Advanced Primary Care Flashcards
(47 cards)
Complex Chronic Illness Models
The Why..
- US ______ diseases account for 70% of all deaths
- US 48 million Americans report a (1) related to a chronic disease
- 2030 Age 65 >6/10 will be managing more than ___ chronic disease
- We are preparing for the so-called “gray ______:” by 2060, one quarter of Americans will be __ or older, up from 15 percent in 2015
- Many more providers will need to be able to manage advanced illness in _______ based settings
- US Chronic diseases account for 70% of all deaths
- US 48 million Americans report a disability related to a chronic disease
- 2030 Age 65 >6/10 will be managing more than one chronic disease
- We are preparing for the so-called “gray tsunami:” by 2060, one quarter of Americans will be 65 or older, up from 15 percent in 2015
- Many more providers will need to be able to manage advanced illness in community based settings
Advanced Primary Care
- Advanced primary care, or APC, is a practice model that incentivizes q____ and v____
- This comprehensive, coordinated approach to patient care focuses on pr____ and improved disease management
- It also supports superior performance on q_____ measures, rather than volume of services delivered, with enhanced payment
- Primary care is essential for patients with chronic diseases that progress over time, to prevent them from having to seek care in ____ acuity care settings
- Advanced primary care, or APC, is a practice model that incentivizes quality and value
- This comprehensive, coordinated approach to patient care focuses on prevention and improved disease management
- It also supports superior performance on quality measures, rather than volume of services delivered, with enhanced payment
- Primary care is essential for patients with chronic diseases that progress over time, to prevent them from having to seek care in higher acuity care settings
Practices Have the Freedom to Innovate While Implementing Core Functions of Comprehensive Primary Care
- Primary Care Function (PCF) that ensures Access and Continuity?
- PCF that ensures care management?
- PCF that ensures comprehensiveness and coordination? (2)
- PCF that ensures patient and caregiver engagement?
- PCF that ensures planned care and population health?
Participants Achieve Model Aims Through Innovations in Their Care Delivery
- Acc____ and C______
- Care M________
- Com_______ and Coo_______
- Patient and Caregiver En_______
- Pl_____ Care and Pop_____ Health
- We are not care coordinators (RNs)- we are independent providers
The PCF Payment Model Option Emphasizes Flexibility and Accountability
The High Need Population Payment Model Option Increases Seriously Ill Populations’ Access to Primary Care
- PCF incorporates the following unique aspects for practices electing to serve seriously ill populations to increase _____ to high-quality advanced primary care
Eligibility and Beneficiary Attribution
- Practices demonstrating relevant capabilities can opt in to be assigned (1) patients or beneficiaries who lack a primary care practitioner or care coordination
- Medicare enrolled clinicians who provide (1) or (1) care can partner with participating practitioners
- PCF incorporates the following unique aspects for practices electing to serve seriously ill populations to increase access to high-quality advanced primary care
Eligibility and Beneficiary Attribution
- Practices demonstrating relevant capabilities can opt in to be assigned SIP patients or beneficiaries who lack a primary care practitioner or care coordination
- Medicare enrolled clinicians who provide hospice or palliative care can partner with participating practitioners
Practices Participating in the High Need Population Model Option Must Meet the Following Eligibility Requirements
- Include practitioners serving seriously ill populations (MD, DO, CNS, NP, PA) in good standing with (1)
- Meet basic com______ to successfully manage com____ patients and demonstrate relevant clinical capabilities (e.g., interdisciplinary teams, comprehensive care, person-centered care, family and caregiver engagement, 24/7 access to a practitioner or nurse call line)
- Have a n_______ of providers in the community to meet patients’ long term care needs for those only participating in the SIP option
- Use 2015 Edition Certified ______ Health Record T_______ (CEHRT), support data ex______ with other providers and health systems via Application Programming Interface (API), and, if available, connect to their regional health information exchange (HIE)
NYS
- New York State Department of Health (NYSDOH), in collaboration with the National Committee for Quality Assurance (NCQA) launched an innovative model for primary care transformation known as the (1) (NYS PCMH).
- The statewide innovative advanced primary care approach is characterized by a systemic focus on high ______ care, po______ health and integrated b______ health
- New York State Department of Health (NYSDOH), in collaboration with the National Committee for Quality Assurance (NCQA) launched an innovative model for primary care transformation known as the New York State Patient Centered Medical Home (NYS PCMH).
