Paying for Dementia care

1. Paying for Dementia care Mary Ann Forciea MD Clinical Professor of Medicine Division of Geriatric Medicine University of Pennsylvania Health System

2. 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 practitioners

3. 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 programs

4. 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 • Hospice

5. 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 cost

6. 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 • Hospice

7. Categories for dementia care • Medicare 8% • Nursing home 22% • Informal (unpaid)home care 48% • Paid home care 11% • Out of pocket spending 11%

8. 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 56,290

9. 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” Odenheimer

10. Models to influence primary care • Reimbursement (time) • Medicare coding • New models • Group visits • Medical Homes • System Integrations (ACOs) • Quality Improvement/Performance Measures

11. 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 collection

12. 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

13. Impact on practice • Resource for individual practitioner • Good linkage to EMR • Guide for facility/system for resource allocation • Behavior change • “Pay for performance” • Incentives • Penalties

14. 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 period

15. Debrief • List:

16. 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/refine

17. 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 audits

18. 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 annually

19. 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 dementia

20. 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.

21. 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.

22. Dementia Quality MeasureDomain 2: Behavioral symptoms • 4. Assessment for neuropsychiatric symptoms • 5. Intervention for neuropsychiatric symptoms • 6. Screened for depression

23. 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 support

24. 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 debrief

25. 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