October 3, 2023 β’ 26 mins
What if there was a way to drastically shift the field of dementia care towards more efficient care coordination and equitable health access? This episode features a conversation with Rory Farrand, Vice President for Palliative and Advanced Care at NHPCO, who unpacks the recently released Dementia GUIDE Model by CMS. Listen in as Rory explains the potential this model holds for not just caregivers but also for healthcare-at-home providers.
In an engaging and enlightening discussion, Rory highlights the model's focus on reducing fragmentation, building health equity, and the unique incentive it offers for programs to ensure full community representation. She emphasizes how organizations, even those lacking all the model's components, can still participate, fostering partnerships within their communities to provide required services. If your practice revolves around dementia care or if you're simply a caregiver seeking to enhance the quality of life for your loved ones, this episode offers valuable insights into a game-changing approach that could significantly benefit you. Tune in and consider how you can apply it to your unique circumstances.
ππππ πππ¦ππ§ππ’π ππ’π¬πππ¬π ππ«π¨π π«ππ¦ πππ«ππ’ππ’ππππ’π¨π§ is a beacon for providers to ensure optimal care. Experience the π¬π²π§ππ«π π² π¨π ππ¨ππ‘ ππ‘π πππππ ππ¨πππ₯ ππ§π ππππ ππ«π¨π π«ππ¦, collaboratively framing a comprehensive care strategy. β£
Visit our website
Connect with us - LinkedIn, Twitter, YouTube, Facebook
Make Lives Better
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Jennifer (00:09):
Greetings.
I'm Jennifer Kennedy, the leadfor quality at CHAP, and welcome
to this month's CHAPcast.
We're talking about the topicof dementia, bringing a
background to specifically talkabout the nuts and bolts of the
dementia guide model with expertRory Farron from NHPCO.
Welcome to the podcast, rory.
(00:30):
Thanks Jennifer.
Rory (00:33):
I'm really happy to be able to speak to you today.
Jennifer (00:35):
Well, Rory, I know you and I know that you're an
expert in your field ofpalliative and hospice care, but
could you do a briefintroduction for our listeners
and tell them a little bit aboutyourself?
Rory (00:48):
I'd be happy to do that.
I am the vice president forpalliative and advanced care at
NHPCO, and by background andtraining I'm a clinician.
So the majority of my careerI've been a nurse practitioner
practicing in long-term care,geriatric space, and, of course,
when you're working with folksthat are older, you tend to sort
(01:09):
of fall naturally intopalliative care, and so that's
partly how I got interested indoing dementia, working in
dementia care.
But the reality is I love itbecause I grew up with a
grandfather who had Alzheimer'sdisease and my first job out of
grad school was working inmemory care units, so this is a
topic that is near and dear tomy heart.
Jennifer (01:31):
So you're the perfect person for us to really take a
good look at what this model is.
I actually, when it came out,I'm on the email list at CMS and
I saw this model pop out and Iwas really interested and
excited when I read some of thecontent of how it's going to
work and who's going to beeligible upstream to participate
(01:55):
in this demonstration model.
So I know that you, in yourexpertise of palliative care,
probably looked at it and said,hey, this might be a good thing.
Can you talk a little bit aboutyour initial reaction to what
the guide model looks like andwhat your thoughts are about it?
Rory (02:18):
I can definitely do that.
Guide is an acronym for guidingan improved dementia experience
and, as you mentioned, it's oneof the newest models that CMMI
or the Center for the MedicationArm for CMS just launched, and
what's really exciting about itis that it's one of the first
models that is really addressingthe challenges that caregivers
(02:41):
have when caring for a loved one, and in this case their focus
is on dementia and illnesses inthat sphere.
But so it's really reallyexciting for a number of reasons
and, like you said, taking alook at this model from the
palliative lens, it's just trulyexciting that the focus is a
lot on care coordination andmanagement, caregiver support
(03:04):
and education and then respiteservices.
So respite is most commonlyseen in the hospice benefit and
this is the first time that weare going to be able to see it
in an upstream model of care.
