Roles and Opportunities in Population Health Management

1. Panel Discussion:NP, PA, and Social Work Practice: Roles and Opportunities in Population Health Management Moderator: Barbara Sutton, MSN APRN ACHPN Panelists: Deborah Wolff-Baker, MSN ACHPN FNP-BC Tammy Browning, PA-C Maureen Ryan, MSW LCSW

2. Faculty Disclosures • Browning – no relevant disclosures • Ryan – no relevant disclosures • Sutton – no relevant disclosures • Wolff-Baker – no relevant disclosures

3. Objectives • Define important clinical competencies APN, LCSW, and PA contribute to high-functioning home based primary and palliative care teams • Illustrate the role of each profession in improving experience of care, improving quality of care, and preventing unnecessary costs in the home-limited population • Describe variation by geography and discipline in scope of practice and regulatory considerations.

4. Importance of the Interdisciplinary Team • Each profession brings a different perspective on patient assessment and treatment that complements and enhances the team • Each state has different practice regulations • PA • APRN • LCSW

5. Nurse Practitioners in Home Based Care Deborah Wolff-Baker, MSN ACHPN FNP-BC Northern California Medical Associates Deborah.baker@ncmahealth.com

6. Who is a Nurse Practitioner? Education & Training • Master’s or doctoral degree in Nursing • Advanced clinical training with a minimum of 500 advanced practice clinical hours • Initial RN preparation which includes 1200 or more clinical hours for BSN degree. • Most NP programs also require a minimum of 2 years RN work experience prior to admission to the NP program which adds another 2000 hours clinical experience. Qualifications • Rigorous national certification with re-certification process every 5 years with CE including pharmacology and other professional development requirements • Periodic peer review, clinical outcome evaluations • Adhere to a code for ethical practices, continuous education and professional development. • Lead and participate in professional and lay health care forums, conduct research and apply findings to clinical practice. Services Practice in primary care, acute care & long-term care settings, emphasizing whole person health and well-being while focusing on health promotion, disease prevention, health education and counseling. Autonomously and in collaboration with other health care professionals, NPs provide a range of primary, acute & specialty health services including: • Ordering, performing and interpreting diagnostic tests such as lab work and x-rays. • Diagnosing and treating acute and chronic conditions • Prescribing medications and other treatments • Managing patients’ overall care • Educating & counseling patients on disease prevention, lifestyle and health promotion.

7. Mission: NCMA Home Based Palliative & Primary Care is an NP run practice designed to meet the palliative, preventative and Primary Care needs of Sonoma County’s frail elderly population. Care is provided in the home setting where the medical and the social meet. Goals: • To improve Access to care for Sonoma County’s frail elderly by providing Palliative, Primary, Transitional care and comprehensive chronic disease management to patients, age 55+ who would otherwise find it difficult to access integrated, coordinated medical services • To extend community survival • To clarify goals of care and Advance Directives • To reduce overall healthcare costs by preventing duplication & overuse of healthcare resources, preventing hospital admissions, re-admissions or by shortening LOS; assuring care is consistent with patient & family values through the prevention of unwanted or futile care. • To improve health, well-being and QOL.

8. Practice • NCMA Structure: Independent Practice Association type model • Collaborating MD does not make House Calls • One NP – Shared call weekends and after hours with LTC on-call group • Panel of approximately 50 fragile homebound patients • Most patients are Dual Eligible • Visits average every two months; weekly + with transitional care • Based on “Medical Necessity” • NP may assume Primary Care Provider status for patient or may report back to PCP within NCMA • Patients are seen in a variety of settings: Private Homes, Senior Living Apartments, Low Income Senior Complexes, Assisted Living & Board and Care Residences, Assisted Living Dementia Facilities, and Group Homes

