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Diagnosis and Management > Advanced Primary Care > Flashcards

Advanced Primary Care Flashcards

1
Q

Complex Chronic Illness Models

A
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2
Q

The Why..

  • US ______ diseases account for 70% of all deaths
  • US 48 million Americans report a (1) related to a chronic disease
  • 2030 Age 65 >6/10 will be managing more than ___ chronic disease
  • We are preparing for the so-called “gray ______:” by 2060, one quarter of Americans will be __ or older, up from 15 percent in 2015
  • Many more providers will need to be able to manage advanced illness in _______ based settings
A
  • US Chronic diseases account for 70% of all deaths
  • US 48 million Americans report a disability related to a chronic disease
  • 2030 Age 65 >6/10 will be managing more than one chronic disease
  • We are preparing for the so-called “gray tsunami:” by 2060, one quarter of Americans will be 65 or older, up from 15 percent in 2015
  • Many more providers will need to be able to manage advanced illness in community based settings
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3
Q

Advanced Primary Care

  • Advanced primary care, or APC, is a practice model that incentivizes q____ and v____
  • This comprehensive, coordinated approach to patient care focuses on pr____ and improved disease management
  • It also supports superior performance on q_____ measures, rather than volume of services delivered, with enhanced payment
  • Primary care is essential for patients with chronic diseases that progress over time, to prevent them from having to seek care in ____ acuity care settings
A
  • Advanced primary care, or APC, is a practice model that incentivizes quality and value
  • This comprehensive, coordinated approach to patient care focuses on prevention and improved disease management
  • It also supports superior performance on quality measures, rather than volume of services delivered, with enhanced payment
  • Primary care is essential for patients with chronic diseases that progress over time, to prevent them from having to seek care in higher acuity care settings
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4
Q

Practices Have the Freedom to Innovate While Implementing Core Functions of Comprehensive Primary Care

  1. Primary Care Function (PCF) that ensures Access and Continuity?
  2. PCF that ensures care management?
  3. PCF that ensures comprehensiveness and coordination? (2)
  4. PCF that ensures patient and caregiver engagement?
  5. PCF that ensures planned care and population health?
A
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5
Q

Participants Achieve Model Aims Through Innovations in Their Care Delivery

  1. Acc____ and C______
  2. Care M________
  3. Com_______ and Coo_______
  4. Patient and Caregiver En_______
  5. Pl_____ Care and Pop_____ Health
A
  • We are not care coordinators (RNs)- we are independent providers
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6
Q

The PCF Payment Model Option Emphasizes Flexibility and Accountability

A
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7
Q

The High Need Population Payment Model Option Increases Seriously Ill Populations’ Access to Primary Care

  • PCF incorporates the following unique aspects for practices electing to serve seriously ill populations to increase _____ to high-quality advanced primary care

Eligibility and Beneficiary Attribution

  • Practices demonstrating relevant capabilities can opt in to be assigned (1) patients or beneficiaries who lack a primary care practitioner or care coordination
  • Medicare enrolled clinicians who provide (1) or (1) care can partner with participating practitioners
A
  • PCF incorporates the following unique aspects for practices electing to serve seriously ill populations to increase access to high-quality advanced primary care

Eligibility and Beneficiary Attribution

  • Practices demonstrating relevant capabilities can opt in to be assigned SIP patients or beneficiaries who lack a primary care practitioner or care coordination
  • Medicare enrolled clinicians who provide hospice or palliative care can partner with participating practitioners
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8
Q

Practices Participating in the High Need Population Model Option Must Meet the Following Eligibility Requirements

  1. Include practitioners serving seriously ill populations (MD, DO, CNS, NP, PA) in good standing with (1)
  2. Meet basic com______ to successfully manage com____ patients and demonstrate relevant clinical capabilities (e.g., interdisciplinary teams, comprehensive care, person-centered care, family and caregiver engagement, 24/7 access to a practitioner or nurse call line)
  3. Have a n_______ of providers in the community to meet patients’ long term care needs for those only participating in the SIP option
  4. Use 2015 Edition Certified ______ Health Record T_______ (CEHRT), support data ex______ with other providers and health systems via Application Programming Interface (API), and, if available, connect to their regional health information exchange (HIE)
A
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9
Q

