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
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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