April 2016 Table of Contents Purpose... 1 Timeline... 1 Long Term Care (LTC) Facility Eligibility... 2 CMS retains the right to waive or modify any of these requirements.... 2 Eligible Beneficiaries... 2 Practitioner Eligibility... 2 Practitioner Letter of Intent... 3 Readiness Assessment... 5 Payment Reform... 6 Work Plan... 13
Purpose HealthInsight Nevada is one of seven organizations across the nation selected by the Centers for Medicare & Medicaid Services (CMS) to lead the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. The statewide initiative, Admissions and Transitions Optimization Program (ATOP), is testing models to improve quality of care and reduce avoidable hospitalizations in 24 of Nevada s Medicare-Medicaid-certified eligible nursing facilities by 2016. As an Enhanced Care and Coordination Provider (ECCP), HealthInsight Nevada has provided clinical education and supplemental staff to the 24 nursing facilities participating in Phase 1 of the model. Under this second phase, CMS has selected six ECCPs to partner with long-term care (LTC) facilities and practitioners to implement and test a new payment model. Phase 2 will be implemented in a manner consistent with meeting CMS s objectives of the initiative s first phase: 1. Reduce the frequency of avoidable hospital admissions and readmissions 2. Improve resident health outcomes 3. Improve the process of transitioning between inpatient hospitals and LTC facilities 4. Reduce overall health care spending without restricting access to care or choice of providers Timeline Project Period: March 21, 2016 Oct. 23, 2020 Anticipated Payment Reform Eligibility: Oct. 1, 2016 Page 1
Long-Term Care (LTC) Facility Eligibility In order to be eligible to apply, LTC facilities must have participated in the initiative during the initial phase. To continue participation in the initiative, a facility must meet the following criteria: Regulatory and Demographic Criteria: (Facility status as of Aug. 27, 2015) 1. Not be on the CMS list of Special Focus Facilities 2. Be Medicare- and Medicaid-certified and not excluded from participation in the Medicare or Medicaid programs CMS retains the right to waive or modify any of these requirements. Eligible Beneficiaries The eligible beneficiary population for this initiative is defined as beneficiaries who meet the following criteria: 1. Have resided in the LTC facility for 101 cumulative days or more starting from the resident s date of admission to the LTC facility 2. Enrolled in Medicare (Part A and Part B FFS) and Medicaid, or Medicare (Part A and Part B FFS) only 3. Have not opted out of participating in the initiative 4. Reside in a Medicare- or Medicaid-certified LTC facility bed 5. Are NOT enrolled in a Medicare managed care plan (e.g., Medicare Advantage) 6. Have not elected Medicare hospice Practitioner Eligibility In order for practitioners (i.e. MD, NP, PA) to participate, they must follow the below criteria: Page 2
1. Have carried an average panel (daily census of beneficiaries) of at least seven long-stay FFS Medicare beneficiaries in the affiliated participating LTC facility over the most recent six months 2. Have all licensure and certification in good standing 3. Not have had any sanctions, indictments, probations, corrective action plans or judgments imposed in the last three years relating to fraudulent or abusive billing practices 4. Not be excluded from participation in the Medicare or Medicaid programs 5. ECCPs shall give preference to recruiting practitioners who use technology to support interoperable health information exchange (for example, use technology that supports the creation and exchange of electronic care plans and creation and exchange of interoperable transition of care summary documents) Practitioner Letter of Intent As part of the application process, practitioners must submit a letter of intent to participate. CMS is open to exploring methods that reduce the burden associated with collecting and submitting practitioner letters of intent, while still ensuring practitioners fully understand and meet the criteria for participation. CMS will ultimately approve the practitioners that participate after reviewing their qualifications. The letter of intent should clearly state that if the practitioner were selected and approved for participation, he/she would adhere or attest to the following (at a minimum): 1. An attestation that the practitioner meets all the regulatory and demographic criteria stated above 2. A statement agreeing to adhere to the requirements and qualifying criteria to receive payment under this initiative 3. A statement agreeing to participate with the learning community for the Initiative (e.g., attend events and webinars) 4. A statement agreeing to respond to requests from CMS or its contractors for the purposes of oversight, monitoring or evaluation Page 3