NYS

  • New York State Department of Health (NYSDOH), in collaboration with the National Committee for Quality Assurance (NCQA) launched an innovative model for primary care transformation known as the (1) (NYS PCMH).
  • The statewide innovative advanced primary care approach is characterized by a systemic focus on high ______ care, po______ health and integrated b______ health
A
  • New York State Department of Health (NYSDOH), in collaboration with the National Committee for Quality Assurance (NCQA) launched an innovative model for primary care transformation known as the New York State Patient Centered Medical Home (NYS PCMH).
  • The statewide innovative advanced primary care approach is characterized by a systemic focus on high quality care, population health and integrated behavioral health
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10
Q

PCMH-EHR/Metrics and RN Coordinators

Some key objectives of the transition to a PCMH included:

  • Improved key metrics such as compliance with recommended preventive sc______
  • Controlled blood _____, as evidenced by reported (1) levels in patients with diabetes
  • Blood ______ within guidelines for patients with hypertension
  • A decrease in (1) visits and ___-day hospital readmission rates
  • A decline in r______ to specialty providers, and
  • Increased use of _______ prescriptions when appropriate
A
  • Some key objectives of the transition to a PCMH included:
    • Improved key metrics such as compliance with recommended preventive screening
    • Controlled blood sugar, as evidenced by reported glycated hemoglobin levels in patients with diabetes
    • Blood pressure within guidelines for patients with hypertension
    • A decrease in emergency department (ED) visits and 30-day hospital readmission rates
    • A decline in referrals to specialty providers, and
    • Increased use of generic prescriptions when appropriate
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11
Q

Extended Stay Clinic

  • Remote clinics to treat patients for more extended periods, including over_____ stays
  • Seriously or critically ill or injured patients who, due to adverse weather conditions or other reasons, could not be transferred to acute care hospitals, or patients who needed mo______ and observation for a limited period of time
  • C___-models
A
  • Remote clinics to treat patients for more extended periods, including overnight stays
  • Seriously or critically ill or injured patients who, due to adverse weather conditions or other reasons, could not be transferred to acute care hospitals, or patients who needed monitoring and observation for a limited period of time
  • CMS-models
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12
Q

LTACHs

=

  • Pr_____ LTACHs
  • Specific patient populations and types of conditions for which having care in a more intensive setting can improve outcomes for patients
A

Long Term Acute Care Hospitals

  • Progressive LTACHs
  • Specific patient populations and types of conditions for which having care in a more intensive setting can improve outcomes for patients
  • For pts who don’t need level of care of a hospital but cannot be managed at home, ie for those who need IV abx, high flow oxygen, intense rehab etc.
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13
Q

Inpatient Rehab Facilities (IRF)

=

  • Patients who are admitted must be able to tolerate _____ hours of intense rehabilitation services per day
  • (4) IRF’s in NYC
A

Freestanding rehabilitation hospitals and rehabilitation units in acute care hospitals

  • Patients who are admitted must be able to tolerate three hours of intense rehabilitation services per day
  • Rusk
  • Burke
  • Helen Hayes
  • Kessler
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14
Q

Advanced Illness Management (AIM)

  • SUTTER HEALTH
  • 2700 patients followed a day
    • Conditions include _____ failure, c______, C____, end stage _____ disease, end stage _____ disease
    • Sutter Health’s Advanced Illness Management program has produced annual savings of $8,000 to $9,000 per patient
      • T______ RN
      • RN H_____ visits
      • S_____ Work
      • NP/MD-____ visits
A
  • SUTTER HEALTH
  • 2700 patients followed a day
    • Conditions include heart failure, cancer, COPD, end stage renal disease, end stage neural disease
    • Sutter Health’s Advanced Illness Management program has produced annual savings of $8,000 to $9,000 per patient
      • Telephonic RN
      • RN Home visits
      • Social Work
      • NP/MD-home visits
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15
Q

Post Acute Care

  • Post acute care (PAC) includes re______ or p_____ services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital
  • Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing ____patient therapy, or care provided at h____
  • Examples =
A
  • Post acute care (PAC) includes rehabilitation or palliative services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital
  • Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing outpatient therapy, or care provided at home
  • Examples
    • Primary Care Clinics
    • Post-discharge clinics
      • Post Intensive Care Clinics (PICS)
      • AAFP Article/Review
    • Chronic-care/high risk clinics
    • Home Care
    • Tele-health
    • Nursing Homes
    • Long term acute care hospitals (LTACH) can be used as substitutes for short-term acute care
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16
Q

PICS and PICS-F ‘

Post Intensive Care Syndrome

Focused on integrating the (1) after ICU and focuses alot on C______ to maximize f_____ outcomes

A

Focused on integrating the (1) after ICU and focuses alot on Cognition to maximize functional outcomes