- The statewide innovative advanced primary care approach is characterized by a systemic focus on high quality care, population health and integrated behavioral health
PCMH-EHR/Metrics and RN Coordinators
Some key objectives of the transition to a PCMH included:
- Improved key metrics such as compliance with recommended preventive sc______
- Controlled blood _____, as evidenced by reported (1) levels in patients with diabetes
- Blood ______ within guidelines for patients with hypertension
- A decrease in (1) visits and ___-day hospital readmission rates
- A decline in r______ to specialty providers, and
- Increased use of _______ prescriptions when appropriate
- Some key objectives of the transition to a PCMH included:
- Improved key metrics such as compliance with recommended preventive screening
- Controlled blood sugar, as evidenced by reported glycated hemoglobin levels in patients with diabetes
- Blood pressure within guidelines for patients with hypertension
- A decrease in emergency department (ED) visits and 30-day hospital readmission rates
- A decline in referrals to specialty providers, and
- Increased use of generic prescriptions when appropriate
Extended Stay Clinic
- Remote clinics to treat patients for more extended periods, including over_____ stays
- Seriously or critically ill or injured patients who, due to adverse weather conditions or other reasons, could not be transferred to acute care hospitals, or patients who needed mo______ and observation for a limited period of time
- C___-models
- Remote clinics to treat patients for more extended periods, including overnight stays
- Seriously or critically ill or injured patients who, due to adverse weather conditions or other reasons, could not be transferred to acute care hospitals, or patients who needed monitoring and observation for a limited period of time
- CMS-models
LTACHs
=
- Pr_____ LTACHs
- Specific patient populations and types of conditions for which having care in a more intensive setting can improve outcomes for patients
Long Term Acute Care Hospitals
- Progressive LTACHs
- Specific patient populations and types of conditions for which having care in a more intensive setting can improve outcomes for patients
- For pts who don’t need level of care of a hospital but cannot be managed at home, ie for those who need IV abx, high flow oxygen, intense rehab etc.
Inpatient Rehab Facilities (IRF)
=
- Patients who are admitted must be able to tolerate _____ hours of intense rehabilitation services per day
- (4) IRF’s in NYC
Freestanding rehabilitation hospitals and rehabilitation units in acute care hospitals
- Patients who are admitted must be able to tolerate three hours of intense rehabilitation services per day
- Rusk
- Burke
- Helen Hayes
- Kessler
Advanced Illness Management (AIM)
- SUTTER HEALTH
- 2700 patients followed a day
- Conditions include _____ failure, c______, C____, end stage _____ disease, end stage _____ disease
- Sutter Health’s Advanced Illness Management program has produced annual savings of $8,000 to $9,000 per patient
- T______ RN
- RN H_____ visits
- S_____ Work
- NP/MD-____ visits
- SUTTER HEALTH
- 2700 patients followed a day
- Conditions include heart failure, cancer, COPD, end stage renal disease, end stage neural disease
- Sutter Health’s Advanced Illness Management program has produced annual savings of $8,000 to $9,000 per patient
- Telephonic RN
- RN Home visits
- Social Work
- NP/MD-home visits
Post Acute Care
- Post acute care (PAC) includes re______ or p_____ services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital
- Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing ____patient therapy, or care provided at h____
- Examples =
- Post acute care (PAC) includes rehabilitation or palliative services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital
- Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing outpatient therapy, or care provided at home
- Examples
- Primary Care Clinics
- Post-discharge clinics
- Post Intensive Care Clinics (PICS)
- AAFP Article/Review
- Chronic-care/high risk clinics
- Home Care
- Tele-health
- Nursing Homes
- Long term acute care hospitals (LTACH) can be used as substitutes for short-term acute care
PICS and PICS-F ‘
Post Intensive Care Syndrome
Focused on integrating the (1) after ICU and focuses alot on C______ to maximize f_____ outcomes
Focused on integrating the (1) after ICU and focuses alot on Cognition to maximize functional outcomes
Post Intensive Care Syndrome
Survivor
- C______ Impairments
- Ph_____ Impairments*
- M_____ Health
Family
- M_____ Health
Survivor
- Cognitive Impairments
- Physical Impairments*
- Mental Health
Family
- Mental Health
Post Covid Clinics
- Montefiore
- Any patient who has had a COVID-19+ test (PCR or IgG antibody), whether the illness was mild and treated at home or severe and required hospitalization
