1 / 40

Improving our Programs- A Ride that Never Ends

This report discusses the findings of a Medicare/MAC audit of outpatient cardiac and pulmonary rehabilitation services and provides lessons learned and strategies for increasing participation in cardiac rehabilitation programs. It also highlights the importance of timely referrals, enrollment, and adherence to improve meaningful outcomes.

psears
Download Presentation

Improving our Programs- A Ride that Never Ends

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Improving our Programs-A Ride that Never Ends Karen Lui, RN, MS, MAACVPR SACPR Montgomery, Alabama April 5, 2019

  2. I have no disclosures. GRQ, LLC

  3. 2019 Work Plan-Office of Inspector General Report # W-00-18-35808 “Previous OIG work identified outpatient cardiac and pulmonary rehabilitation service claims that did not comply with Federal requirements. We will assess whether Medicare payments for outpatient cardiac and pulmonary rehabilitation services were allowable in accordance with Medicare requirements.” GRQ, LLC

  4. Medicare/MAC Audits of CR/PR Lessons learned: • Communicate regularly with billing office • You want to know of any denials or audits • Typically given 30 days to respond (“ADR”) • Educate them on new regulations, coding or billing issues specific to CR/PR GRQ, LLC

  5. Medicare/MAC Audits of CR/PR Lessons learned: • Don’t let this happen to you: I never even knew our rehab was audited. I wasn’t informed of the denials. GRQ, LLC

  6. Who’s Behind Million Hearts & Why • 2015 CMS Million Hearts Project invited AACVPR & 20 other organizations to address the underutilization of CR • Cardiac Rehab Collaborative was formed • 2016 AACVPR Roadmap to Reform Initiative • MH 2022 adopted the 70% CR participation goal GRQ, LLC

  7. ….increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the U.S. GRQ, LLC

  8. GRQ, LLC

  9. CRCP CMS MILLION HEARTS Project- Taking the road map on the road! GRQ, LLC

  10. CRCP https://millionhearts.hhs.gov/files/Cardiac_Rehab_Change_Pkg.pdf • Systems Change • Referrals • Enrollment & Participation • Adherence • Why - evidence • How - implementation • Case studies of successful strategies • Links to evidence, resources, and strategies GRQ, LLC

  11. Goal: Meaningful Outcomes • Assess where you want to go • Know where you’re starting • Know where you’ve gone As Dr. Steven Keteyian likes to say, “It’s about doing away with outdated dogma.” GRQ, LLC

  12. Step 1: What are your program’s priority potholes on this road? • Eligible to referred? • Referred to enrolled? • Average wait time from discharge/referral to CR enrollment (1st session)? • Average # of sessions delivered? GRQ, LLC

  13. Increasing CR Referrals-Why Evidence • While current participation rates are 20-30%, increasing rate to 70% would: • save 25,000 lives • Prevent 180,000 hospitalizations annually GRQ, LLC

  14. Increasing CR Referrals-Why Evidence • CR participation benefits: • 13%-24% reduction in total mortality over 1-3 years • 31% decrease in re-hospitalization over 1 yr • Increase in quality of life • Ades et al. Mayo Clin Proc. 2017:92(2):234-242 GRQ, LLC

  15. Increasing CR Referrals-How Best Practice • EMR-based (systematic) referral • Increased referral rates to 70% • Opt-out is more effective than opt-in • CR staff “liaison” referral • In combination, attained referral rates of 86% GRQ, LLC

  16. Increasing CR Referrals-How Best Practice CR referral performance measure • Published, endorsed, updated measures JACC & Circ, April, 2018 • ACC National Cardiovascular Data Registry (NCDR) documented significant improvement in referral in over 80% of hospitals in this registry • Grace SL, Russell KL, et al. Arch intern Med. 2011:171(3)235-241 GRQ, LLC

  17. Time from Discharge to CR Enrollment-Why Evidence • For every 1 day delay in starting CR, there is a 1% less likelihood of patient enrolling • Multi-disciplinary, team-based approach (i.e., CR) reduces readmissions by addressing multiple issues concurrently • Enrollment in CR post-MI is strongly & independently associated with improved adherence to medications • Pack QR, Mansour M, Barboza JS, et al. Circ. 013;127(3):349-355 • Russell KL, Holloway TM, Brum M, et al. JCRP 2011;31:373-377 • Jack BW. Annals Intern Med 2009 • Shah ND, Dunlay SM, Ting HH, et al. AJM 2009;122(10)961.37-13 GRQ, LLC

