF will spearhead Project Innovation, a social activation effort to involve patients, their family members and local citizens in speaking out about the importance of accelerating cancer innovation. Utilizing the online hub – www.projectinnovation.org – digital advertising and multiple information channels, Project Innovation will tap the energy and ideas of cancer patients, advocates, healthcare professionals, biomedical researchers, medical innovators, payers, policymakers and 21st century thinkers on ways to move cancer discovery forward. Plans call for hosting regional town halls, workshops and advocacy forums across the country; scheduling meetings with federal and state legislators and regulators; and arming interested citizens and patient advocate volunteers nationwide to advocate for cancer innovation in their communities.
Project Innovation is a collaboration of leaders from national cancer advocacy organizations, providers, biomedical research institutions, the business community and industry to put cancer innovation on the policy agenda.
Three pillars of innovation
Through Project Innovation, NPAF’s agenda-setting report will be distributed widely to patient advocates, healthcare professionals, biomedical researchers, medical innovators, payers, and policymakers with the goal of elevating cancer innovation as a national priority and advancing policy solutions addressing three pillars of innovation. Specifically, NPAF’s action agenda calls for action in the following areas:
Expand the science of innovation by reducing logistical obstacles
Improve the value of innovation by bolstering funding opportunities
Enhance the delivery of innovation through improved communication and coordination between providers and patients