-
Clinic Scope: The CORE clinical referral will be for patients who have had COVID-19 infection and have:
- Questions, concerns, and/or new or r______ symptoms
- New or worsening impairments in their phy____, cog____ or em______ health after a recent hospitalization
- Montefiore
- Any patient who has had a COVID-19+ test (PCR or IgG antibody), whether the illness was mild and treated at home or severe and required hospitalization
-
Clinic Scope: The CORE clinical referral will be for patients who have had COVID-19 infeciton and have:
- Questions, concerns, and/or new or residual symptoms
- New or worsening impairments in their physical, cognitive or emotional health after a recent hospitalization
Post Covid Clinic Mount Sinai
- Treating the Whole ______, Not Just the Disease
- The Center has the resources to help you manage an____ and dep_____, P_ _ _, and other emotional issues
- Getting “back to n_____” may require physical therapy, occupational therapy, or other types of support - whether in groups or one-on-one. Whatever your needs, the Center is a compassionate, holistic source of care.
- Treating the Whole Person, Not Just the Disease
- The Center has the resources to help you manage anxiety and depression, PTSD, and other emotional issues
- Getting “back to normal” may require physical therapy, occupational therapy, or other types of support - whether in groups or one-on-one. Whatever your needs, the Center is a compassionate, holistic source of care.
Home Based Primary Care
- Home based primary care practices
- Optimize care by: fielding interdisciplinary teams, incorporating be_____ care and s_______ supports into primary care, responding rapidly to urgent and acute care needs, offering p______ care, and supporting f____ members and caregivers
- Examples (3)
- Home based primary care practices
- Optimize care by: fielding interdisciplinary teams, incorporating behavioral care and social supports into primary care, responding rapidly to urgent and acute care needs, offering palliative care, and supporting family members and caregivers
- Manhattan House Calls- NP Model Northwell-
- Mount Sinai Visitng Doctors Program
- Essen
Chronic Care Management
=
- 994__ non complex CCM is a 20 minute timed service provided by clinical staff to coordinate care across providers and support patient accountability
- 994__ complex CCM is a 60-minute timed services provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate-to high complexity medical decision making
- 994__ is each additional 30 minutes (cannot be billed with CPT code 99490)
- 994__ CCM services provided personally by a physician or other qualified HCPs for 30 minutes
Chronic care management (CCM) are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- 99490 non complex CCM is a 20 minute timed service provided by clinical staff to coordinate care across providers and support patient accountability
- 99487 complex CCM is a 60-minute timed services provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate-to high complexity medical decision making
- 99489 is each additional 30 minutes (cannot be billed with CPT code 99490)
- 99491 CCM services provided personally by a physician or other qualified HCPs for 30 minutes
Advanced Care Planning for Chronic/Advanced Illness
- Table 1. CPT Codes and Descriptors CPT Codes Billing Code Descriptors
- 99497 Advance care planning including the explanation and discussion of advance d______ such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; _____ 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
- 99498 Advance care planning including the explanation and discussion of advance d______ such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each ______ 30 minutes (List separately in addition to code for primary procedure)
- Table 1. CPT Codes and Descriptors CPT Codes Billing Code Descriptors
- 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
- 99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)
Managing Chronic Care Needs from the Community
Hospital Readmissions Reduction Program (HRRP)
The Hospital Readmissions Reduction Program (HRRP) is a Medi____ value-based purchasing program that ______ payments to hospitals with excess readmissions. The program supports the national goal of improving healthcare for Americans by linking payment to the ______ of hospital care.
Upcoming Waiver Program
- C_ _
- C_ _ _
- E_ _ _
- Pn______
- Hotspotting-recent data, s_____ determinants of health and housing
The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions. The program supports the national goal of improving healthcare for Americans by linking payment to the quality of hospital care.
Upcoming Waiver Program
- CHF
- COPD
- ESRD
- Pneumonia
- Hotspotting-recent data, social determinants of health and housing