  18. Time from Discharge to CR Enrollment-How Best Practice • Enrollment should be within 21 days of discharge • CMS expectation & ACC/AHA CR quality measure • Schedule 1st CR appointment before discharge • 20%-25% improvement in enrollment • Flexible hours of operation • 10% improvement in enrollment & participation GRQ, LLC

  19. Get ‘Em Started Sooner …decrease discharge-to-start time (d2s)! Patient Participation Flow Diagram Primary Outcome Assessed for Eligibility, n=203 StandardAppointment EarlyAppointment Excluded, n=53 Randomized, 74%, n=150 Attended Orientation, N=57 77%* Attended Orientation, N=44 59% Standard Appointment to CR, n=74 Early Appointment to CR, n=76 Withdrew consent, n=2 Median Time from Dischargeto Orientation 42 Days Median Time from Discharge to Orientation 9 Days** * P = 0.022 ** p = <0.001 Analyzed for attendance, n=74 Analyzed for attendance, n=74 Pack QR, et al. Circulation. 2013;127:349-55 GRQ, LLC

  20. Program Average Number of Sessions-Why Evidence • Strong dose-response between # of sessions and long-term outcomes • Those who received 36 sessions had: • 14% lower risk of death & 12% lower risk of MI compared to 24 sessions • 22% lower risk of death & 23% lower risk of MI compared to 12 sessions • 47% lower risk of death & 31% lower risk of MI compared to 1 session • Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Circ. 2010;121:63-70 GRQ, LLC

  21. Program Average Number of Sessions-How Best Practice • Select participation/adherence strategies • 36 sessions of CR is recommended • Adherence of > 36 sessions is an ACC/AHA CR quality measure Fletcher SM, McBurney H. Identifying opportunities to engage clients in attending CR & maintaining lifestyle changes. JCRP 2016;36:346-351. Worth reading GRQ, LLC

  22. Group Orientation-Why • Inverse relationship between time to enrollment & participation • System & process barriers to early enrollment can be addressed • Group “effect” occurs • Group screening improves staff efficiency • 22% decrease in wait times • 14.9 days vs 19.5 days indiv apt Bachmann JM, et al. -No change in # of staff or equipment -Ample time to develop ITPs -Equal outcomes GRQ, LLC

  23. Group Orientation-How Various ways to do this: • Pre-enrollment (not billable) - Scheduled 1-2 days weekly • 1st session with some 1:1 & exercise (billable) • Hybrid of # 1 & 2 (billable) • Shared medical apt (SMA) with NP/PA (NPP code) GRQ, LLC

  24. Group Orientation-How • Adjust resource use to increase throughput: • Instead of starting/orienting new patients 1 at a time (1 patient to 1 staff person), consider a ratio of 1 staff starting/orienting 2-8 patients at the same time • Improves resource use from 3-10 hours of a staff person’s time to prepare for and meet with 2-8 patients to ~2.5 hours to get the same number of patient’s started • “Experiment” to identify the ratio that works the best for your program GRQ, LLC

  25. References • Bachmann JM, Klint ZW, Jagoda AM, et al. Group enrollment & open gym decreases CR wait times. JCRP 2017;37:322-328 • Russell, K.L et al.; Cardiac Rehabilitation Wait Times: Effect on Enrollment. JCRP 31(6):373‐377, November/December 2011 • Pack, Q.R., Mansour, M., Barboza, J.S. et al. An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single‐blind, controlled trial. Circulation 2013; 127: 349–355 GRQ, LLC

  26. ECG Monitoring as Needed-Why • Safety of CR is well-established; extent of ECG use does not impact adverse events • Van Camp, 1986; Pavy, 2006, Saito, 2014 • Stratifying patients & setting ECG policies based on “risk” do not predict events in CR • Merz, 2000, Grall, 2000 • “Modified” CR programs that limit ECG monitoring are cost-effective, safe, and can improve patient adherence, whereas excessive ECG use lessens patients’ self-efficacy • Carlson, 2000 GRQ, LLC

  27. ECG Monitoring1970’s →1980’s → 2006 → 2010 “ … Given the variable occurrence of dysrhythmias … and given that the safety of exercise regimens has been determined only by means of aggregate data, the use of continuous versus intermittent (i.e., change in clinical status) ECG monitoring remains a matter of clinical judgment” 2013: Page 85-86 Requirement for “continuous ECG monitoring” was changed to “appropriate ECG monitoring” in March, 2006 (NCD 20:10) and removed entirely from Medicare’s CR revised coverage policy in January, 2010 (42 CFR 410.49) GRQ, LLC

  28. ECG Monitoring as Needed-Why • Reduces costs to program in staff/time efficiency, hardware, less intrusive to patients • Allows program to expand # of patients, limited only by pieces of equipment • Primary benefit is in fostering patients’ self- management skills • Use HR device (such as chest strap) from day 1 • Teach correlation between HR intensity & RPE GRQ, LLC

