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|2008 Annual Meeting|
ACADEMY ANNUAL MEETING IN WASHINGTON A SELL-OUT
The Academy held its Annual Scientific Meeting in Washington, DC on April 30, 2008. As in years past, the meeting was held in tandem with the American Geriatrics Society meeting and was a sell-out. This year’s meeting focused on Independence at Home and the new initiatives in chronic care management. Two awards were featured this year – The Eric Baron House Call Physician of the Year and House Call Clinician of the Year. Board members were also re-appointed and the Poster of the Year Award winner announced.
Board President, Dr. Joe Ramsdell, welcomed over 135 attendees to the Academy’s meeting and opened the day by thanking our exhibitors and sponsors. Dr. Ramsdell also presented an overview of clinical issues in Independence at Home during the afternoon session.
Independence at Home: The Future of Medicare
Board member James Pyles, Esq. was the kick-off speaker and presented an inspirational talk on Independence at Home and the future of chronic care delivery. Stated Mr. Pyles, "Though the Academy is not the largest organization, you are about to have the biggest impact on Medicare in history.” IAH is only the second new benefit in 30 years, the first being the chronic care benefit. Mr. Pyles commended Academy members on confronting the toughest issue in Medicare and turning it from a disadvantage into an advantage. He went on to explain that the new IAH model is physician-driven, provides care that patients want and produces better outcomes. If IAH passes, house call providers will have the potential to be paid well while tailoring a health treatment plan to each patient’s condition. One universal desire among patients is being able to remain independent. This model allows the provision of care where the patients want it – at home.
Mr. Pyles went on to explain that the IAH program is trained teams of health care professionals directed by qualified physicians, providing continuous care to beneficiaries in their places of residence. Any combination of qualified physicians, physician groups and providers can participate with a three-year agreement. Eligible beneficiaries must have two or more of nine chronic conditions, an inability to perform without assistance two or more ADLs and in the past twelve months, must have had non-elective inpatient hospital services, services in an ER, and extended care services, services in a rehab facility or home health services. He also reviewed the services that must be provided under IAH and the three performance specifications: patient satisfaction, good outcomes, and a minimum 5% Medicare savings. For savings generated above 5%, the provider would be able to keep 80% and Medicare would receive 20%. Sponsors of the bill have told the Academy that if the bill is to pass this year, it must be made a demonstration project. Proposed are thirteen high cost states, along with thirteen additional representative states for the three-year demonstration.
Practice Management Update: FFS & IAH Trends, Near Term Survival Strategies, Technology, Managing under IAH & related programs
Past President and Board member Dr. Kevin Jackson presented practical strategies for integrating IAH-type care into a medical practice and adapting a practice from long term care in the home to, perhaps, 24/7 coverage. He emphasized that implementing IAH is not something that can be done solo, and providers must find other providers who are good at making house calls and enjoy doing this type of practice when building their team. He described the potential crisis for primary care given anticipated Medicare cuts and increasing costs for practices. Independence at Home changes the focus of care from acute, problem-oriented care to chronic illness management. Dr. Jackson went on to discuss strategies such as partnering with HHAs, urgent care or ER groups, or adding a parallel urgent care group to an existing group. Some type of computerized records will be a must, though not necessarily an EMR. He also presented several issues to be considered when making decisions under IAH, such as specialty services, nutritional issues, ancillary testing and care coordination. Identifying strategic partners was highlighted, as was working with health plans, integrating technology and optimizing revenue.
IAH: Preparing Your Practice Using MC Advantage Experiences
Member Services Committee member Brent Feorene, MBA, presented the House Call Solutions business model to show how a house call program developed to serve a Medicare Advantage population can serve as a guide for Independence at Home. Mr. Feorene began by reviewing the fundamentals of his firm’s House Call Program (HCP) - to provide or coordinate all patient care, serve as the patient’s PCP, collaborate with hospitalists and coordinate specialty care and other services. This model uses one full-time physician and two full-time nurse practitioners, each making 8-10 patient home visits, on average, per day. The team also includes a team coordinator and social worker, with limited work space required for administrative functions. Mr. Feorene went on to describe the impact this type of model has on the health system and the Medicare Advantage Plan, including comprehensive, high-quality and appropriate care for targeted enrollees and the ability to move Medicare fee for service patients to a Medicare Advantage product. HCP also offers a network development tool that enables MCOs to offer participating hospitals the option to target specific portions of the service area, including fringe markets where increased market share or competitive positioning is desired. House Call Solutions’ clients include Summa Health System, University Hospitals/Case Medical Center and Montefiore Medical Center. Many similarities exist between IAH and the Medicare Advantage HCP, including patient population served, quality, cost and satisfaction, financial risk, psychosocial support and EMR. Mr. Feorene concluded by describing several fundamentals to consider when evaluating and preparing to offer this type of program, including scope of service, payment, financial risk, relationships to external providers and agencies and scalability.
