an acp innovation in sc: chaplain interviews at physician...
Post on 30-Jul-2020
0 Views
Preview:
TRANSCRIPT
An ACP Innovation in SC: ChaplainInterviews at Physician Practices
Tamara Flinchum
Chaplain & ACP Coordinator
AnMed Health, Anderson, SC
Innovation and Excellence in Advanced Illness at End of Life 43rd Annual Hospice & Palliative Care Conference – September 2019 – Greenville, SC
Overview
➢History of Advance Care Planning (ACP) in communities within the reach of AnMed Health
➢ACP Tools: Respecting Choices/Serious Illness Conversation Questions
➢ACP Process: Sample Process Maps
➢Medicare Reimbursement Facts
➢Documentation
➢Charge Capture
➢ACP Initiative in SC: My Life My Choices
Innovation and Excellence in Advanced Illness at End of Life 43rd Annual Hospice & Palliative Care Conference – September 2019 – Greenville, SC
Objectives
At the conclusion of this activity, the learner will be able to describe . . .
• how to use specific ACP tools to facilitate a conversation,
• the process and benefits of scheduled ACP conversations within a healthcare system’s physician practice network,
• a sample method of documentation and charge capture within the EHR.
Innovation and Excellence in Advanced Illness at End of Life
“We’re in this together”
Innovation and Excellence in Advanced Illness at End of Life
How can we have better ACP Conversations that lead to a completed HCPOA?
Mike Johnston, director of Spiritual Care, and Dr. Melody Franks, AH Lakeside Family Medicine, created an innovative plan for ACP at AnMed Health.
Innovation and Excellence in Advanced Illness at End of Life
Not in the Emergency Room
Innovation and Excellence in Advanced Illness at End of Life
Not During a Hospital Stay
Innovation and Excellence in Advanced Illness at End of Life
But at the Physician Practices’Medicare Annual Wellness Visits
Innovation and Excellence in Advanced Illness at End of Life
HISTORY:2016-2019 ACP Outreach to
AnMed Health Family Medicine Practices
• Mike was trained as Respecting Choices First and Last Steps facilitator.
• Four staff chaplains, as well as FCNN Coordinator, were trained as First and Last Steps facilitators. (Total = 6)
• Mike Johnston was trained as an instructor for the First and Last Steps course (one of three in SC).
• Two clinical staff were trained for Anderson Free Clinic. (Total = 8)
• Eight more chaplains were trained. (Total = 16)
Innovation and Excellence in Advanced Illness at End of Life
AH Physician Practices scheduling ACP interviews in 2016-2017
Anderson Family Medicine
Clemson
Fair Play
Family Medicine Center (ACP Residents Clinic)
Hartwell
Honea Path
Lakeside
Williamston (Total = 8)
Innovation and Excellence in Advanced Illness at End of Life
2018-2019 Additions to Physician Practices Scheduling ACP Conversations
• Anderson Free Clinic• Centerville• Pendleton• Westside (Total = 13; active total = 8)
• Cornerstone (referrals to ACP Coordinator)
Four chaplains cover the eight practices; ten do ACP in hospital setting.
Innovation and Excellence in Advanced Illness at End of Life
Began . . .
• ACP interviews in 2016 in 45-minute sessions, 2 days a month for most practices.
• ACP charting in EPIC in Spring 2018.
• Capturing charges in Fall 2018 at a few test practices before charging at all of them.
Innovation and Excellence in Advanced Illness at End of Life
AnMed Health Physician PracticeACP Monthly Schedule
Monday Tuesday Wednesday Thursday Friday
1st Family Medicine
Center
Tamara
1st Monday all day
Begin 8:00 am
Westside
Wanda
1st Friday
morning
Begin 8:30 am
2nd Honea Path
Cindy
2nd Wednesday
all day
Begin 8:30
Lakeside
Tamara
2nd Thursday
afternoon
Begin 1:00 pm
Clemson
Tamara
2nd Friday
morning
Begin 8:30 am
3rd
4th Hartwell
Tricia
4th Monday all day
Begin 8:30 am
(need GA HCPOA)
Anderson
Family
Medicine
Tamara
4th Tuesday
afternoon
Begin 2:00
pm
Centerville
Wanda
4th Thursday
afternoon
Begin 1:45
Innovation and Excellence in Advanced Illness at End of Life
Discussion
• Who could serve as a clinical champion for your department?