o This may include requests to participate in conference calls, submit data, conduct chart reviews, conduct site visits and/or participate in surveys (phone or internet). 5. A statement committing to make the best available decisions for care for beneficiaries at all times regardless of payments received through the initiative o There shall be no withholding of care or services in lieu of payments. 6. For practitioners already partnering with ECCPs through Phase One of the initiative, a statement committing to continue to partner with the ECCP on all relevant aspects of the clinical interventions o This includes regular communication, coordinating care, adhering to previous commitments or agreements, or any other activities that are part of the original ECCP s intervention design. 7. The practitioner s average panel (daily census of beneficiaries) of long-stay FFS Medicare beneficiaries in the corresponding participating LTC facility over the most recent six months 8. A statement agreeing to apply the payment model under this initiative exclusively to the target population 9. A statement of the practitioner s commitment to meeting and maintaining the above criteria through the end of the initiative (we note that a practitioner s ability to meet the demographic criteria of an average panel of seven residents in the target population over the most recent six months may be outside of the practitioner s control and may fluctuate throughout the period of performance, so CMS will address these fluctuations on a case by case basis) 10. A statement regarding whether the practitioner uses an ONC-certified EHR and whether the practitioner uses health IT for care planning or the creation and exchange of transition of care documents 11. A commitment to promptly communicate any changes in the practitioner s information to the ECCP and CMS or its contractors (change of ownership, TIN, NPI, CCN, etc.) Page 4
Readiness Assessment In addition to the eligibility criteria, LTC facilities also must provide documentation that they can enhance the prevention of the conditions and administer the necessary treatments at any time. This will be verified through the readiness review process prior to allowing LTC facilities to participate. The readiness review requirements include: Prevention Criteria: 1. The adherence to the conditions of participation and adoption of best practices related to prevention of the six targeted conditions 2. The implementation of a structured tool for identifying early signs of a potential change in a beneficiary s condition that would require additional monitoring or other activities to prevent an acute change in condition 3. The creation of facility-wide policy and procedure that defines the process to be followed to prevent acute changes in condition (e.g. using the tools and guidelines referenced above) o Policies and procedures should specifically identify, but not be limited to, the six targeted conditions. Policies and procedures must also describe the facility s process to transfer a beneficiary to the hospital (e.g., when the beneficiary cannot be safely treated in the facility, upon the physician s orders, at the beneficiary s or health care proxy s discretion). 4. LTC facilities must submit a sample or copy of the tool(s) to be used, evidence that all appropriate staff has been trained, and a copy of the policy and procedures Treatment Criteria: 1. Twenty-four-hour availability (phone or in-person) by LTC facility key staff (medical director, administrator, director of nursing, RN manager, etc.) and attending practitioners (MP, NP, PA) with RN onsite 24 hours per day preferred 2. The ability to start and maintain parenteral (e.g., IV, hypodermoclysis) medications and fluids 24 hours a day for eligible beneficiaries by a certified staff member on all units o LTC facilities may also contract with external companies licensed to furnish some of these services in the LTC facility (e.g., LTC pharmacy). 3. The ability to address complex wounds through debridement, high frequency dressing changes, cleansing and antibiotics (LTC facility or external consultant) Page 5
