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|2006 Annual Meeting|
Academy Scientific Meeting Features Full-Day Practice Management Sessions and Role of High Technology Medicine in the Home
The Annual Scientific Meeting of the Academy was held at the Hyatt Regency Chicago on May 4, 2006, in conjunction with the meeting of the American Geriatrics Society. On May 3, the first full-day practice management seminar was held, offering a morning session for those just beginning a house call practice and an afternoon session for those in established practices. Because both practice management sessions sold out early, two "mini” sessions were added to accommodate those unable to register for the original sessions. Due to this high demand and the popularity of practice management topics, the Academy will again host this full-day seminar next year as an add-on to our 2007 Annual Scientific Meeting in Seattle, WA.
Board President Dr. C. Gresham Bayne, pictured right, welcomed 125 attendees to the Academy’s annual meeting. Dr. Bayne also served as a panelist, along with several other Board members, including Dr. Joe Ramsdell, Dr. Peter Boling, and Jean Yudin, MSN, RN, CS.
Clinical Applications of Computerized Impedance Cardiography
The day began with a presentation by Dr. James Buell, from the Cardiology Clinic of San Antonio, on the usefulness of the impedance cardiogram during which high frequency (80-100khz), low energy alternating current is passed through the thorax. Resistance to the alternating current is known as electrical impedance, and the change in electrical impedance can be displayed as a waveform. Dr. Buell first became interested in impedance cardiography in the 1970s when the role between emotional stress and cardiac disease was being publicized. Following an in-depth explanation of the biophysics involved in impedance cardiography, Dr. Buell highlighted several clinical applications for its use, including hypertension, orthostatic hypotension, LV preload, afterload (TSR), pacemaker setting and evaluation, and contractility. Assessing a patient’s hemodynamics non-invasively in this manner is particularly helpful when managing abnormal hemodynamic states. He ended his presentation with a picture of a cardiac impedance measuring device which hopefully will be ready for use by the home care physician and other physicians.
Application of the Community Acquired Pneumonia Guidelines in the Home-Based Patient
In a well-received presentation, Dr. Joe Ramsdell, Director of the University of California at San Diego Clinical Trials Center and President-Elect of the Academy, presented the AAHCP/ACCP Clinical Position Statement regarding the management of community acquired pneumonia (CAP) in the home, published in the Academy Newsletter and in Chest 2005, 127(5):1752-63. He began by reviewing elements of in-home treatment of CAP, including initial patient evaluation and diagnosis in the home environment; determining site of care; elements of an in-home management plan; patient/caregiver commitment to the care plan; goals for the nurses providing interim home care; and monitoring, assessment of risk of recurrence, preventive measures, and closure. He stressed that the initial evaluation should be performed in person by a physician, NP or PA, or by a visiting home nurse in contact with a qualified provider at the time of the evaluation. Chest X-ray is recommended, along with a history and physical examination, oxygen saturation or arterial blood gas level, CBC, chemistry panel, and risk stratification during the initial evaluation of patients with suspected CAP. Elements to consider when developing a home treatment plan include in-home capability to carry out the plan, caregiver education, smoking cessation, nutrition, maintenance of functional capacity, treatment of ancillary symptoms and coexisting illnesses, and professional follow-up. Dr. Ramsdell went on to discuss how effective macrolides have revolutionized the ability to treat CAP and pointed out several modifying factors that increase the risk of infection with specific pathogens. He further discussed the need for effective follow-up on the part of the provider—i.e., making sure home medical equipment (HME) is delivered as directed and that the patient understands its use. While four to eight hours is considered an appropriate time line for the principal elements of in-home management, such as the first dose of antibiotic or oxygenation, four hours is the optimal window.
Also covered were elements of a contract for participation in home care, identifying responsibilities of both provider and patient/caregiver to ensure that the patient’s needs are met. Every patient should have a closure visit during which risk of recurrence is evaluated, preventive measures are discussed, and functional status is assessed. Dr. Ramsdell’s presentation stimulated many questions from the audience and demonstrated the importance of a good relationship with the HME provider.
Personal Visiting Physician Delivery System: The Model and the Three-Year CMS Demonstration Project of Care Level Management
Pictured left, Dr. Joseph W. Spooner, Senior Vice President of Outcomes, Academic and Government Relations for Care Level Management (CLM), provided an overview of CLM’s Care Management for High-Cost Beneficiaries (CMHCB) Demonstration, awarded in July 2005. Dr. Spooner began by discussing the background of CLM, co-founded by Dr. Henri Becker, Chief Patient Advocate. Like house call providers who are in private practice, CLM views their patient population as those having multiple chronic conditions. Their physicians are trained in "bi-directional access”-- to be proactive in seeking access to their patients. Cultivating a home-centric view of care, CLM’s physicians collaborate with primary care physicians and emergency rooms. After Section 721 of the Medicare Modernization Act provided for the Chronic Care Initiative Program (CCIP) now known as Medicare Health Support, it became clear that CCIP was not designed to demonstrate the value of physician-based methods of managing chronic illness in the elderly. In October 2004, CMS released a solicitation for CMHCB to develop and test multiple strategies to improve coordination of Medicare services for high-cost fee for service beneficiaries. CLM was one of six organizations awarded the demonstration and began enrolling beneficiaries in October 2005. Their intervention group includes 15,000 high-cost beneficiaries in California, Texas, and Florida. There is a control group of approximately 6,000. CLM’s physicians are employed full-time, most of whom come from fellowships and residencies. They have experienced an overall staff increase of 350%. Their geographic reach, particularly in California, has increased dramatically as a result of this demonstration. Joining Dr. Spooner were Drs. Tamika Henry and Rengena Chan-Ting, two field physicians, who were pleased to answer many questions from our audience.