The goal of the model is reallyjust to improve quality of life
for folks living with dementiaand their caregivers, and CMS is
(03:24):
really hoping to see that therewill be a delay in long-term
nursing home placement so folkscan age at home, live at home
throughout the end of their life, and one of the unique aspects
of this model is that there willbe a standardized approach
that's really hoping willtransform care of people who
(03:46):
have dementia.
Jennifer (03:49):
Some of the things that popped out when I read the
description of the model werewords like interdisciplinary and
coordination and individualizedplan of care, all of and, of
course, respite.
You did mention that All ofthese words are something I know
from my longtime hospice nursehistory and it seems to me, like
(04:11):
CMS said oh, these things aregood and we can pull them from
the Medicare hospice benefit andtry to embed some of those
items that make personalized orperson-centered care into the
model in other places in CMS,what are your thoughts on some
(04:32):
of those aspects of the model?
Rory (04:34):
I would 100% agree with what you just said, jennifer.
In fact, take it a step further.
The National Consensus ProjectQuality Guidelines for Politive
Care actually uses the worddomains, and so when you look at
what CMS, cmmi, is hoping totest within this model, they
also use the word domain, andthat was just.
Maybe it was a coincidence ormaybe they were a little
(04:55):
influenced by palliative care,but I thought that was really.
I really I just sort of foundsome sort of synergy there.
So, as you mentioned, when youread what those domains are,
that is 100% what palliativecare is and does and, of course,
what hospice does.
Just to a point of fact, hospicebeneficiaries, folks who are
(05:15):
actually enrolled in the hospicemodel, will be excluded from
this demonstration, right, but ahospice organization that has
perhaps a palliative care lineof business or the home health
agency that has a palliativecare line of business, those
folks would be able toparticipate, and what's
wonderful about this is thatthis is focused on keeping
people in the home, and who'sbetter at keeping people in the
(05:38):
home than folks that areexperienced in working in
palliative care and in homehealth?
We are really good at thecomprehensive assessment piece,
designing care plans, makingsure that we are focusing on
what people need and not as muchon prognosis.
And, as you mentioned, there'sa lot of focus on care
coordination and management andsupport for caregivers.
(06:02):
So all of those things are whatwe are really good at doing in
palliative care.
So I think that this model isreally in the right swim lane
for palliative care providers.
Jennifer (06:13):
Yeah, it really is, and you know, as you mentioned,
it's targeted for upstreet.
So someone gets that diagnosis,you know, whenever, whatever
age they are, and they get it.
It seems to me like CMS isinvested in focusing let's,
let's put some resources towardswhen this person is starting to
(06:38):
decline and you know they're inthat trajectory, rather than,
oh my gosh, you know they'regetting towards the end of their
life and what do we do withthem?
So raising all quality boats isis one of the goals here.
Also, cost savings.
We know that CMMI is alwaysfocused on cost savings and it
(06:58):
seems to me by developingsomething that's more upstream
would help do that.
And where I'm going with thisworry is, you know, there was a
recent research that came outspecifically about hospice and
dementia and you know thatthere's actually cost savings
there.
So what are your thoughts onthat?
Rory (07:20):
Well, what is interesting is in the study that you're I
hope you're referencing is theone that we co-sponsored with
the National Association ofHospice and Home Care, or NAC,
where we commissioned NORC atthe University of Chicago to
look at the value of hospice inMedicare.
And what was wonderful aboutthis study is that it was one of
(07:41):
the most robust analyses ofclaims-based administrative data
that actually took matchedcohorts and looked at patients
that, based on the claims dataand based on the information
that they were able to determine, looked like patients who could
benefit from hospice.
They of course, had data frompatients who utilized the
hospice benefit, but they wereable to sort of design this
(08:02):
matched cohort study and, incontrast to where a lot of folks
have been concerned, thatpeople who have longer lengths
of stay are costing CMS to mucha lot of money, the study
actually showed that costsavings continued even after
that six month mark, so after180 days of somebody being
(08:24):
enrolled in hospice.