Update on Billing, Coding and LCD Issues
Past President and Board member Dr. Peter Boling presented valuable information on the Medicare fee schedule, Local Coverage Determination (LCD) efforts in Florida, Connecticut and Wisconsin and the importance of attention to diagnosis coding in managed care. He began by giving special thanks to several Board members and staff for their efforts on the above issues as well as Independence at Home. After reviewing the fee schedule from 1997-present and explaining reasons why the fee for service model is not sustainable over the long haul, Dr. Boling summarized key LCD issues and the process of development and change. He discussed the success the Academy has had with LCDs, where in many cases, educating the carriers resulted in achieving requested changes to the LCD language. One potential area of concern to the Academy is comparison of the "equal quality and frequency” of visits as seen in other settings such as the office. Dr. Boling then discussed the importance of ICD-9 codes as we move into a SNF world, including a review of the Risk Adjusted Payment Model (RAP), which now develops an overall picture of the patient using ICD-9 codes rather than demographic data alone. Dr. Boling reminded the audience of the old adage "If it’s not documented, it didn’t happen.” Members wanting to know more about Medicare managed care coding, can contact their state MA program. If IAH is passed, the Academy plans to establish an IAH "school” to educate members on this and other issues.
Where do we go from here with IAH?
Technology: The Case for Physician Housecalls
The morning session ended with two presentations. First, Immediate Past President Dr. Gresham Bayne presented the technological issues that will arise under IAH, as well as issues that currently present a challenge. Describing paper as the enemy, Dr. Bayne encouraged members to look for a designated health service, such as a pharmacy or medical equipment company, who may be able to pay up to 85% of a house call practice’s HIT costs. He discussed the difference between data and charts, explaining that the typical house call chart contains only 4 KB of data, but when put into a full EMR document, results in 1-4 MB in his own practice - which could translate into 10MB of data for a single house call when factoring in email, Blackberry messages and scans. Dr. Bayne went on to express why our members are so important and that some supportive partners are coming on board. Tools for tomorrow include PC HUB, telemonitors that can be configured specifically to the patient and the opportunity provided by Advanced Medical Home. Dr. Bayne concluded by providing a list of resources for members seeking more information.
Relationships to Other Providers
Board Treasurer Stephen Holt, MBA, described the role of a home health agency (HHA) in IAH by citing two options. First, HHAs can become an IAH organization. Physicians are hired as employees, or an NP, PA or CNS coordinates services and provides home care services directly, i.e., the same services currently being provided as a Medicare certified HHA. The advantage to this option is that the HHA maintains a position of control. The second option involves the HHA becoming a subcontractor to an IAH organization, providing services currently provided as a Medicare certified HHA under contract to an IAH.
ANNUAL MEETING FEATURES TWO AWARDS, RE-ELECTION OF BOARD MEMBERS
President Dr. Joe Ramsdell began the Annual Meeting by thanking the following exhibitors: Janus Health, Inc., Home Physicians Management, KCI and Senior Care of Colorado. He continued with a snapshot of the many accomplishments the Academy has achieved this past year, which include the victory in our fight to increase work RVUs for home and domiciliary care visits in 2008; efforts toward introduction of Independence at Home; a membership fund drive which exceeded its goal of $50,000 and a change in two regional LCDs. He reminded Academy members of the opportunity to become involved in our committees and that all committees are recruiting for membership. A special plea was made to include as many non-Board members as possible on next year’s Annual Meeting program committee, chaired by Dr. Bruce Leff. Members were also asked to re-elect Board members whose terms were expiring.
Dr. Tom Cornwell, Chair of the awards committee, presented two Academy members with our highest honor. For the second year in a row, the awards were presented in association with the Pfizer Medical Humanities Initiative, a research and educational program committed to the study and enhancement of the patient-physician relationship in the U.S. and around the world. The Academy extended its thanks to Michael Flesher, Director of Global Medical Relations for Pfizer, who was not able to be present at the meeting.
