Transcript The Value of ICF - Kidney Supportive Care

End Stage Renal Disease:
When Is It Time for Hospice?
With
Perry Fine, MD
Harry Feliciano
Malene Davis
1
Introduction and
Background
Perry G. Fine, MD
Professor, School of Medicine, U. of Utah
And
Senior Fellow for Medical Leadership, NHPCO
Panel
Harry Feliciano, MD
Medical Director
Palmetto GBA, Columbia, SC
Malene Davis, RN, MBA
President and CEO, Capital Hospice
Chairwoman of the Board, NHPCO
Use of Hospice in the
US Dialysis Population
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US Renal Data System
2-yr cohort 1/1/01-12/31/02=115,239 pts
Medicare as primary payer (78% of pts)
Death-related characteristics
– Age at death
– Cause of death
– State in which death occurred
Hospice in ESRD Population
• Secondary 6-month cohort in which pts
on dialysis for entire 6 months prior to
death
• Costs of care and site of death
• Withdrawal status from CMS 2746 form
• Hospice status from CMS hospice claims
Standard Analytical Files
Murray et al. Use of Hospice in the United States Dialysis Population.
Clinical J Am Soc Nephrol. 2006;1:1248-1255.
Death After Dialysis Withdrawal:
Are these patients hospice eligible?
Study
Year
N
Mean
Range
Neu &
Kjellstrand
1986
155
8.1 days
1 - 29
Sekkarie &
Moss
1998
60
12 days
0 - 150
Cohen et al
2000
126
8.2 days
1 - 46
96% of patients dead within 30 days of dialysis withdrawal
Murray et al. Use of Hospice in the United States Dialysis Population.
Clinical J Am Soc Nephrol. 2006;1:1248-1255.
Medicare Benefit Policy Manual
Chapter 11 – End Stage Renal Disease (ESRD)
Table of Contents
(Rev. 27, Issued 11-23-04)
http://www.cms.hhs.gov/manuals/Downloads/bp102c11.pdf
50.6.1.4 – Coverage Under the Hospice Benefit
(Rev. 1, 10-01-03)
If the patient’s terminal condition is not related to ESRD, the patient
may receive covered services under both the ESRD benefit and the
hospice benefit. A patient does not need to stop dialysis treatment to
receive care under the hospice benefit. Consequently, hospice
agencies can provide hospice services to patients who wish to
continue dialysis treatment.
Current Benefit Summary
• CMS provides hospice benefit for ESRD
• Withdrawal not a prerequisite
• Individual hospice entities have the option
to choose NOT to accept ESRD patients
• Non-ESRD terminal diagnosis required
for ESRD patients choosing to continue
dialysis, retain their ESRD benefit, AND
be covered with hospice benefit
Conclusions
• Underutilization of hospice, especially for
patients who withdraw
• Higher use for older patients
• Hospice results in lower EOL costs and more
deaths at home
• Regional variation in hospice use requires
further attention
• Bottom line: Opportunity to improve access to
hospice for dialysis patients
ICD-9-CM 585.6
End-stage Renal Disease
Harry Feliciano, MD, MPH
Director, Part A Medical Affairs
May 10, 2007
Going Beyond
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Diagnosis
Case Scenario
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Diagnosis
Care Pathways
• Routes to consider when addressing common
clinical scenarios in a traditional Medicare
reimbursement environment
• Medicare coverage creates care pathways
• The selection of particular pathways is often
affected by provider/beneficiary/caregiver:
– Knowledge
– Experience
– Preference
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Diagnosis
Care Pathways Available to JP
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Inpatient Care
Skilled Nursing Facility Care
Outpatient Care
Home Health Care
Hospice Care
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Diagnosis
Identifying Viable Care Pathways for JP
Requires Specific Information
• Knowledge regarding existing advanced
directives
• Beneficiary prognosis
– What is his baseline functional status?
– Are impairments easily reversible?
– What is the anticipated response to any proposed
intervention?
• Availability of health care resources
• Availability of coverage under Medicare
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Diagnosis
Need for Decision Support
• Types of decisions:
– Structured decisions
• Repetitive, routine problems; clear procedures exist
– Unstructured decisions
• Non-routine, require decision-maker to provide judgment,
evaluation and insight in defining problem. No wellunderstood or agreed upon procedure exists
– Semi-structured decisions
• Only part of the problem has a clear-cut answer provided by
an acceptable procedure.
Source: Management Information Systems: Managing the Digital Firm. Kenneth C. Laudon,
Jane Price Laudon, 9th edition. Prentice Hall, Inc 2006.
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Diagnosis
Relevant Variables
Potential confounding factors
ICD-9-CM
Outcomes
Health status of the individual
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Diagnosis
Describing Health Status
• What is needed?