So they actually looked at italmost 12 months total amount of
time to you know, really figureout what those savings were
when the break-even pointhappened.
And they looked at thosepatients across disease types so
they broke them into you knowsort of primary disease
categories and it was a really,really promising I shouldn't say
(08:47):
promising, it was a reallyexciting but discovery to
understand that even thoselonger lengths of stay are still
saving the Medicare program alot of money.
Where this ties into the guidemodel, of course, is that
dementia is one of thoseillnesses that has a very
unpredictable trajectory.
A lot of these patients maylive with the illness for eight
(09:09):
years, 10 years, and the guidedemonstration model is expected
to go until 2032.
So after implementation in 2024, it's going to run for eight
years.
Part of the reason for that isbecause of that long, if you
will runway towards the end oflife that dementia patients have
.
So it'll be a reallyinteresting opportunity to
provide support for thosecaregivers to make sure that, as
(09:31):
patients and their caregiversneeds change, that the level of
care can be adapted to whereverthey are in that illness process
and not tied to prognosis, likethe hospice benefit is.
Jennifer (09:42):
Right and that totally makes sense to me to
structure it that way.
We know that without any kindof a framework, many individuals
that are living with dementiahave really fragmented care.
They're doing that churn thatER hospital, maybe back out to
(10:05):
home health, maybe out to astint and a sniff and come back
out to the community.
It's that huge churn and thenthey're back and they're back
and they're back.
And when I look at this model,it's really focused on that
coordination piece, thatdecrease of fragmentation piece,
and there's building of healthequity into the model as well,
(10:30):
which we know that CMS is reallyfocused on sprinkling health
equity in everything that theydo these days.
But in your experience withcaring for individuals living
with dementia, that underservedpopulation is probably a huge
consideration.
What are your?
How can you talk to us aboutthat?
Rory (10:54):
Yeah, I'm really excited that there is this health equity
component to the guide model,because one thing we know in
general is that traditionallymarginalized communities or some
of those underservedpopulations, historically do not
have a great uptake of thehospice benefit.
So this is an opportunity towork with folks as you mentioned
(11:15):
upstream, but programs thatdesign opportunities to engage
members of their community whoare in those traditionally
marginalized groups, we may beable to see them having better
supports and hopefully betteroutcomes throughout the entire
eight or 10 years that they'reliving with this illness and, as
you mentioned, dementiasometimes disproportionately
(11:37):
affects people in thosepopulations black families,
families that are Hispanic orLatino.
So it's really interesting thatthis health equity component is
built in and CMS has.
Cms has mentioned that this isgoing to be part of the way they
analyze almost all of theirmodels moving forward, so that's
really really exciting.
(11:58):
As it pertains to the guidemodel, this is also something
that's interesting there will bea health equity adjustment as
in a payment adjustment.
Jennifer (12:07):
That's really exciting.
Rory (12:09):
Yeah, so it's going to be based on beneficiaries, health
equity scores, and those aregoing to be determined by social
, certain social risk factors,and that's going to depend on
the proportion of thatpopulation that makes up a
program's patient panel.
But if you, if there's, likethe National Area Deprivation
(12:30):
Index and the State AreaDeprivation Index, patients who
have low income subsidies, maybefor Medicare Part D, or they're
duly eligible, if you're aprogram that's serving a lot of
those patients, there would bean adjustment to your payment in
addition to the per beneficiaryper month payment that already
comes within the model.
(12:50):
So there is an incentive forprograms to ensure that their
entire community is wellrepresented in the program and
to find ways to engage membersof their community that may
historically not have beeninterested in hospital
circulated care because ofcultural miscommunications,
misconceptions around whathospice is or does.
Jennifer (13:14):
Yeah, I see this as a possible game changer in the
pathway or the flight path tohospice.
You know, if we're engaged witha family in this model and we
know that right now there isn'tany kind of a cure for different
types of dementia, alzheimer'setc.
There would be a bettertransition to end of life care
(13:38):
in a Medicare model.
So I see that as a total plus.