9. Uniqueness of Practice • Independent Practice Association (IPA) – type Model • Older adults/chronic disease management • Palliative & Primary Care • NP continues as PCP even after making a Hospice referral • Referrals to Home Based Primary Care Program come from: • MD Offices (both NCMA and others) • Home Health Agencies and Hospices • Council on Aging • Hospital Case Managers/Discharge Planners • Self Referral • Assisted Living Facilities/Board and Care Domiciles and Skilled Nursing Facilities • Word of Mouth

10. Collaboration • Dr. Timothy Gieseke – Collaborating MD • Other House Call Specialists • Podiatrist • Geriatric Neuropsychologist • Geriatric Psychiatrist • Various Specialists – Cardiology, GI, Ortho, Surgery • Academic affiliation: RN to BSN, FNP & Health Navigator Certificate students • Home Health Agencies and Hospices • Sonoma County Department of Adults and Aging • APS, MSSP, IHSS, Linkages • Imaging, Spirometry, BMD, Doppler, Holter monitor, EKGs • Laboratory • DME companies

11. Dollars and Cents Departments: • Coding and Billing • Credentialing • Human Resources • Information Technology and EMR • CEO & Other Ancillary Support These resources are utilized by all practices within NCMA including House Calls. Finances and Reimbursement (For Profit): • HMO Contracts • Traditional Fee for Service • Medicare and Medi-cal (Medicaid) • Private Insurances, Supplements, TriCare, etc. All billing is done by NCMA billers.

12. Barriers to Nurse Practitioner Practice • Lack of standardized NP Scope of Practice (SOP) from State to State – or even within a State due to differences in individual Practice Protocols leads to misunderstandings and confusion related to what a Nurse Practitioner is able to do. • Full Practice States (22 + DC) • Reduced Practice States (16) • Restricted Practice States (12) • California, for example, is a Restricted Practice State. Each NP writes Practice Protocols and Standardized Procedures specific to the practice setting, individual competencies, NP and Physician preferences. All Advance Practice functions beyond the RN role must be defined within these Practice Protocols.

14. Other NP Barriers to Practice • Unable on the Federal Level to sign for Medicare Certified Home Health Orders – even in States with Full Practice Authority. • Delays in providing care. • Increased chance of poorly coordinated care. • Costs associated with NPs having to pay an MD to sign the Home Health Plan of Care (485). • Home Health Planning and Improvement Act 2015 S.578 (Collins) and H.R. 1342 (Walden) • In States without Full Practice Authority, NPs must have a signed agreement with collaborating or supervising MD. • Costs associated with paying for MD agreement / oversight • What if the MD leaves the Practice, goes on vacation, dies? • How many NPs can be supervised by one MD determined by State as well as how far the distance between them can be during patient visits.

15. Barriers to NP Practice - Continued • Insurance panels and reimbursements: • Medicare reimburses NPs at 85% of Physician rates • Many Insurance panels do not credential NPs • Depending on the State, SOP, and Practice agreements, some NPs cannot: • Sign a death certificate • Order a Schedule II narcotic • Order DME Important to know your State BRN regulations regarding NP Practice. This will vary greatly depending on the State Practice environment. In States with restricted or reduced SOP, written and signed Practice Protocols/Standardized procedures must cover functions which would otherwise be considered the practice of medicine.

16. Physician Assistants in Home Based Primary Care Tammy Browning, PA-C tbrowning@grace-at-home.com

17. What is a Physician Assistant PA is a nationally certified and state-licensed medical professional. PAs are concerned with preventing and treating human illness and injury by providing a broad range of health care services under the supervision of a physician. Their scope of practicecan vary according to jurisdiction and healthcare setting. Physician Assistant’s work may include conducting physical exams, ordering and interpreting tests, diagnosing illnesses, developing treatment plans, performing procedures, prescribing medications, advising on preventive health care, and assisting in surgery.

18. Training and Qualifications • Most PA programs are a masters level programs (bachelor and certificate programs in past) • 2,000 hours of clinical rotations • Must pass a National Certifying Exam to practice • Must retake/pass certification exam every 10 years (recently changed from every 6 years) • Must complete 100 hours of CME every two years • Must maintain medical licensure in State of practice • Must have a Supervising Physician agreement and scope of practice should be outlined and correspond with the supervising physicians scope of practice.