4. The ability to furnish respiratory and bronchodilator therapy, and oxygen 24 hours per day 5. The ability to furnish EKGs and access to a clinician (e.g., external consultant) to read and interpret EKGs within two hours (e.g. via letter of agreement stating availability and response time) 6. The implementation and use of a structured tool to document and communicate a resident s change in condition, including hospital transfers (INTERACT, AMDA tools, etc.) o Note: Separate from this, LTC facilities may need to complete the MDS assessment for beneficiaries experiencing a significant change in condition, in accordance with prevailing MDS requirements. 7. Information and specifications of telemedicine system (if applicable) 8. Information and specifications related to the health IT used to support assessments, care planning and/or health information exchange at times of transitions in care Payment Reform Components 1. Payments to a SNF under Medicare Part B for the treatment of qualifying conditions (for beneficiaries not on a covered Medicare Part A SNF stay) 2. Increased practitioner payments under Medicare Part B for the treatment of conditions onsite at the LTC facility 3. Practitioner payments under Medicare Part B for care coordination and caregiver engagement for beneficiaries in a SNF or NF stay o Note: The term practitioner refers to physicians, nurse practitioners (NPs) and physician assistants (PAs) Conditions 1. Pneumonia 2. Dehydration 3. Congestive heart failure (CHF) 4. Urinary tract infection (UTI) 5. Skin ulcers, cellulitis 6. COPD, asthma Page 6
Acute care pneumonia This code is for onsite acute care treatment of a nursing facility resident with pneumonia. May only be billed once per day per beneficiary. Pneumonia Qualifying Diagnosis: Chest X-ray confirmation of a new pulmonary infiltrate OR TWO or more of the following: Fever >100 F (oral) or two degrees above baseline Blood oxygen saturation level<92% on room air or on usual 0 2 settings in patients with chronic oxygen requirements Respiratory rate above 24 breaths/minute Evidence of focal pulmonary consolidation on exam, including rales, rhonchi, decreased breathe sounds, or dullness to percussion Symptomatic guidance: Productive cough, increased functional decline, increase dependence in ADLS, reduced oral intake, increased lethargy, altered mental status, dyspnea Treatment: Antibiotic therapy (oral or parental), hydration (oral, sc, or IV), oxygen therapy, and/or bronchodilator treatments. Additional nursing supervision for symptom assessment and management (vital sign monitoring, lab/diagnostic test coordination and reporting) Maximum Benefit Period: 7 days Page 7
Acute care congestive heart failure (CHF) Acute care skin infection This code is for onsite acute care treatment of a nursing facility resident with CHF. May only be billed once per day per beneficiary. This code is for the onsite acute care treatment a nursing facility resident with a skin infection. May only be billed once per day per beneficiary. Congestive Heart Failure Qualifying Diagnosis: Chest X-ray confirmation of a new pulmonary congestion OR TWO or more of the following: Blood oxygen saturation level below 92% on room air or on usual O 2 settings in patients with chronic oxygen requirements New or worsening pulmonary rales New or worsening edema New or increased jugulo-venous distension BNP>300 Symptomatic Guidance: Acute onset of dyspnea (shortness of breath), orthopnea (SOB when lying down), paroxysmal nocturnal dyspnea (SOB waking the patient at night), new or increased leg or presacral edema and/or unexpected weight gain. Treatment: Increased diuretic therapy, obtain EKG to rule out cardiac ischemia or arrhythmias such as atrial fibrillation that could precipitate heart failure, vital sign or cardiac monitoring every shift, daily weights, oxygen therapy, low salt diet, and review of medications, including beta-blockers, ACE inhibitors, ARBS, aspirin, spironolactone, and statins, monitoring renal function, laboratory and radiologic monitoring Maximum Benefit Period 7 Days Skin Infection Qualifying Diagnosis: New onset of painful, warm and/or swollen/indurated skin infection requiring oral or parenteral antibiotic therapy If associated with a skin ulcer or wound, there is an acute change in condition with signs of infection, such as purulence, exudate, fever, new onset of pain and/or induration. Treatment: Frequent turning, nutritional assessment and/or supplementation, at least daily wound inspection and/or periodic wound debridement, cleansing, dressing changes and antibiotics (oral or parental) Maximum Benefit Period: 7 Days Page 8