Rory (13:43):
Right and of course the model is also focused on keeping
folks out of nursing facilitiesif possible.
You know, of course, if it'sappropriate and needed, they're
not going to say no, you can'tgo to a nursing facility.
But we know patients andfamilies for the most part don't
want to spend their days,especially their end days, in a
nursing facility.
(14:03):
So what's exciting is thatmaybe by better use of the
respite approach, helpingprovide some relief to those
caregivers, providing us what'sLorde looking for stipend for
respite that will help keepthose caregivers, give them that
(14:24):
great that they need so thatthey can come back and continue
to take great care of theirloved one.
So that again is a game changerfor the entire palliative care
field, because respites reallyonly ever been available to
folks in world of hospice.
So I'm eager to see how that onein particular shakes out.
Jennifer (14:41):
As am I.
So, Roy, let's say that I'm ahome health or a palliative care
or even a home care provider.
Why should I be interested inparticipating in this model?
Rory (14:55):
Well, in addition to the fact that, as we know,
palliative care the way thereimbursement is structured
currently with a Medicare Part Bbilling, is generally not
sustainable for a lot ofprograms.
This is an opportunity to haveanother revenue stream.
And, of course, we're not herejust to talk about revenue, but
it is important to have a PDPMmodel for your members based on
(15:17):
their level of acuity or theircomplexity in their illness and
whether or not they have acaregiver.
There's different tiers ofpayment.
This is a huge opportunity tohave some revenue coming into
your program to better supportthese patients with dementia.
So if you are a palliative careprovider or if you're a home
health agency that finds thatyou see a lot of patients with
(15:38):
dementia in your patient panel,there's an opportunity to
partner with other folks in yourcommunity to serve these
patients.
If you don't have a specificdementia program or maybe your
program is fairly robust butyou're missing a couple of
things that CMMI is looking for,you can partner with other
(15:59):
members in your community.
Whether that's a geriatricpractice, assisted living maybe
you have some need a place tohave folks go for respite
there's a whole host ofopportunity for your palliative
or home health practice topartner with folks in the
community to develop this reallyrobust service.
So I'm really hoping that a lotof agencies or organizations,
(16:21):
physician practices that providehome health or palliative care
are interested in looking,interested in participating in
the model, because I think it'sgoing to be the rising tide.
You know, graces all votes.
I'm really hoping that thatwill improve care for a lot of
folks across the community.
Jennifer (16:38):
Yeah, I agree, and I think we need to have as many
folks in the pool as possible inorder to get a really good feel
for how this might work.
And we know that adjustmentscan be made to a demonstration
as it moves forward, and youknow CMS has done that before
and I'm sure they would do thatas we move forward as well with
(17:00):
this demo.
You mentioned partners, and I'mglad you did that, because
another partner in thisparticular model could be CHAP,
because we do have dementiaprogram practice standards and
we develop those with theassistance of experts in the
(17:22):
field and they're very practical, they're very easy to
understand and they cancertainly help an organization
that already might have dementiaprogram outlined, or if an
organization is just thinkingabout getting going with
something, I think they could beapplicable to that organization
(17:43):
as well.
So I mentioned two pathways.
Can you talk a little bit aboutthe two pathways of the model?
Rory (17:52):
Yeah.
So what is wonderful about thisnew model is that there are
these two pathways.
If you are an organization thathasn't established program, you
can pretty much get startedafter they can submit an
application this fall.
They're not ready, they're notreleased yet, but they're coming
out soon and you can prettymuch get started in July of 2024
.
If you are an organization thatis not quite fully fleshed out
(18:16):
in terms of your dementia caremodel but you're interested in
participating in this program,you can also submit this
application.
But you may be slotted into thenew program and you have a year
, basically a year's runway toget your program fully fleshed
out according to the guidelinesof the model.
It gives you some time to maybebolster your technology suite,
(18:39):
maybe partner withcommunity-based organizations
that fill in the gaps in yourprogram.
So those are sort of the twomain tiers a runway for an
established program that's readyto go in July and then a year's
startup that you can get yourprogram off the ground with.