• What are the drawbacks to your chaplains visiting physician practices regularly to do ACP?
• What are the benefits?
Innovation and Excellence in Advanced Illness at End of Life
Drawbacks
• Minimal staffing at facility
• Mileage reimbursement
• Cost for non-staff chaplains
• Buy-in from each practice/physician
Innovation and Excellence in Advanced Illness at End of Life
Benefits
• Greater visibility for chaplains
• Possible funding stream?
• Deeper, more thorough ACP conversations
Innovation and Excellence in Advanced Illness at End of Life
Tools for Conversation
Innovation and Excellence in Advanced Illness at End of Life
Respecting Choices First Steps Training
Innovation and Excellence in Advanced Illness at End of Life
Respecting Choices® is an internationally recognized, evidence-based model of advance care planning (ACP) that creates a healthcare culture of person-centered care—care that honors an individual’s goals and values for current and future healthcare.
RC’s goal is to design a system of person-centered care that is guided by the best scientific evidence and is aligned with an individual’s goals and values.
This system requires a shared decision-making process that involves respectful interaction among providers, individuals, and families, and keeps the focus of planning on what matters most to each and every person for any healthcare decision.
https://respectingchoices.org/about-us/
Serious Illness Conversation Guide
Innovation and Excellence in Advanced Illness at End of Life
The Serious Illness Care Program was created by a team of palliative care experts at Ariadne Labs. . . . At the center of the program is the Serious Illness Conversation Guide, which offers clinicians language to ask patients about their goals, values, and wishes. The guide is one element of a multi-component program creating system-level support for clinicians to have these important conversations with their patients.
Findings show that the program resulted in more, earlier, and better conversations between patients and their oncology clinicians, and led to significant reductions in emotional suffering for patients with advanced cancer.
The program’s goal is for every seriously ill patient to have more, better, and earlier conversations with their clinicians about their goals, values, and priorities that will inform their future care.
https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
Drawbacks
Training:• First Steps, 8 hours (on-line modules 6 hours)• Advanced Steps, 8 hours• Serious Illness Conversation class, 3 hoursExpense:• Materials ($155 per participant, plus 30.60 for shipping
and admin fee)• Instructor
You will need funding for training!Contact Wilma Rice at Wilma.Rice@rsfh.com for more information.
Innovation and Excellence in Advanced Illness at End of Life
ACP Questions
• Experience(s) that have shaped their feelings about end of life care
• Important factors for them to live well now• Requirements for them to live well at the end of
life• Aspects that give their life meaning and joy • Cultural/religious/spiritual beliefs that matter to
them/affect their choices• Goals of care for a A) severe, permanent brain
injury or B) Progressive neurological debilitation
Innovation and Excellence in Advanced Illness at End of Life
ACP Questions (continued)
• Most important goals if their health situation worsens
• Greatest fears/worries about the future with their health
• Tradeoffs for the possibility of gaining more time, if they become sicker
• Abilities so crucial to life that they can’t imagine living without them
• Choices for healthcare agent(s) if the patient has a sudden medical event and cannot make their own decisions (is willing and able, can make decisions under stress, and can honor patient’s wishes)
Innovation and Excellence in Advanced Illness at End of Life
Practice
Get in pairs and read the questions to one another.
• What questions do you like?
• What questions are uncomfortable for you?
• What questions don’t “click” with you?
Innovation and Excellence in Advanced Illness at End of Life
Digging deeper . . .
• Experience(s) that have shaped their feelings about end of life careHas a friend or family member had an EOL experience
that you thought, “I don’t want to end up like Aunt Ruth!” Or a positive experience?• Important factors for them to live well now
Describe what you enjoy in a day that is very ordinary, but is still the best day ever!• Requirements for them to live well at the end of life
If you could choose, would you be at home or in the hospital—or at hospice?
Innovation and Excellence in Advanced Illness at End of Life
Digging deeper . . .