The 2007 Eric Baron House Call Doctor of the Year was awarded to Dr. Robin Beck. Dr. Beck joined the faculty at Indiana University School of Medicine in June 1999. Just two months later, she started the House Calls for Seniors program, which is the only health system-sponsored house call program in Indiana. For the first five years of the program, she was the only physician routinely performing home visits. Under Dr. Beck’s leadership, the program has expanded to include one other physician, two nurse practitioners, two social workers, a triage nurse and patient services assistant. The house call program serves mostly a low income, inner city population. Dr. Beck also trains medical students, internal medicine residents and geriatric medicine fellows and gives lectures on house call medicine.
Dr. Beck is praised by both colleagues and patients alike, who say that she exemplifies spirit, skill, dedication and commitment to her patients and the House Calls team. She is described as an excellent doctor and very compassionate person who has the welfare of her patients at heart. Her patient satisfaction ratings are among the highest in her practice. The House Calls for Seniors program at Wishard Health Services was recently selected as the winner of the Indianapolis Business Journal Health Care Heroes Award in the category of Community Achievement in Health Care.
The House Call Clinician of the Year Award was presented to nurse practitioner Ancy Zacharia, RN, MSN, GNP. Ms. Zacharia received her Geriatric Nurse Practitioner degree at Rush University Medical Center in 1999. While earning her degree, she was honored as the geriatric nurse of the year. She began her house call career with HomeCare Physicians in December 1999, and has made over 10,000 house calls. Ms. Zacharia’s clinical skills are frequently recognized, but it is her bedside manner that is constantly praised by patients and families.
Equally notable is her advocacy work on behalf of house calls and their impact on the care of the frail elderly. She has served on her County’s Elder Abuse and Neglect Multidisciplinary team for the past four years. She was also selected by the Illinois Nurses Association, representing 6,000 nurses, and the Chicago Geriatric Nurse Practitioner Association to represent them on the State of Illinois’ Older Adult Services Advisory Committee. In April, Ms. Zacharia spoke in the Illinois state capital to the Services Subcommittee on care coordination and the impact house calls have on enabling patients to remain at home. Says one colleague, "Ancy has a way of planting seeds of blessing as tiny gifts straight from the heart, her loving words, the thank you’s, encouragement and a smile to all who pass her way.”
Congratulations also went to Board member Kathy Kemle who has been selected as the 2008 Outstanding Physician Assistant of the Year by the American Academy of Physician Assistants.
Finally, at the AGS Presidential Poster Session, Catherine Smigelski received the Poster of the Year award for her poster on Transitional Model of Care at VCU Medical Center – Six Years’ Experience.
Homecare Literature: The Year in Review
Dr. Colin Thomas began the afternoon session with his second annual review of the homecare literature. Articles highlighted included "Brief communication: National quality-of-care standards in home-based primary care,” Ann Intern Med, 2007 Feb 6;146(3):188-92; "Intermediate care – Hospital at Home in COPD: British Thoracic Society guideline,” Thorax, 2007 Mar;62(3):200-10; and "Systematic review of home telemonitoring for chronic diseases: the evidence base,” J Am Med Inform Assoc., 2007 May-Jun;14(3):269-77. Dr. Thomas cited the most important article of the year as "Geriatric care management for low-income seniors: a randomized controlled trial,” JAMA, 2007 Dec 12;298(22):2623-33. This intervention consisted of a two-year period of home visits by a nurse practitioner and social worker. Results provided strong evidence that home care can improve clinical outcomes and utilization of costly services. All above articles were published in 2007 issues of Frontiers. Any members with articles of interest are encouraged to contact Dr. Thomas.
Current Clinical Management Approaches to IAH-like Programs
Dr. Ramsdell introduced a panel which took turns presenting on the following clinical strategies and approaches:
There’s no Place Like Home –VA Model
Board member and Director of Home & Community-Based Care for the VA, Dr. Thomas Edes presented the VA Home Care for Chronic Disabling Disease program. Dr. Edes began by defining home based primary care (HBPC) and processes of care. He then compared and contrasted HBPC with Medicare home care. Characteristics of the HBPC population were reviewed, as were disease prevalence and the cost of care before versus during HBPC, and reduction in hospital utilization reflected during HBPC. Outcomes from the HBPC program showed a 78% reduction in inpatient days, an 18.2% decrease in 30-day readmission rate and the highest overall satisfaction rating from all VA patient surveys. Dr. Edes cited key factors for success as an interdisciplinary team, visits by physicians/nurse practitioners, comprehensive and longitudinal care. He concluded by summarizing that success in IAH will require physician involvement, care that is longitudinal, comprehensive and interdisciplinary and integrated primary care.