So it's really exciting.
Jennifer (18:59):
I really think an organization, no matter what it
is, that they focus onparticipation in a model like
this helps expand their qualityfootprint, so to speak.
I think organizations thatdon't do things outside of their
scores are not proving theircomplete value, if you will.
(19:25):
So we know that, as people areaging out, that dementia is one
of those things that could bepossible in their array of
diagnoses that they may have.
And we have a whole slew ofbaby boomers that are going to
be aging now.
It doesn't mean that every babyboomer is going to have
(19:46):
dementia, but the odds ofpercentage increase are there
that these providers upstreamwill be caring for individuals,
as we have high percentages ofboomers aging out coming to them
for various services.
Again, I'm going to put you onthe spot and say what are your
(20:12):
thoughts about the value oforganizations really thinking
about this, you know, from avariety of different
perspectives.
Rory (20:24):
You mentioned quality and you mentioned the boomers and
you mentioned all of thesedifferent things, and I think
this model is a huge opportunityfor palliative care, because a
lot of times we've describedpalliative care providers as a
quarterback, Somebody who cankind of look across the field
and see what's going on with thepatient and their family and,
you know, just kind of steer I'mgonna mix metaphors here steer
(20:47):
the ship.
You know I had a quarterback inand now we're on a boat
Quarterback on a boat.
Exactly.
You can drive your boat as aquarterback, because there's a
lot of things that are gonnaimprove the quality of life for
patients that sometimes maybeyour primary care doc, even
though the intention when thoseroles were created was for that
person to be the quarterback.
(21:07):
That hasn't always borne outthe way I think it was intended.
So you may have folks who havea lot of different illnesses.
They may be seeing a number ofdifferent specialists.
They could be on a bunch ofdifferent medications.
Maybe not all of them areworking well together.
So some of that quality datareporting that CMMI is looking
for in this model is going to beaddressed.
(21:30):
You know there's gonna bethey're looking at high risk
medication use and so hopingthat beneficiaries are able to
get rid of some of thosemedications that might actually
be causing them problems.
Of course they're gonna belooking at the quality of life
and that's gonna be beneficiaryself-report or caregiver
self-report.
They're gonna be looking atcaregiver burden.
(21:50):
We know that caregivers areincredibly stressed out.
Arc Angels, the organization,has what they call a distress
thermometer that you can, as acaregiver, type a bunch of your
feelings into about certainquestions that they ask and
it'll tell you your distresslevel and it's really helpful to
realize if you're in the red,you know, maybe that's the time
that you need to be looking intoa respite situation for your
(22:13):
loved one.
And then, of course, you knowcertain care delivery metrics
and social determinant of help.
All of those things fall intoimproving quality.
So I think that there is againa lot of reasons for palliative
care organizations to want Ithink they should want to
participate in this.
I think it's gonna be reallywonderful for folks.
Jennifer (22:34):
I hope so, and I'm kind of of the mind that you
know, if you didn't step up tothe plate and try, at least try
to participate.
Put your name in the ring,maybe get selected.
Maybe you don't.
Don't gripe on the back endright About how you're not
getting paid for this, as shouldit move forward into a
permanent arrangement, all right.
(22:57):
So let's say I'm anorganization and I'm trying to
make that decision whether I'minterested in throwing my hat in
the ring or not.
What are some factors that Ican consider to help me make
that decision?
Rory (23:11):
One thing I really like about this model excuse me is
that your organization does nothave to have all of the
components of the model in orderto be selected.
This model is reallyencouraging organizations to
partner with other folks in thecommunity to flesh out those
gaps.
So if you take a look at your,you take a look at the model
(23:34):
fact sheets that are availableon CMMI's website.
They have a one-pagerinfographic that's really
helpful.
You can basically say you knowwhat, I'm 80% of the way there.
So figure out where that 20%your organization is missing and
then figure out who in yourcommunity has those capabilities
whether that's a technology ormaybe it's 24 seven coverage, or
(23:56):
maybe you don't have a greatpartner right now for respite,
but you know a nursing facilityor an assisted living who might
be a good partner that you canestablish relationships with
those organizations and thencome into the model together as
almost like a new co.
