an acp innovation in sc: chaplain interviews at physician...

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”


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.


Not in the Emergency Room


Not During a Hospital Stay


But at the Physician Practices’Medicare Annual Wellness Visits


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)


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)


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.


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.


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


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?


Drawbacks

• Minimal staffing at facility

• Mileage reimbursement

• Cost for non-staff chaplains

• Buy-in from each practice/physician


Benefits

• Greater visibility for chaplains

• Possible funding stream?

• Deeper, more thorough ACP conversations


Tools for Conversation


Respecting Choices First Steps Training


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/

https://respectingchoices.org/about-us/

Serious Illness Conversation Guide


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/

https://www.ariadnelabs.org/areas-of-work/serious-illness-care/resources/#Downloads&%20Tools


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 [email protected] for more information.


mailto:[email protected]

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


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)


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?


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?



• 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)



• 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?



• 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


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.


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)


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.


For more information . . .


• Contact Tamara R. Flinchum, AnMed Health Advance Care Plan Coordinator, at 864-512-3251 or [email protected].

• 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

mailto:[email protected]

https://aging.sc.gov/sites/default/files/documents/Legal/SCHealthCarePowerOfAttorney.pdf

How does the process work?


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


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.


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


Medicare Reimbursement for ACP


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)



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.



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.



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)



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.



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.



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



Documenting the Visit



Right click on a patient on the schedule and select “Change provider to me.”

Charting ACP in EPIC: Documentation



Double click on the patient to enter the encounter. Go to the ACP activity.



• 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.


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.


Capturing Charges


Charting ACP in EPIC: Capturing Charges


Navigate to the Charge Capture Activity on the left.



In the Visit Diagnosis Section, choose the one diagnosis available.



Click Advanced Care Planning.



Select an appropriate charge.



Click on the charge line for more options.



Enter a billing provider and accept the charges.



This is usually the PCP that can be found in the header.



Click Sign Encounter in the bottom right corner.



Enter a Cosigner. This will be the same as the billing provider.



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


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.


• Improve accessibility of advance care planning documents through technology.

https://vyncahealth.com/technologies/eregistry/





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


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)


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


Resources

• Medicare Reimbursement FAQs


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf

• Serious Illness Care Program


• 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/



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf


https://respectingchoices.org/types-of-curriculum-and-certification/facilitator-certification/



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