• Aspects that give their life meaning and joySocial, faith family, hobbies, activities
• Cultural/religious/spiritual beliefs that matter to them/affect their choicesFaith beliefs—consult your faith group leader if
anything causes you unease.• Goals of care for a A) severe, permanent brain injury or
B) progressive neurological debilitationA) Never aware of environment againB) Body wastes away but brain is functioning
(Questions that lead to tube feeding discussion)
Innovation and Excellence in Advanced Illness at End of Life
Digging deeper . . .
• Most important goals if their health situation worsens
Describe your current medical conditions and potential results. (This information can help with specific details in the “tradeoffs” questions.)
• Greatest fears/worries about the future with their health
Do you worry about your current medical conditions or inherited family medical complaints?
Innovation and Excellence in Advanced Illness at End of Life
Digging deeper . . .
• Tradeoffs for the possibility of gaining more time, if they become sicker
Examples based on disease—chemo, radiation, BiPAP, ventilator support (This can lead to a discussion of quality of life vs. quantity of life.)
• Abilities so crucial to life that they can’t imagine living without them
Examples: thinking, speaking, walking, hearing, seeing, interacting with environment
Innovation and Excellence in Advanced Illness at End of Life
Important Point
Although each question may not trigger a response in the patient, the variety of ways the questions are asked may begin to trigger memories and beliefs. Later questions may trigger responses appropriate to earlier questions.
Innovation and Excellence in Advanced Illness at End of Life
ACP Explanations
____ Difference between code status within hospital and HCPOA form.____ CPR success stats: Patient’s return to same quality of life before heart stopped . . .
while in hospital, 17-22 %; while out of hospital, 8%; if older, feeble, in long-term care, or with life-limiting or terminal illness, <3%.(Respecting Choices First Steps CPR leaflet)
Innovation and Excellence in Advanced Illness at End of Life
ACP Plan
_____ 1. Complete the HCPOA form and arrange to have two non-relatives witness your signature._____ 2. Make copies of the HCPOA form and give them to your agent(s).____ 3. Send a copy of the completed form (with birthdate on the top right of the first page) to Health Information Management department at AnMed Health (or another hospital) and/or your physician practice.
Mailing address: AnMed Health, Health Information Management, 800 North Fant Street, Anderson, SC 29621
Fax Number: 864-512-1683_____ 4. Follow up with PCP in 1 month to discuss further or to ask questions.
Innovation and Excellence in Advanced Illness at End of Life
For more information . . .
Innovation and Excellence in Advanced Illness at End of Life
• Contact Tamara R. Flinchum, AnMed Health Advance Care Plan Coordinator, at 864-512-3251 or tamara.flinchum@anmedhealth.org.
• If you need to make changes to your HCPOA, tear up your old form, print off a new form, and complete it. Just be sure you give new copies to your agents and to your healthcare system. South Carolina HCPOA forms are always available at the following link: https://aging.sc.gov/sites/default/files/documents/Legal/SCHealthCarePowerOfAttorney.pdf
How does the process work?
Innovation and Excellence in Advanced Illness at End of Life
Process Map from Sample Physician Practice: Part 1
Patient comes in for an
appointment.
Is it an Annual Wellness Visit
(AWV) or a general
appointment?
[General Appt]
Completes check-in
paperwork/
documents.
[AWV]
Gives Patient AWV checklist to
complete.
Completes AWV with patient.
Completes general
appointment.
Has the patient had an
ACP conversation?
[No]
Introduces Advance
Care Planning to the patient.
Patient takes information
home to review.
Does the patient call
for ACP appt.?
[Calls]
Reserves ACP appt.
on schedule.
Patient comes in for ACP
appt.
[Yes]
Encourages patient to
schedule ACP appt. to complete
Advance Directive.
[Does not call]
Pt will be seen at a future
appointment/
AWV.
[Patient does not know]
Explains the purpose of Advanced Directives, provides
a copy of the form w/additional information.
Does the patient know about
Advance Directives?
[Patient does know}
Asks if patient has form and whether it needs updating.
Medi-carePatient
FrontDeskStaff
Nurse
Process Map from Sample Physician Practice: Part 2
Patient comes in for ACP
appointment.
Checks patient in and brings patient
back to conference room.
Has ACP conversation with patient.
Patient returns home.
Is the form completed?
[Yes]
Explains each section of the form.