That allows you to yeah, thatallows you to provide all of the
(24:18):
services that the model isasking for.
So I would say that hospice, orI would say to palliative care
programs, just because you don'thave all of the elements of the
model does not preclude youfrom participating.
Figure out who in yourcommunity you can work with and
make some phone calls and makesome new friends.
Jennifer (24:34):
It's definitely a partnership community model, for
sure, and I love to see thatbecause I think you know most
people want to stay in situ.
They want to be there for aslong as they can, if not up till
they take their last breath.
So, oh my gosh, Rory, thanks somuch for sharing all of your
expertise with us today.
(24:55):
Do you have any final thoughtsfor our listeners?
Rory (24:59):
I think my final thought really would be I would just
strongly encourage, as I justsaid, encourage folks to go to
CMMI's website, take a look atthe material that they have
there and try to put anapplication in when that becomes
available later this fall.
Jennifer (25:14):
Great, and I know we're gonna provide some links,
Many of them that you suppliedfor us.
We'll have that available toour listeners as well, and thank
you again, Rory.
You're just a plethora ofinformation.
Rory (25:29):
Thank you for inviting me to speak about this, Jennifer.
I'm really happy to have doneso.
Jennifer (25:33):
Thanks.
We'll talk again, I'm sure, andthanks to all of you for taking
time out of your day to pluginto CHAPcast From me and the
entire CHAP team.
Stay safe and well, and thanksfor all you do.
Upbeat music playing.
Greetings.
I'm Jennifer Kennedy, the leadfor quality at CHAP, and welcome
to this month's CHAPcast.
We're talking about the topicof dementia, bringing a
background to specifically talkabout the nuts and bolts of the
dementia guide model with expertRory Farron from NHPCO.
Welcome to the podcast, rory.
(00:30):
Thanks Jennifer.
Rory (00:33):
I'm really happy to be able to speak to you today.
Jennifer (00:35):
Well, Rory, I know you and I know that you're an
expert in your field ofpalliative and hospice care, but
could you do a briefintroduction for our listeners
and tell them a little bit aboutyourself?
Rory (00:48):
I'd be happy to do that.
I am the vice president forpalliative and advanced care at
NHPCO, and by background andtraining I'm a clinician.
So the majority of my careerI've been a nurse practitioner
practicing in long-term care,geriatric space, and, of course,
when you're working with folksthat are older, you tend to sort
(01:09):
of fall naturally intopalliative care, and so that's
partly how I got interested indoing dementia, working in
dementia care.
But the reality is I love itbecause I grew up with a
grandfather who had Alzheimer'sdisease and my first job out of
grad school was working inmemory care units, so this is a
topic that is near and dear tomy heart.
Jennifer (01:31):
So you're the perfect person for us to really take a
good look at what this model is.
I actually, when it came out,I'm on the email list at CMS and
I saw this model pop out and Iwas really interested and
excited when I read some of thecontent of how it's going to
work and who's going to beeligible upstream to participate
(01:55):
in this demonstration model.
So I know that you, in yourexpertise of palliative care,
probably looked at it and said,hey, this might be a good thing.
Can you talk a little bit aboutyour initial reaction to what
the guide model looks like andwhat your thoughts are about it?
Rory (02:18):
I can definitely do that.
Guide is an acronym for guidingan improved dementia experience
and, as you mentioned, it's oneof the newest models that CMMI
or the Center for the MedicationArm for CMS just launched, and
what's really exciting about itis that it's one of the first
models that is really addressingthe challenges that caregivers
(02:41):
have when caring for a loved one, and in this case their focus
is on dementia and illnesses inthat sphere.
But so it's really reallyexciting for a number of reasons
and, like you said, taking alook at this model from the
palliative lens, it's just trulyexciting that the focus is a
lot on care coordination andmanagement, caregiver support
(03:04):
and education and then respiteservices.
