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Paying for Dementia care Paying for Dementia care

Paying for Dementia care - PowerPoint Presentation

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Paying for Dementia care - PPT Presentation

Mary Ann Forciea MD Clinical Professor of Medicine Division of Geriatric Medicine University of Pennsylvania Health System Goals of this workshop Increased awareness of financial challenges during the course of a dementia illness ID: 260121

dementia care stage quality care dementia quality stage fast patients patient measures medicare person cost severe family caregivers scale

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Slide1

Paying for Dementia care

Mary Ann Forciea MD

Clinical Professor of Medicine

Division of Geriatric Medicine

University of Pennsylvania Health SystemSlide2

Goals of this workshop

Increased awareness of financial challenges during the course of a dementia illness

Increased awareness of

quality measures for dementia care

incentives/penalties as they apply to:

Sites of care

Individual practitionersSlide3

Possible concerns about costs of dementia care

Time required to meet needs of patient or caregiver

Payment options for interprofessional team members

Unfamiliarity with Medicare/Medicaid/insurers special

programsSlide4

How much is the annual cost of care for a patient with dementia?

Office care

Co pays, transport, attendant, meds

Home care

Attendant

Pay

Missed wages of family caregivers

Home modification

NH care

Self pay

Medicaid issues

HospiceSlide5

Task 1 – Estimates of Costs of Care

Write down your estimate of

annual

cost of care for a patient/family with moderate dementia for:

Share of costs covered by Medicare

Out of pocket costs, or

caregiver costSlide6

How much is the annual cost of care for a patient with dementia?

Office care

Co pays, transport, attendant, meds

Home care

Attendant

Pay

Missed wages of family caregivers

Home modification

NH care

Self pay

Medicaid issues

HospiceSlide7

Categories for dementia care

Medicare 8%

Nursing home 22%

Informal (unpaid)home care 48%

Paid home care 11%

Out of pocket spending 11%Slide8

Yearly cost per person with dementia in 2010 dollars

Care purchased

Out of pocket 6,194

Medicare 2,752

Formal Home Care 5,678

Nursing home 13.876

Informal home care

Replacement cost 27,789

TOTAL 56,290Slide9

How can health care professionals help?

Better attention to the

primary care

needs of the patient with a dementing illness will improve:

Quality of life of patients

Quality of life of caregivers

Cost

Decreased hospital/ER use

End of life care

“much of health care for dementia patients is

reactive and unsystematic

, rather than

proactive and planned

OdenheimerSlide10

Models to influence primary care

Reimbursement (time)

Medicare coding

New models

Group visits

Medical Homes

System Integrations (ACOs)

Quality Improvement/Performance MeasuresSlide11

Challenges: Quality Measures

Definition of quality care

National

Specialty societies

“neutral” entities (non profit consortia)

Local:

experts/teams of leaders

Source of data

Evidence base

Expert opinion

Ease of data collectionSlide12

Quality measures for dementia care

Clinical care ‘items’ which should be offered to all patients within a disease category

“Quality assessment” indicators

Payers: Medicare, private insurers

Certifiers: Joint commission, Medicare, State Departments of Health, Practitioner certification agencies

Systems

Facilities

Individual practitioners

Slide13

Impact on practice

Resource for individual practitioner

Good linkage to EMR

Guide for facility/system for resource allocation

Behavior change

“Pay for performance”

Incentives

PenaltiesSlide14

Task 2: Quality Measure for Dementia Care

Form groups of 3 with neighbors

You have been named to your health system’s IP quality assurance panel as a representative of your discipline.