[No]
Reserves a follow-up ACP
appt. with chaplain.
Medi-carePatient
FrontDeskStaff
Chaplain
Witnesses completed
ACP document.
Enters document into EMR.
Prints copies for
agents and EMR.
Gives original and
copies to patient.
[Yes]Witnesses completed
ACP document.
Is the patient ready to
complete the document?
Issues
• Copay deterrent
• Presence of agents
• Choice of witnesses
• Notary Public
• Return of HCPOA form if patient completes
• Efficiency—no shows
Innovation and Excellence in Advanced Illness at End of Life
The Result
• Approximately 182 ACP conversations have occurred, with 136 completed SC HCPOA formssince May 2018. (No
• Approximately $15,000 in charges has been filed, using CPT codes 99497 (first 30 minutes) and 99498 (second 30 minutes) since September 2018.
Innovation and Excellence in Advanced Illness at End of Life
Congratulations!
July 2, 2019
I was looking at some numbers this morning and wanted to report this as a celebration...
In regards to patients seen on the supportive care service, for 2017 Q1 12% had advance directives on file, for 2018 Q1 18% had advance directives on file, and for 2019 Q1 23% had advance directives on file!
I was not exactly sure when the outpatient advance directive push began, but I think it is pretty awesome that the number of people just on our service that presented here with some form of document almost doubled in 2 years.
As always, there is still lots of ground to cover with this initiative, but there is definitely progress being made!
Thanks to everyone for the hard work.Laura
Laura Saylors, MSN, APRN, FNP-CNurse PractitionerSupportive Care ServicesAnMed Health
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement for ACP
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement FAQs
What are the new advance care planning (ACP)
codes from CMS that became active in 2016?
• 99497 – ACP, 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 professional
• 99498 – Each additional 30 minutes (list separately in addition to code for primary procedure)
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement FAQs
How much time must be spent to use the new codes?
More than half of each interval must be used. For example:
• Use 99497 if you meet or exceed 16 minutes.
• Use 99497 + 99498 if you meet or exceed 46 minutes.
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement FAQs
Does the conversation have to be in-person to use the new codes? Does it have to be with the patient?
The conversation has to be in-person (you cannot use the code for telehealth), but it doesn’t have to be with the patient. It can be with a surrogate or family members.
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement FAQs
What are the documentation requirements?
• Total time in minutes
• Patient/surrogate/family “given opportunity to decline”
• Details of content (e.g. Who was involved? What was
discussed? Understanding of illness, spiritual factors.
Why are they making the decisions they are making?
Was any advance directive offered/filled out? Follow-up)
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement FAQs
What costs might patients incur from these codes?
When a provider discusses advance care planning with
a patient at his/her Annual Wellness Visit, there is no
cost to the patient. However, if the provider has an ACP
conversation at other times, Part B cost sharing applies
and the patient may be responsible for copay/
coinsurance.
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement FAQs
Are there limits to the number of times that the new codes can be used?
There are no limits to the number of times the codes can be used. ACP can be readdressed as needed with a change in condition. Each time they are used, 99497 should be used for the first 30 minutes and 99498 should be used for each additional 30 minutes.
Innovation and Excellence in Advanced Illness at End of Life
Medicare Reimbursement FAQs
Documentation Requirements
• Total time in minutes• Patient/surrogate/family “given opportunity to decline”• Details of content• Attending MDs and DOs, as well as NPs and Pas (i.e., those who are authorized to independently bill Medicare for CPT services), are the only providers who can use these codes.• If medical management billing is based on medical decision making, then you can bill as you normally would in that scenario. On top of that, you should also bill based on time spent for ACP.• If instead you are billing for the medical management based on time, you should be sure you do not double count the time spent on the advance care planning conversation.
https://theconversationproject.org/wp-content/uploads/2016/06/CMS-Payment-One-Pager.pdf
Innovation and Excellence in Advanced Illness at End of Life
Documenting the Visit
Innovation and Excellence in Advanced Illness at End of Life
Innovation and Excellence in Advanced Illness at End of Life
Right click on a patient on the schedule and select “Change provider to me.”