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17
Q

Post Intensive Care Syndrome

Survivor

  1. C______ Impairments
  2. Ph_____ Impairments*
  3. M_____ Health

Family

  1. M_____ Health
A

Survivor

  1. Cognitive Impairments
  2. Physical Impairments*
  3. Mental Health

Family

  1. Mental Health
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18
Q

Post Covid Clinics

  • Montefiore
    • Any patient who has had a COVID-19+ test (PCR or IgG antibody), whether the illness was mild and treated at home or severe and required hospitalization
    • Clinic Scope: The CORE clinical referral will be for patients who have had COVID-19 infection and have:
      • Questions, concerns, and/or new or r______ symptoms
      • New or worsening impairments in their phy____, cog____ or em______ health after a recent hospitalization
A
  • Montefiore
    • Any patient who has had a COVID-19+ test (PCR or IgG antibody), whether the illness was mild and treated at home or severe and required hospitalization
    • Clinic Scope: The CORE clinical referral will be for patients who have had COVID-19 infeciton and have:
      • Questions, concerns, and/or new or residual symptoms
      • New or worsening impairments in their physical, cognitive or emotional health after a recent hospitalization
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19
Q

Post Covid Clinic Mount Sinai

  • Treating the Whole ______, Not Just the Disease
  • The Center has the resources to help you manage an____ and dep_____, P_ _ _, and other emotional issues
  • Getting “back to n_____” may require physical therapy, occupational therapy, or other types of support - whether in groups or one-on-one. Whatever your needs, the Center is a compassionate, holistic source of care.
A
  • Treating the Whole Person, Not Just the Disease
  • The Center has the resources to help you manage anxiety and depression, PTSD, and other emotional issues
  • Getting “back to normal” may require physical therapy, occupational therapy, or other types of support - whether in groups or one-on-one. Whatever your needs, the Center is a compassionate, holistic source of care.
20
Q

Home Based Primary Care

  • Home based primary care practices
    • Optimize care by: fielding interdisciplinary teams, incorporating be_____ care and s_______ supports into primary care, responding rapidly to urgent and acute care needs, offering p______ care, and supporting f____ members and caregivers
    • Examples (3)
A
  • Home based primary care practices
    • Optimize care by: fielding interdisciplinary teams, incorporating behavioral care and social supports into primary care, responding rapidly to urgent and acute care needs, offering palliative care, and supporting family members and caregivers
  1. Manhattan House Calls- NP Model Northwell-
  2. Mount Sinai Visitng Doctors Program
  3. Essen
21
Q

Chronic Care Management

=

  • 994__ non complex CCM is a 20 minute timed service provided by clinical staff to coordinate care across providers and support patient accountability
  • 994__ complex CCM is a 60-minute timed services provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate-to high complexity medical decision making
  • 994__ is each additional 30 minutes (cannot be billed with CPT code 99490)
  • 994__ CCM services provided personally by a physician or other qualified HCPs for 30 minutes
A

Chronic care management (CCM) are generally non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

  • 99490 non complex CCM is a 20 minute timed service provided by clinical staff to coordinate care across providers and support patient accountability
  • 99487 complex CCM is a 60-minute timed services provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate-to high complexity medical decision making
  • 99489 is each additional 30 minutes (cannot be billed with CPT code 99490)
  • 99491 CCM services provided personally by a physician or other qualified HCPs for 30 minutes
22
Q

Advanced Care Planning for Chronic/Advanced Illness

  • Table 1. CPT Codes and Descriptors CPT Codes Billing Code Descriptors
  • 99497 Advance care planning including the explanation and discussion of advance d______ such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; _____ 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
  • 99498 Advance care planning including the explanation and discussion of advance d______ such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each ______ 30 minutes (List separately in addition to code for primary procedure)
A
  • Table 1. CPT Codes and Descriptors CPT Codes Billing Code Descriptors
  • 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
  • 99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)
23
Q

Managing Chronic Care Needs from the Community

A
24
Q

Hospital Readmissions Reduction Program (HRRP)

The Hospital Readmissions Reduction Program (HRRP) is a Medi____ value-based purchasing program that ______ payments to hospitals with excess readmissions. The program supports the national goal of improving healthcare for Americans by linking payment to the ______ of hospital care.

Upcoming Waiver Program

  • C_ _
  • C_ _ _
  • E_ _ _
  • Pn______
  • Hotspotting-recent data, s_____ determinants of health and housing
A

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing program that reduces payments to hospitals with excess readmissions. The program supports the national goal of improving healthcare for Americans by linking payment to the quality of hospital care.