Acute care fluid or electrolyte disorder or dehydration Acute care chronic obstructive pulmonary disease (COPD)/asthma This code is for the onsite acute care treatment of a nursing facility resident with fluid or electrolyte disorder or dehydration (similar pattern). May only be billed once per day per beneficiary. This code is for onsite acute care treatment of a resident with COPD or asthma. May only be billed once per day per beneficiary. Fluid or Electrolyte Disorder, or Dehydration Qualifying Diagnosis: Any acute change in condition AND TWO or more of the following Reduced urine output in 24 hours or reduced oral intake by approximately 25% or more average intake for three consecutive days New onset of systolic BP 100 mm Hg (lying, sitting or standing) 20% increase in blood urea nitrogen (e.g. from 20 to 24) 20% increase in serum creatinine (e.g. from 1.0 to 1.2) Sodium 145 or < 135 Orthostatic drop systolic BP of 20 mmhg or more going from supine to sitting or standing Treatment: Parental (IV or clysis) fluids, lab/diagnostic test coordination and reporting, and careful evaluation for the underlying cause, including assessment of oral intake, medications (diuretics or renal toxins), infection, shock, heart failure and kidney failure Maximum Benefit Period: 5 days COPD/Asthma Qualifying Diagnosis: Known diagnosis of COPD/asthma or CXR showing COPD with hyperinflated lungs and no infiltrates AND TWO or more of the following: Symptoms of wheezing, shortness of breath or increased sputum production Blood oxygen saturation level below 92% on room air or on usual O 2 settings in patients with chronic oxygen requirements Acute reduction in Peak Flow or FEVI on spiromentry Respiratory rate > 24 breaths/minute Treatment: Increased bronchodilator therapy, usually with a nebulizer, IV or oral steroids, oxygen and sometimes antibiotics Maximum Benefit Period: 7 Days Page 9
Acute care urinary tract infection (UTI) This code is for the onsite acute care treatment of a nursing facility resident for a UTI. May only be billed once per day per beneficiary. Urinary Tract Infection Qualifying Diagnosis: >100,000 colonies of bacteria growing in the urine with no more than two species of microorganisms AND One or more of the following: Fever>100 F (oral) or two degrees above baseline Peripheral WBC count > 14,000 Symptoms of: dysuria, new or increased urinary frequency, new or increased urinary incontinence, altered mental status, gross hematuria, or acute costovertebral angle pain or tenderness Symptomatic Guidance: Dysuria, frequency, new incontinence, altered mental status, hematuria, CVA tenderness Treatment: Oral or parenteral antibiotics, lab/diagnostic test coordination and reporting, monitoring and management or urinary frequency, incontinence, agitation and other adverse effects Maximum Benefit Period: 7 Days Facility Payment Onsite acute care: Approximately $218 per day Twenty percent beneficiary co-insurance or payment of a deductible under the model is waived Payments to a SNF for onsite acute care are subject to ALL of the below criteria: 1. The confirmation of the qualifying diagnosis and the prescription of treatment by the attending practitioner o This confirmation must include an in-person evaluation by a practitioner or a qualifying telemedicine assessment with minimum system requirements as determined by CMS by the end of the second day after the change in condition. 2. The in-person practitioner evaluation is a separately billable service and not included in the onsite acute care payment 3. The LTC facility may also need to complete a Minimum Data Set (MDS) assessment for a significant change in condition (not included in the onsite acute care payment). Page 10
Note: This visit by the practitioner is not included in the onsite acute care payment. If billed separately by a non-eccp practitioner (e.g. attending physician), it is billed separately by the practitioner. ECCP practitioners (e.g. NPs) may conduct the visit to confirm the diagnosis to qualify the LTC facility for payment. In this case, Medicare is not billed (consistent with the terms and conditions of the initiative), but ECCPs are required to provide comparable information to CMS in lieu of a claim. Practitioner Payment Treatment First visit assessment: Approximately $70 increase Nurse practitioners and physician assistants are reimbursed at 85 percent of the physician fee schedule amount. When a practitioner sees a beneficiary in the LTC facility for an acute change in condition, the practitioner would be paid for the service at the equivalent of an acute hospital initial visit code. This code could only be used for the first visit in an LTC facility in response to a beneficiary who has