– A taxonomy (classification system) that
allows Part A providers and physicians to
describe the components of health status.
• The taxonomy must:
– Be comprehensive, valid, and reliable
– Be flexible
– Be relevant throughout the continuum of care
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Diagnosis
The World Health Organization’s
ICF
• International Classification of Functioning,
Disability, and Health (ICF).
• Defines and describes domains using
categories that are relevant to Medicare
providers, and not found in ICD-9-CM.
– Standardizes the characterization of structural and
functional impairments and helps relate them to
activity limitations and participation restrictions
– Includes environmental factors.
– Complements ICD-10
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Diagnosis
Components of ICF
• ICF has two parts, each with two components
– Part 1. Functioning and Disability
• Body Functions and Structures
• Activities and Participation
– Part 2. Contextual Factors
• Environmental Factors
• Personal Factors
• Part 1 describes health domains and Part 2
describes health-related domains
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Diagnosis
Defining and Describing
Functioning & Disability
• Impairments are problems in body
function or structure such as significant
deviation or loss
– Domains include:
• Structures related to movement
• Sensory functions and pain
• Neuromusculoskeletal and movement-related
functions
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Diagnosis
Defining and Describing
Functioning & Disability
• Activity limitations are difficulties an individual
may have in executing activities
• Participation restrictions are problems an
individual may experience in involvement in life
situations.
– Domains include:
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Communication
Mobility
Self-care
Interpersonal interactions & relationships
Community, social, and civic life
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Diagnosis
Defining and Describing
Contextual Factors
• Environmental factors make up the
physical, social, and attitudinal
environment in which people live and
conduct their lives
– Domains include:
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Products and technology
Support and relationships
Attitudes
Services, systems, and policies
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Diagnosis
Variables Supporting Reasonable &
Necessary Services
• Diagnosis
• Impairment
– Structural
– Functional
• Activity Limitation
• Participation Restriction
• Disability
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Diagnosis
Comorbid Conditions
• Comorbid conditions are distinct from the
primary disease
• Common examples in the Medicare population
include:
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Cerebrovascular Disease
Congestive Heart Failure
Chronic Pulmonary Disease
Diabetes
Peripheral Vascular Disease
Coronary Heart Disease
Renal Disease
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Going Beyond
Diagnosis
Secondary Conditions
• Secondary conditions are directly related to a
primary disabling condition
• Common secondary conditions seen with
neuro-musculoskeletal impairments of body
structure and function:
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Pressure ulcers
Joint contractures
Urinary tract infections
Depression
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Diagnosis
Documenting Comorbid &
Secondary Conditions
• Keys to success:
– Identify relevant conditions
– Describe related:
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Structural impairments
Functional impairments
Activity limitations
Participation restrictions
– Incorporate this information into care plan
– Track the effects of any intervention
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Diagnosis
Description of Case
• ICD-9-CM
– 585.6 - End stage renal disease
• Comorbid Conditions
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290.41 Vascular dementia with delirium
787.2 Dysphagia
507.0 Pneumonitis due to solids and liquids
396.2 Mitral valve insufficiency and aortic stenosis
441.4 Aortic aneurysm – Abdominal, without rupture
414.9 Chronic ischemic heart disease, unspecified
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Diagnosis
Going Beyond Diagnosis
• ICF
– Impaired Body Structures
– Impaired Body Functions
– Activity Limitations
– Participation Restrictions
– Environmental Factors
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Diagnosis
Going Beyond Diagnosis:
Structural Domains
• Structures of the nervous system
• Structure of the cardiovascular…and
respiratory system
• Structures related to the digestive,
metabolic & endocrine systems
• Structure related to the genitourinary and
reproductive system
Going Beyond
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Diagnosis
Going Beyond Diagnosis:
Functional Domains
• Mental function
• Functions of the cardiovascular…and
respiratory system
• Functions of the digestive, metabolic and
endocrine system
• Genitourinary and reproductive functions
• Neuromusculoskeletal and movement related
functions
Going Beyond
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Diagnosis
Going Beyond Diagnosis:
Activity & Participation Domains
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General tasks and demands
Mobility
Self Care
Interpersonal interactions and relationship
Going Beyond
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Diagnosis
Going Beyond Diagnosis:
Environmental Factors Domains
• Products and technology
• Support and relationships
• Services, systems, and policies
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Diagnosis
Palmetto GBA’s Approach
• Utilize the domains contained in the ICF
to draft a new Hospice Local Coverage
Determination (LCD) to help providers
document reasonable and necessary
services.
• Use case scenarios to help educate Part
A providers and physicians regarding
care pathways available to Medicare
beneficiaries.