You are working with a mini-team to plan a quality audit of a group of primary care practices

For a medical office caring for a patient who has been diagnosed already with dementia,

Agree on 3 clinical services/care items which should be documented in the chart in a 12 month periodSlide15

Debrief

List:Slide16

PCQI (AMA) Quality Measure:Dementia Care

AMA convened a workgroup panel (2010-2011, final report Oct 2011):

MDs (neurology, psychiatry, geriatrics, primary care), Nursing, Rehab Med

Review of existing guidelines and supporting data bases of information

Series of meetings to define/refineSlide17

Final Measures

10 measures of quality care in 3 domains:

Dementia subtyping and staging

Assessment and management of behavioral symptoms

Caregiver education, assessment, assistance

Data available through chart auditsSlide18

Measure set: Domain 1 – dementia staging (Measures 1, 2, 3)

1: Patients with dementia who were staged:

Mild, mod, severe

GDRS

Fast

2: Cognition assessed and/or reviewed annually

3: Functional status assessment annuallySlide19

FAST scale grading

FAST SCALE ADMINISTRATION

The FAST scale is a functional scale designed to evaluate patients at the more moderate-severe stages of dementia

when the MMSE no longer can reflect changes in a meaningful clinical way. In the early stages the patient may be

able to participate in the FAST administration but usually the information should be collected from a caregiver or,

in the case of nursing home care, the nursing home staff.

The FAST scale has seven stages:

1 which is normal adult

2 which is normal older adult

3 which is early dementia

4 which is mild dementia

5 which is moderate dementia

6 which is moderately severe dementia

7 which is severe dementiaSlide20

Fast: instructions

FAST stage 1 is the

normal adult

with no cognitive decline.

FAST stage 2 is the normal older adult with very

mild

memory loss. (

MCI

)

Stage 3 is early dementia. Here memory loss becomes

apparent to co-workers and family.

The patient may be unable to remember names of persons just introduced to them.

Stage 4 is

mild

dementia. Persons in this stage may have difficulty with finances, counting money, and travel to new locations. Memory loss increases. The person's knowledge of current and recent events decreases.

( early IADL issues)

Stage 5 is

moderate

dementia. In this stage, the person needs more help to survive. They do not need assistance with toileting or eating, but do need help choosing clothing. The person displays increased difficulty with serial subtraction. The patient may not know the date and year or where they live. However, they do know who they are and the names of their family and friends

(severe IADL issues).

Stage 6 is

moderately severe

dementia. The person may begin to forget the names of family members or friends. The person requires more assistance with activities of daily living, such as bathing, toileting, and eating. Patients in this stage may develop delusions, hallucinations, or obsessions. Patients show increased anxiety and may become violent. The person in this stage begins to sleep during the day and stay awake at night

(ADL Issues

).

Stage 7 is

severe

dementia. In this stage, all speech is lost. Patients lose urinary and bowel control. They lose the ability to walk. Most become bedridden and die of sepsis or pneumonia.Slide21

FAST sub staging

7a. Speech ability limited to the use of a single intelligible word in an average day

7b. Ambulatory ability lost (cannot walk without personal assistance).

7c. Ability to sit up without assistance lost (e.g., the individual

7d. will fall over if there are no lateral rests [arms] on the chair).

e. Loss of the ability to smile.Slide22

Dementia Quality MeasureDomain 2: Behavioral symptoms

4. Assessment for neuropsychiatric symptoms

5. Intervention for neuropsychiatric symptoms

6. Screened for depressionSlide23

Dementia Quality MeasureDomain 3 - Caregiving

7. Caregivers or patients counseled for safety

8. Counseling/assessment of driving risk

9. End of life counseling:

Goals of care documentation

Proxy identification/review (within 2 yrs. of diagnosis)

10. Caregivers

Education

Sources of additional supportSlide24

Task 3

You are asked to design a QI project for your site related to dementia care

Which performance measure would you choose to focus on in your own practice site?

Debrief in your mini group

Big debriefSlide25

Summary

Patients with dementia and their families/caregivers have a long journey to travel

Dementia care elements should not be overshadowed by acute or comorbid illness care

Performance (quality) measures may be a tool to influence care

And hopefully reward quality practice