experienced an acute change in condition (to confirm and treat the diagnosed conditions). Subsequent visits would be billable at current rates using existing codes. In conjunction with the visit, the LTC facility may also need to complete a corresponding MDS assessment for a significant change in condition. A practitioner may bill for the acute nursing facility care service even if the service is furnished because a LTC facility suspects that a beneficiary has one of the six targeted conditions, but upon examination it turns out that the beneficiary does not have such a condition. Finally, this code could also be billed for beneficiaries in the target population who have Medicaid currently paying for their stay as well as beneficiaries in the target population who are on a covered Medicare Part A SNF stay, and per the requirements listed above. Practitioner Payment Care Conferences Nursing facility conference: $77.64 Nurse practitioners and physician assistants are reimbursed at 85 percent of the physician fee schedule amount. As with the first component of the payment model, CMS intends to waive any requirement for a 20 percent beneficiary coinsurance or payment of a deductible under the model. Page 11
In order to bill for this service, the practitioner must conduct the discussion: 1. With the beneficiary and/or individual(s) authorized to make health care decisions for the beneficiary (as appropriate) 2. In a conference for a minimum of 25 minutes 3. Without performing a clinical examination of the beneficiary during the discussion (this should be conducted as needed through regular operations -- this session is focused on a care planning discussion) 4. With at least one member of the LTC facility interdisciplinary team 5. And document the conversation in the beneficiary s medical chart o This documentation should include information on the above requirements of the conversation. Where possible, the documentation could be created electronically in the LTC facility s EHR and electronically exchanged with the practitioner and other members of the interdisciplinary team. The project described was supported by Funding Opportunity Number CMS-1E1-16-001-10 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of the HHS or any of its agencies. Page 12
Work Plan Group B (Nevada) Work Plan CMS Deadline Start Complete Responsible Contract Award Date 3/24/16 Kick-off Teleconference 3/31/16 3/31/16 CMS Detailed Work Plan 4/7/16 4/7/16 HI-LJ Facility Recruitment Obtain signed participation agreements 10/1/15 10/28/15 HI Screening CMS approval of screened facilities 6/22/16 6/22/16 CMS Practitioner Recruitment Develop Educational Packet 4/15/16 HI-AM Implement Group B website resource 4/6/16 4/15/16 HI-AM Develop letter of intent 4/14/16 4/21/16 HI-AM Develop education/recruitment material 4/14/16 4/21/16 HI-AM Develop education/recruitment webinar 4/14/16 4/21/16 HI-AM Complete data collection regarding practitioner criteria 4/22/16 5/9/16 HI-DH Confirm practitioner contacts 4/22/16 5/9/16 HI-Pods Distribute education/recruitment material 4/22/16 5/6/16 HI-AM Conduct education/recruitment webinar #1 4/22/16 HI-AM Develop participation agreement 4/28/16 5/5/16 HI-Pods Recruitment personal contacts 4/29/16 5/23/16 Singh/ Erickson Obtain signed letters of intent 5/23/16 4/29/16 5/23/16 HI-AM Obtain signed participation agreements 8/15/16 HI-AM Education and Learning Community Develop detailed education plan 5/2/16 5/31/16 HI-EC Education support on-site 6/1/16 10/24/16 HI-Pods Page 13
Group B (Nevada) Work Plan CMS Deadline Start Complete Responsible Group B teleconference 6/15/16 HI-AM Group B webinar 7/15/16 HI-AM Group A & B joint teleconference 8/15/16 HI-DH Group B webinar 9/15/16 HI-AM Group B joint teleconference 10/14/16 HI-AM Readiness Review Finalize readiness review tracker documentation 5/2/16 5/10/16 HI-SH Conduct initial readiness review of targeted facilities 5/10/16 5/31/16 HI-SH Compile action plans from each facility for meeting readiness review 6/1/16 6/30/16 HI-SH Direct Pod staff training efforts for meeting readiness review 6/1/16 7/30/16 Conduct readiness review against action plans 7/1/16 7/30/16 HI-SH Finalize readiness reviews 8/1/16 8/15/16 HI-SH Submission of Readiness Review Tracker 9/1/16 9/1/16 HI-SH Initiative Payment Period 10/1/16 10/1/16 CMS Monitoring and Reporting (as defined by CMS) 10/1/16 9/30/20 HI HI-LJ = Leslie Johnstone HI-EC = Eileen Colen HI-AM = Adriana Mahoney HI-DH = Deb Himes HI-SH = Saundra Hart Singh = Dr. Singh Erickson = Steve Erickson, PA CMS = Centers for Medicare & Medicaid Services Page 14