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Diagnosis
Draft Hospice Renal Care LCD
• Published March 14, 2007
• Comment period ended April 30, 2007
– Comments currently being reviewed
• Descriptive rather than prescriptive
• Includes both comorbid and secondary
conditions
• Suggests use of ICF framework
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Diagnosis
Information on ICF
• The ICF is available through:
WHO Publications Centre, USA
49 Sheridan Avenue
Albany, New York 12210
Telephone: 518-436-9686
• View online at:
– http://www.who.int/classifications/icf/en
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Diagnosis
Summary
• Going Beyond Diagnosis can be used to:
– Identify relevant health conditions
– Describe health status
– Improve documentation
– Provide decision support
– Educate referral sources
– Promote continuous quality improvement
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Diagnosis
Contact Information
Harry Feliciano, MD, MPH
Director, Part A Medical Affairs
Palmetto GBA
Mail Code AG-300
Post Office Box 7004
Camden, South Carolina 29021-7004
E-Mail: [email protected]
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Diagnosis
Could the Going Beyond Diagnosis
approach to decision-support help your
organization make decisions
concerning: (Click all that apply)
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Diagnosis
Had you ever heard of the ICF prior to
this seminar?
Will this information help you
communicate with physicians?
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Diagnosis
The Hospice
ESRD Patient
Dialysis Center
Interface
Malene Davis, RN, MSN, MBA
Capital Hospice
Falls Church, Virginia
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Growth In ADC
250
243
215
200
187
Open Access
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133
100
69
50
0
75
70
1999
2000
87
45
1997
1998
2001
2002
2003
2004
2005June
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Why offer palliative care and
hospice services in ESRD?
• Heavy symptom burden
• High mortality rate
• High discontinuation of dialysis rate
• Poor quality of dying
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Heavy symptom burden
(N=80)
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fatigue- highest endorsed
insomnia (38%)
cramping (36%)
pruritis (35%)
neuropathic symptoms (29%)
poor spirits (24%)
et al., unpublished. See Cohen LM, Levy NB,
N&V (20%) Cohen
Tessier E, Germain M: Renal Disease. American
Psychiatric Publishing Textbook of Psychosomatic
Medicine, Levenson J (ed), American Psychiatric
Publishing, Inc.
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Symptoms During Last 24 Hours Following
Discontinuation
(N=79)
Symptom
Pain
Agitation
Myoclonus/twitchin
g
Dyspnea/agonal
Fever
Diarrhea
Dysphagia
Nausea
% present
42
30
28
25
20
14
14
13
Cohen et al. AJKD, 2000;36:140-144
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Barriers to the Provision of
Hospice Services for
ESRD Patients
• Financial disincentives
• Lack of patient awareness of life-limiting nature of
ESRD resulting in many not wanting to discuss
end-of-life issues
• Nephrologists and dialysis staff lack of familiarity
with hospice
• Hospice providers lack of familiarity with ESRD
patients and their issues
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Who are the Nephrologists?
Fellowship Survey
Holley et al. Am J Kidney Dis 42(4):813-820, 2003.
• N=171
• Almost all in 2nd year of Nephrology Fellowship
• 73% characterized themselves as more inclined
towards the technological and scientific, rather
than the social and emotional aspects of medical
care.
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Fellows Exposure to Palliative Care
Holley et al.
Geriatric Critical
Care
Completed Rotation
Focused on Palliative
Care
Had Contact with
Palliative Care Specialist
Quality of teaching with
respect to end-of-life
care rated ‘very good’
or ‘excellent’
Nephrol.
71%
2%
1%
80%
46%
45%
53%
34%
15%
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Fellowship Survey
Holley et al.
During your fellowship, were you explicitly taught to:
Determine when to refer to hospice
Respond to request to stop dialysis
Help with reconciliation and goodbyes
Assess and manage depression at eol
Tell patient he/she is dying
Treat pain
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
% fellows who received explicit teaching on topic
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100%
Developing Criteria
• Is the renal problem the ‘terminal’ dx?
• Do other co-morbidities exist? CHF, FTT, CA,
COPD, AIDS,
• Major symptoms
• Documentation: CKD
• Identifying patients: “dwindlers”
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How do we break the cycle?
• Consumers – Building effective
relationships at all levels of the community
is the cornerstone of success
• Health care providers, Dialysis providers
• Nephrologists – Partners in service
-medical director
53
Interfacing dialysis units and
hospice
• Transportation – volunteer support is a
huge asset to the staff at the dialysis
center
• Team – community, health process
• Supportive counseling
• Advance directives
• Family services
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Education
• Renal physicians
• Health care professionals: Dialysis center staff,
Network staff (chains may have several centers
in one geographical area)
• Community Educate dialysis patients, families,
staff hospices, payers on the value, scope and
role of hospice in end of life care 55
Does your hospice admit ESRD patients?
Does your hospice admit ESRD patients
who require dialysis?
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Q&A
57