Charting ACP in EPIC: Documentation
Charting ACP in EPIC: Documentation
Innovation and Excellence in Advanced Illness at End of Life
Double click on the patient to enter the encounter. Go to the ACP activity.
Charting ACP in EPIC: Documentation
Innovation and Excellence in Advanced Illness at End of Life
• Click “Create Note.” • Type “.acp” to pull in the ACP SmartText. • Click F2 on your keyboard and fill out all wildcards (***).
(Optionally, you can free text or create your own Smartphrase.) • Sign your note.
Charting ACP in EPIC: Documentation
With the patient's permission and at a level considering their educational and socioeconomic needs, Advanced Care Planning was discussed today.
The talk was conducted in an environment conducive to the discussion and allowed adequate time for patient and/or family to express their wishes.
Participants: Patient, Provider Other: N/A Time spent in exercise this visit: *** minutes
Content of Discussion: Patient desires following to be Medical Power of Attorney: ***POA documents have been filled out? ***End of Life Wishes: Patient generally Values Quality of life over quantity of lifeCPR only if there is good chance of full recoveryNo prolonged life support if terminalNo feeding tubes to prolong life if terminal No IVF to prolong life if terminalPatient has advanced directive and/or living will: ***
Other comments: ***
This discussion is archived in the medical record and is available to the patient's care team and patient is encouraged to share their wishes with other providers. Patient is aware that this ACP note is not a legal POA or living will, but can be used to help guide care team if needed.
Innovation and Excellence in Advanced Illness at End of Life
Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Navigate to the Charge Capture Activity on the left.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
In the Visit Diagnosis Section, choose the one diagnosis available.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Click Advanced Care Planning.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Select an appropriate charge.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Click on the charge line for more options.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Enter a billing provider and accept the charges.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
This is usually the PCP that can be found in the header.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Click Sign Encounter in the bottom right corner.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Enter a Cosigner. This will be the same as the billing provider.
Charting ACP in EPIC: Capturing Charges
Innovation and Excellence in Advanced Illness at End of Life
Click ‘Good To Go’.
Charting ACP in EPIC Summary:
Requirements for Signing Visits
• A signed note
• A diagnosis
• A charge – the charge must have a billing provider
• Change the provider to an actual provider
• A cosigner
Innovation and Excellence in Advanced Illness at End of Life
My Life My Choices ACP Initiative
in South Carolina
GOALS
• Increase both community awareness of and the quality of advance care planning.
https://www.mylifemychoices.org/
• Improve healthcare professionals’ ability to initiate and integrate advance care planning conversations and processes into their daily practice.
https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
• Improve accessibility of advance care planning documents through technology.
https://vyncahealth.com/technologies/eregistry/
Innovation and Excellence in Advanced Illness at End of Life
ACP Initiative Objectives
Minimum expectations by the end of 2019
1. 25 completed Physician Orders for Scope of Treatment (POST) forms
2. 100 ACP conversations in primary practitioner offices
3. 25% completed ACP forms resulting from ACP conversations
4. 125 practitioners and healthcare professionals trained in ACP
Innovation and Excellence in Advanced Illness at End of Life
ACP Initiative Objectives (cont.)
5. 900 community members educated re. the value and need for ACP and given an ACP guide
6. Formal processes developed to integrate ACP into clinical workflow in local healthcare organizations (hospitals, skilled nursing facilities, primary care practitioner offices)
Innovation and Excellence in Advanced Illness at End of Life
AnMed Health as Grant Recipient
One of 5 recipients of $100,000 in SC
From Blue Cross Blue Shield
Through the SC Coalition for the Care of the Seriously Ill (CSI)
Administered through The Carolinas Center
Innovation and Excellence in Advanced Illness at End of Life
Resources
• Medicare Reimbursement FAQs
https://theconversationproject.org/wp-content/uploads/2016/06/CMS-Payment-One-Pager.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf
• Serious Illness Care Program
https://www.ariadnelabs.org/areas-of-work/serious-illness-care/
• First Steps ACP Facilitator Certification
https://respectingchoices.org/types-of-curriculum-and-certification/facilitator-certification/
• SC ACP website https://www.mylifemychoices.org/
• Vynca Health: https://vyncahealth.com/technologies/eregistry/
Innovation and Excellence in Advanced Illness at End of Life
top related