House call providers know well the value of providing home-centric care. By successfully completing this study, Care Level Management hopes to generate necessary discussions in government, as they collect data to prove the success of the home versus office model.
Panel Discussions on Case Presentations
The well-received post-luncheon session featured a panel chaired by President-Elect Dr. Joe Ramsdell in which the use (or non-use) of technology was discussed in the care of a case study patient, an 88-year-old bed bound patient who awoke feeling short of breath and feeling "horrible” with cough, chest pain, and a history of CHF and other diseases. Inspector Gadget (Dr. Gresham Bayne) would have diagnosed and treated the patient with all available miniaturized equipment—iStat, ekg, and much more. Detective Miss Marple (Jean Yudin, NP) and M. Piorot (Dr. Peter Boling) took different approaches. Miss Marple would have taken a low tech approach, but made a house call, and assessed and given the patient a start on an antibiotic. M. Piorot would not have wasted his time on the house call, but rather have sent in Visiting Nurses. If a house call was made, there was general agreement that a glucometer, oxymeter, and urinalysis kit were needed for this patient. The pros and cons of using higher caliber equipment was discussed along with its financial feasibility. The second issue was who does what as between MDs and NPs and PAs. Again there was agreement that it depends on the situation, and the skill sets and needs of the patients, and that there is no one pattern. Said Dr. Ramsdell in summary: "Medicine is an art that uses science.” There are many ways to accomplish patient care objectives that represent your judgment on the use of technology, the resources available, and your trust in the information from others, particularly nursing staff. In the comment session, the opportunity for research on patterns that would produce the best outcomes was stressed by one of the audience members
Practice Management Sessions
The sold-out practice management sessions began with Dr. Kevin Jackson’s presentation on Beginning a House Call Practice: Issues in Starting a Practice and Choosing an Electronic Medical Record. In Dr. Jackson’s practice, Geriatric Solutions, about 12 patients are seen daily by a physician (8.5 by NPs), and their revenue has been helped significantly by the increase in domiciliary care rates. Most of their patients are "home-limited,” meaning they need the assistance of another person to leave the home, rather than being simply "homebound.” Dr. Jackson cited the joys of a paperless practice including availability of the patient’s record anywhere and ease of communication with other physicians. Providers should take into consideration the size of their practices when selecting an EMR. Dr. Jackson described an integrated system that handles scheduling, billing, and reporting. He discussed basic start-up equipment for those beginning a practice, and stressed the need for good IT support and proper documentation of medical necessity in patients’ progress notes. He went on to cover billing issues such as in-house versus an outside billing service, patient insurance verification, and the dual problems of billing too little or too much. Possible avenues for patient recruitment include word-of-mouth, discharge planners, HHAs, senior centers, churches, news articles, and even the yellow pages. While NPs and PAs are recruited fairly easily for Geriatric Solutions, physicians can be more challenging to hire due to the attractive higher earning potential of hospitalists. Other topics covered during the beginners session included malpractice issues, ancillary services such as labs and EKG, contracting with Medicare and other insurers, and where to find resources. In competitive areas, some start-up practices turn to nursing homes or home health agencies to find patients.
Dr. C. Gresham Bayne began the afternoon session with a greatly appreciated and much needed presentation on Advanced Billing Issues. He pointed out that providers should use caution in using the prolongation code, citing that while lucrative, it is often targeted because of overuse. Dr. Bayne gave specific examples of how his practice, The Call Doctor Medical Group, bills for services such as blood gases and medications. He further discussed problems experienced by both CMS carriers and house call physicians, respectively. CMS carrier issues include the rarity of seeing E/M fees that are not upcoded, coupled with the problem of only short training periods for most billing intake personnel and a short duration of employment for the average in-house reviewer. House call physicians in turn face being compared to office-based primary care physicians and being seen as "guilty until proven innocent” when it comes to coding. Dr. Bayne then shared secrets to help house call physicians with challenges such as coding and managing the audit process.
Dr. Bayne’s tips are contained in his essential Standards of Conduct. .
Dr. Michael Gregory, the head of a large multi-state hosptialist-provider company and former home care physician, discussed the hot topic of payor contracting. Among his key points of advice: 1) know what your health plans want; 2) be prepared to discuss your practice with metrics such as bed days per thousand that your practice can deliver; 3) try to capture prospective agreements, gain-sharing, and escape from legal liability that should not be yours.
The final talk was on the future of home care practice. Dr. Kevin Jackson discussed the coming of a unifying source with collaboration among providers, hospices, home health agencies, DME and others. Dr. Gregory predicted the growth of groups able to engage in effective payor contracting, metrics, control of practice patterns, and the ability to calculate how much money one saves. Past-President Dr. Edward Ratner emphasized what to do now including working with home care agencies on pay for performance, and with infusion providers. Dr. Bayne emphasized the work of the Academy toward a new Medicare home medical care benefit in which the providers would get back part of the savings to the system. Dr. Jackson mentioned the use of palliative care benefits between hospice and home health.