Upcoming Waiver Program

  • CHF
  • COPD
  • ESRD
  • Pneumonia
  • Hotspotting-recent data, social determinants of health and housing
25
Q

Medicare Qualifiers

  • Age ___+ or ___
  • US C_____ or Permanent L_____ Resident
  • Exceptions: (2)
A
  • Age 65+ or SSD (disabled)
  • US Citizen or Permanent Legal Resident
  • Exceptions: ALS or ESRD
26
Q

Medicaid Qualifiers

=

A

Means tested (Financial)

NYS: $934/Month

(payer’s last resort, medicaid kicks in after medicare exhausted)

27
Q

Medicare Covers

  • H______ stays
  • ____patient appointments
  • Emergency Ambulance t_____
  • Short term _____ stay (SAR)
    • Certification period is ___ days
    • One time benefits of ___ lifetime days
  • Short term _____ care
A
  • Hospital stays
  • Outpatient appointments
  • Emergency Ambulance transport
  • Short term rehab stay (SAR)
    • Certification period is 90 days
    • One time benefits of 60 lifetime days
  • Short term home care
28
Q

Medicaid Covers

  • H______ stays
  • ___patient appointments
  • Emergency and outpatient tr______
  • Short and long term care in (1)
  • Short and long term care at ______
  • Selected ass______ living facilities
A
  • Hospital stays
  • Outpatient appointments
  • Emergency and outpatient transportation
  • Short and long term care in skilled nursing facilities
  • Short and long term care at home
  • Selected assisted living facilities
29
Q

Applying for Coverage

A
  • HRA offices (Health Reimbursement Arrangement)
  • City Hospitals
  • Private hospital if already admitted
  • NY State of Health Marketplace https://nystateofhealth.ny.gov/
30
Q

Emergency Medicaid

For who?

  • Covers ac_____ hospital stay
  • Outpatient life _______ treatment (Hemodialysis, Chemotherapy, Radiation)
  • Outpatient care can be provided at (1) Health Centers for sliding scale services (appointments and pharmacy services)
    • Applications are reviewed at FQHC or Hospital-based Medicaid Offices
A

For undocumented patients

  • Covers acute hospital stay
  • Outpatient life sustaining treatment (Hemodialysis, Chemotherapy, Radiation)
  • Outpatient care can be provided at Federally Qualified Health Center (FQHC) for sliding scale services (appointments and pharmacy services)
    • Applications are reviewed at FQHC or Hospital-based Medicaid Offices
31
Q

Certified Home Health Agency Services (CHHA)

  • Short term _____ services at ____ (Under Medi____*, Medicaid or Commercial)
  • Must have ______ need: RN (wound care, HF management) and or PT/OT
  • Possible home (1) while skilled need continues
  • Requires MD/NP _____ (Face to Face - PECOS certification required)
  • Social Work home s_____ evaluation
    • Example (1)
    • 886-MD CALLs (866-632-2557)
A
  • Short term skilled services at home (Under Medicare*, Medicaid or Commercial)
  • Must have skilled need: RN (wound care, HF management) and or PT/OT
  • Possible HHA while skilled need continues
  • Requires MD/NP order (Face to Face - PECOS certification required)
  • Social Work home safety evaluation
    • VNS
    • 886-MD CALLs (866-632-2557)
32
Q

Managed Long Term Care (MLTC)

=

  • Referrals to Maximus (Conflict Free Evaluation Service)
  • Requires in-home evaluation by ___ for eligible hours
    • CDPAP =
      • _____ member is paid to be home attendant
      • Family member _____ hold another job and cannot be the health care agent
      • Maximum hours approved is ___ hours/week
      • Potential for c_____ of interest
A

Medicaid program for long term home attendant services

  • Referrals to Maximus (Conflict Free Evaluation Service)
  • Requires in-home evaluation by RN for eligible hours
    • Consumer Directed Personal Assistant Program (CDPAP)
      • Family member is paid to be home attendant
      • Family member cannot hold another job and cannot be the health care agent
      • Maximum hours approved is 40 hours/week
      • Potential for conflict of interest
33
Q

Charity Care for Hospital Transitions

  • M_______
  • D______ Medical E______
  • H____ care services
  • Hos______
  • Follow up care is at FQHC
    • *All companies are required to give __% back as charity services if they are a for-p_____ entity
A
  • Medications
  • Durable Medical Equipment
  • Home care services
  • Hospice
  • Follow up care is at FQHC
    • *All companies are required to give 20% back as charity services if they are a for-profit entity
34
Q