  29. ECG Monitoring as Needed-How • Use of chest strap HR monitor from 1st session to teach correlation to RPE • ECG monitor 1st ___ sessions before going to non-ECG monitored sessions • Intermittent ECG monitoring after 1st week • 1 session/week monitored & non-monitored rest of week • Dept policy should reflect protocol GRQ, LLC

  30. ECG Telemetry Monitoring: Henry Ford Hospital Model Yes No Yes No No Yes Yes No GRQ, LLC

  31. ECG Telemetry Monitoring: Henry Ford Hospital Model Table 1: Indications for CR patients to remain on ECG telemetry Table 2: Indications to continue, or resume, ECG telemetry for an additional 3-6 sessions Observed or documented arrhythmias of the following Sustained ventricular tachycardia (8 or more beats) Supraventricular tachycardia (relative based on Sx and frequency/duration of SVT) Heart block or bradyarrhythmias Non-sustained VT up 7 beat runs (relative based on Sx and extent of non-sustained VT) Medically managed MI?? ST or QRS changes, such as ST depression >1.0 mm during exercise (or additional ST depression of 1.5 mm if baseline abnormality present) Addition of an anti-arrhythmic drug (e.g. amiodarone) New or worsening angina? Patient with recent cardiac-related IPD stay who returns to CR • Higher Risk Patients • Patients with CHF on positive inotropes (e.g. milrinone) • Patients with a left ventricular assist device • Patients who are currently undergoing dialysis • Patients who have insurance providers that do not reimburse non-monitored cardiac rehabilitation (private payer Aetna plan only requires tele for high risk and only for 3 wk) • Request from physician to remain on monitor throughout GRQ, LLC

  32. Open Gym-Flexible Hours • Programmed independence • Simulates real world gym • Better prepares patient for long-term exercise routine • Patient selects days & times • M-F works very well; 2 or 3x/wk works, too • Self directed warm-ups & cool-downs • Facility capacity per day is greater • Less down time • Limited by # of equipment stations • Does not take more staff • Works well with ECG prn and group orientation strategies GRQ, LLC

  33. Open Gym-Flexible Hours • Vanderbilt University (4000 CR sessions/yr) • Group enrollment & open gym format • Decreased wait times by 22% • Same # staff and equipment • 3 CEPs, 1 RN, psychologist, dietician • Staff: ample time to develop ITPs • Group enrollment/open gym vs indiv appointments were equally beneficial • ex capacity, depression, QOL • Bachmann et al. JCRP 2017;37:322-328-worth reading GRQ, LLC

  34. Open Gym-Flexible Hours Schedule is adapted for size of program • # of columns • # of staff (will take time to guide staff coverage) • # of ECG monitors • If combined with maintenance GRQ, LLC

  35. Accelerated CR-Why • Goal-completion of 36 sessions • CMS expectation (Federal Register, 1-3-2017, pg 574) • Dose dependent effect on mortality (Hammill et al) • ACC/AHA 2018 quality measures • CMS priority category of “Effective Clinical Care” • Time to enrollment < 21 days • CR Adherence > 36 sessions GRQ, LLC

  36. Accelerated CR-How • Uses Intensive CR model of multiple sessions/day • Utilizes both CR CPT codes 93798 & 93797 • One co-pay/day, not per session, on some plans • Exercise & education (nutrition, stress mngmnt, etc) • Progress exercise to 90-120 min/day for appropriate patients • Offer CR 4-5 days/week • Patients eager to return to work appreciate these options GRQ, LLC

  37. Safe Start to Supervised Maintenance CR-Why • Fact of life: Co-payments are a major barrier for CR/PR • Philosophical question: Is some CR better than none? • CMS expectation: Beneficiaries are to receive individualized (patient-centric) services! • Urban legend: “You must give the same service to all patients” GRQ, LLC

  38. Safe Start to Supervised Maintenance CR-How • A la carte menu of distinct program options • Program policies establish appropriateness criteria for a well-defined menu • Self-pay cost to patient for safe-start is short-term arrangement; precursor to long-term maintenance GRQ, LLC

  39. Safe Start to Supervised Maintenance CR-How • Collaborate with other local facilities • Fast track Phase II to supervised “safe-start” Phs III • Repeat CR patient seeks supervised exercise • Shady Grove, Rockville, MD-Barb Courtney • Memorial Hospital, Chattanooga TN-Allan Lewis GRQ, LLC

  40. Thank-you GRQ, LLC

More Related