19. AAPA “Six Key Elements Six Key Elements “Licensure as the regulatory term Full prescriptive authority Scope of practice determined at the practice level Adaptable collaboration requirements Chart co-signature requirements determined at the practice Number of PA’s a physician may supervise determined at the practice level

20. How does a PA practice in Home Care Medicine • Integral part of team, enhances physicians capacity to provide care to larger number of patients • Physician oversight is required, varying regulations state to state • PA vs NP vs Physician – what is the differences in what PA’s bring

21. Barriers to PA Practice • Medicaid Reimbursement – state dependent and not recognized providers in all 50 states • Limitations in number of PA’s a physician can supervise (state by state differs) • Certain states limit ability to prescribe controlled substances • Federal limitation on signing Medicare Home Health Plan of Care or orders • Patient view/understanding of PA role • Physician view of PA and role in primary care

22. Resources • American Academy of Home Care Medicine • American Academy of Physician Assistants www.aapa.org • State Medical Association or Licensure board • Provider Relations department of your state Medicaid office

23. Social Workers in Home Based Primary Care Maureen Ryan, MSW LCSW

24. What is a Social Worker? Graduates of schools of social work who use their knowledge and skills to provide social services for clients.  Social workers help people increase their capacities for problem solving and coping, and they help them obtain needed resources, facilitate interactions between individuals and between people and their environments, make organizations responsible to people, and influence social policies. Social workers may work directly with clients addressing individual, family and community issues, or they may work at a systems level on regulations and policy development, or as administrators and planners of large social service systems.

25. What is a Palliative Care Social Worker? • Counseling • Education • Planning • Crisis • Mediate Conflict • Resources • Advocacy

26. Licensure and Certification • Licensure varies by state (some do not require licensure) • Exam • Maintain CE’s • Billing • Only MSW or DSW can bill for services • Must have two years experience • ACHP-SW (2008)

27. Barriers to Practice • Reimbursement rates • Cannot bill in skilled nursing facilities or hospitals • Services must be aimed at the diagnosis and treatment of mental, emotional, behavioral illnesses • Negative connotation with social worker • New concept for many practices

28. Panel Discussion Go to: 2Shoesapp.com/AAHCM2016 Click on the session you are in Ask and vote on questions

29. Annie is an independent 71 year old woman with COPD living at home in the community. She lives with, and provides care for her spouse, who has a known dementia diagnosis. • Annie also has two out of state adult children who visit twice a year. Annie is very private, and has quietly been managing her own and her husband’s finances, medications, and doctor visits, not wanting to bother others for assistance. • Annie was diagnosed with COPD last year, after visiting her doctor for what she believed to be bronchitis what wouldn’t improve. • Annie has been increasingly tired, is now dependent on 4L 02. Annie has been a smoker for 40 years and is currently smoking ½ ppd. • Comorbidities of: • Pulmonary hypertension • DM2 • Osteoarthritis

30. What Plan of Action Would a NP, PA and SW have for Annie? Current Medications: • Metformin 1000 mg bid • Prandin 1 mg po ac tid • Valsartan 80 mg daily • HCTZ 25 mg daily • ASA 81 mg daily • Advair 250/50 One puff bid • Spiriva 18 mcg cap inhaled daily • Albuterol Unit dose ABT via in home nebulizer q 1h prn wheezing • Tylenol 650 mg tid • Multiple Vitamin with minerals daily • Vitamin D 2000 IU daily • O2 as needed Diagnosis List: • COPD – O2 dependent • Cough/SOB • Fatigue • Pulmonary Hypertension • DMT2 • OA • Tobacco use disorder • At risk of Caregiver burnout • Lack of social support/social isolation • Knowledge deficit related to disease management • Possible medication non-compliance • Unknown goals of care • High use of hospital ER