Hospice

  • Life expectancy of __ months or less
  • Not pursuing _______ treatments (or palliative chemo or radiation)
  • P____ and s_____ management
  • RN/MSW visits, limited HHA services, DME, pain meds
A
  • Life expectancy of 6 months or less
  • Not pursuing curative treatments (or palliative chemo or radiation)
  • Pain and symptom management
  • RN/MSW visits, limited HHA services, DME, pain meds
35
Q

Private Pay and Foundations

  • Home ______ services - $28/hr
    • (Partners in Care, Best Care, Allen Home Care)
  • Expanded In-home Services for the _____ (EISEP) - Department for the A____
  • NY Foundation for S_____ (3 months of services for $13.50/hr - then negotiated rate for 9 months)
A
  • Home attendant services - $28/hr
    • (Partners in Care, Best Care, Allen Home Care)
  • Expanded In-home Services for the Elderly (EISEP) - Department for the Aging
  • NY Foundation for Seniors (3 months of services for $13.50/hr - then negotiated rate for 9 months)
36
Q

Health Homes

  • C_____ management services offered through Medicaid to co_____ care, support access to be_____ services, social service needs
  • Criteria
    • ____ or more chronic conditions or one single qualifying condition (ie HIV/AIDs, serious mental illness)
A
  • Case management services offered through Medicaid to coordinate care, support access to behavioral services, social service needs
  • Criteria
    • Two or more chronic conditions or one single qualifying condition (ie HIV/AIDs, serious mental illness)
37
Q

Health Plans

  • Contact Provider Services on the patient’s Health Plan Card
  • Ask for C____ Management/Care C_______ Services (disease management, chronic care management, intensivist care) for maintenance and oversight
  • Patients should always be encouraged to review b_____ on the plan’s website or call Member Services
A
  • Contact Provider Services on the patient’s Health Plan Card
  • Ask for Case Management/Care Coordination Services (disease management, chronic care management, intensivist care) for maintenance and oversight
  • Patients should always be encouraged to review benefits on the plan’s website or call Member Services
38
Q

Community Partners

  • Meals on _____ (Case Management)
  • G___’s Love We Deliver
  • S_____Centers
  • Adult D___ Programs
  • N______ Occurring Retirement Communities

HITE Site: Online resource directory for NYC

A
  • Meals on Wheels (Case Management)
  • God’s Love We Deliver
  • Senior Centers
  • Adult Day Programs
  • Naturally Occurring Retirement Communities

HITE Site: Online resource directory for NYC

39
Q

Behavioral Health

Psych Referrals

A
40
Q

Behavioral Health

Substance abuse referrals

=

A
41
Q

Women, Infants and Children

A
  • Services for low-income pregnant and breastfeeding women and women with children under age 5.
    • Nutrition services
    • Breastfeeding counseling
    • Food coupons
  • WIC Medical Referral Form
42
Q

Transportation to medical appointments

  1. MAS =
  2. ______ a Ride
  3. ____ Discount
A
43
Q

Pharmacy

  • Med to B___ Options
  • Home de______ medications
  • Verifying be_____
  • Medicare Part __
    • Donut Hole
    • EPIC
    • Prescription assistance programs
A
  • Med to Bed Options
  • Home delivered medications
  • Verifying benefits
  • Medicare Part D
    • Donut Hole
    • EPIC
    • Prescription assistance programs
44
Q

Case Management Professional Organizations

(2)

A

Case Management Society of America (CMSA)

American Case Management Association (ACMA)

45
Q

ED Navigator Programs

A

Call most emergency rooms and there will be an ED navigator or case manager who can help with communication and care coordination if visit is not indicated

46
Q

Adult Protective Services

=

A

The Adult Protective Services Program (APS) provides services for physically and/or mentally impaired adults. APS works to help at-risk clients live safely in their homes. APS clients can be referred by anyone.

Not ACS

47
Q

COVID Resources

(1), website (1)

  • T_____ locations and v_____ sites
  • Fi______ assistance
  • H_____
  • H______ for quarantining
  • F______ resources
  • M______ Health Resources (nycwell)
A

311 or www.nyc.gov

  • Testing locations and vaccination sites
  • Financial assistance
  • Housing
  • Hotels for quarantining
  • Funeral resources
  • Mental Health Resources (nycwell)

Diagnosis and Management (36 decks)

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