Elder PAC: Sewing a "Program of All-Inclusive Care for the Elderly” Quilt from Community-Based Patches
Board Secretary Jean Yudin, CRNP and Dr. Bruce Kinosian presented the Elder Partnership for All-Inclusive Care program (Elder PAC), which provides an opportunity for multiple dimensions of medicine in the home. Ms. Yudin described different types of home care arrangements such as the Aging Network Model, which is similar to Elder PAC. This program combines community-based long term care services through the local Area Agency on Aging with house calls in an integrated academic health system. All initial home visits are done by nurse practitioners in their NP-physician teams. They averaged seven visits per patient per year in 2007. Excluding the 15% who are expected to improve, 70% of patients seen are bed bound and have more than two ADL impairments. Three IAH performance measures have been evaluated by Elder PAC: clinical outcomes, consumer satisfaction and Medicare costs. Dr. Kinosian concluded by presenting a typical Elder PAC patient, "before and after” participation in Elder PAC. The program shows that all-inclusive management of medically complex patients can result in substantial savings compared to similar Medicare beneficiaries.
Evolution of Home Care Practice in Nevada
Board member Dr. Steven Phillips, winner of the 2002 Poster of the Year, closed his office practice one year ago and went to an "office without walls.” He described the Chronic Home Care SHMO II program from the years 1999-2002. The program was designed to augment care of the chronically ill in southern Nevada beyond skilled care needs by bringing the program to where the patient resides. Effectiveness of the program was measured by audit reviewed utilization of acute hospital days, subacute days and skilled days. In 2002, the program showed a bed day savings of $1,424,753 and a total savings of $682,995. The program still exists and serves about 625 patients. Dr. Phillips went on to describe an approach used in northern Nevada by his organization, Geriatric Care of Nevada (GCN). This approach was compared with a non-geriatric approach to care, and GCN showed a savings of $761,925. He concluded by further describing the office without walls, what he describes as "living the dream.”
Preparing for a New Payment System
Dr. K. Eric De Jonge closed the panel by briefly describing Washington Hospital Center’s house call program. This program includes a tight link to hospital service and a wireless EMR, and two teams serving 615 active patients. Dr. De Jonge described the "hub” of the program as the outstanding team of primary care medical and social work staff, along with daily loving care from families, neighbors, aides and church. He cited emotional strain of intense patient care, the short-term/volume mindset of payment systems and portable technology as the program’s toughest challenges. He emphasized that Medicare is changing from paying for volume to paying for results, and gave members specific lessons for IAH. He concluded with a clear example of an IAH sensitivity model and the rewards that will be offered to those with a hub primary care team and all spokes of geriatric services.
Case Studies – The Contrasts in Management of Patients, Now and Under IAH
Following a question and answer time, Dr. Edward Ratner presented a case study illustrating what it takes to prevent a hospitalization in managed care home medicine. Dr. Ratner’s conclusions were that to avoid hospitalization, nearly hospital-level medical care is needed, requiring a complex, coordinated team. Assisted Living Facilities (ALFs) may not be able to upgrade care with in-house staff. Since a significant percentage of people who would be eligible for IAH will be in ALFs, providers need to anticipate and plan for IAH in that setting. Dr. Ratner provided many strategies for preventing hospitalization in a home medical program, such as advance care planning, substitution of hospital with sub-acute nursing home care, use of urgent skilled home care, telemedicine and polypharmacy management. He emphasized the need to preplan at the organizational level of how you will work with other organizations.
Dr. Jon Salisbury then described Visiting Physicians Services, which he started in 1994. The ratio of providers is one physician to three nurse practitioners, and NPs typically live within a ten-mile radius of where patients are seen. Dr. Salisbury described his practice operation and concern that as a group, the Academy should be homogeneous in what we will provide under IAH. (A letter outlining these concerns and the Academy’s response was published in Frontiers following last year’s Annual Meeting).
After describing his own practice, Dr. Kevin Jackson then presented two case studies of actual patients seen in the last month. In this informative real-life example, Dr. Jackson polled the panel, made up of Dr. Edward Ratner and Dr. Jon Salisbury, on what their plans of care would be for each case and whether they would use a different approach under IAH.
The meeting concluded with a presentation by Dr. Peter Boling and Dr. George Taler on remaining clinical issues in implementing IAH and prognostications for the future, followed by a final question and discussion period.