So respite is most commonlyseen in the hospice benefit and
this is the first time that weare going to be able to see it
in an upstream model of care.
The goal of the model is reallyjust to improve quality of life
for folks living with dementiaand their caregivers, and CMS is
(03:24):
really hoping to see that therewill be a delay in long-term
nursing home placement so folkscan age at home, live at home
throughout the end of their life, and one of the unique aspects
of this model is that there willbe a standardized approach
that's really hoping willtransform care of people who
(03:46):
have dementia.
Jennifer (03:49):
Some of the things that popped out when I read the
description of the model werewords like interdisciplinary and
coordination and individualizedplan of care, all of and, of
course, respite.
You did mention that All ofthese words are something I know
from my longtime hospice nursehistory and it seems to me, like
(04:11):
CMS said oh, these things aregood and we can pull them from
the Medicare hospice benefit andtry to embed some of those
items that make personalized orperson-centered care into the
model in other places in CMS,what are your thoughts on some
(04:32):
of those aspects of the model?
Rory (04:34):
I would 100% agree with what you just said, jennifer.
In fact, take it a step further.
The National Consensus ProjectQuality Guidelines for Politive
Care actually uses the worddomains, and so when you look at
what CMS, cmmi, is hoping totest within this model, they
also use the word domain, andthat was just.
Maybe it was a coincidence ormaybe they were a little
(04:55):
influenced by palliative care,but I thought that was really.
I really I just sort of foundsome sort of synergy there.
So, as you mentioned, when youread what those domains are,
that is 100% what palliativecare is and does and, of course,
what hospice does.
Just to a point of fact, hospicebeneficiaries, folks who are
(05:15):
actually enrolled in the hospicemodel, will be excluded from
this demonstration, right, but ahospice organization that has
perhaps a palliative care lineof business or the home health
agency that has a palliativecare line of business, those
folks would be able toparticipate, and what's
wonderful about this is thatthis is focused on keeping
people in the home, and who'sbetter at keeping people in the
(05:38):
home than folks that areexperienced in working in
palliative care and in homehealth?
We are really good at thecomprehensive assessment piece,
designing care plans, makingsure that we are focusing on
what people need and not as muchon prognosis.
And, as you mentioned, there'sa lot of focus on care
coordination and management andsupport for caregivers.
(06:02):
So all of those things are whatwe are really good at doing in
palliative care.
So I think that this model isreally in the right swim lane
for palliative care providers.
Jennifer (06:13):
Yeah, it really is, and you know, as you mentioned,
it's targeted for upstreet.
So someone gets that diagnosis,you know, whenever, whatever
age they are, and they get it.
It seems to me like CMS isinvested in focusing let's,
let's put some resources towardswhen this person is starting to
(06:38):
decline and you know they're inthat trajectory, rather than,
oh my gosh, you know they'regetting towards the end of their
life and what do we do withthem?
So raising all quality boats isis one of the goals here.
Also, cost savings.
We know that CMMI is alwaysfocused on cost savings and it
(06:58):
seems to me by developingsomething that's more upstream
would help do that.
And where I'm going with thisworry is, you know, there was a
recent research that came outspecifically about hospice and
dementia and you know thatthere's actually cost savings
there.
So what are your thoughts onthat?
Rory (07:20):
Well, what is interesting is in the study that you're I
hope you're referencing is theone that we co-sponsored with
the National Association ofHospice and Home Care, or NAC,
where we commissioned NORC atthe University of Chicago to
look at the value of hospice inMedicare.
And what was wonderful aboutthis study is that it was one of
(07:41):
the most robust analyses ofclaims-based administrative data
that actually took matchedcohorts and looked at patients
that, based on the claims dataand based on the information
that they were able to determine, looked like patients who could
benefit from hospice.
They of course, had data frompatients who utilized the
hospice benefit, but they wereable to sort of design this
(08:02):
matched cohort study and, incontrast to where a lot of folks
have been concerned, thatpeople who have longer lengths
of stay are costing CMS to mucha lot of money, the study
actually showed that costsavings continued even after
that six month mark, so after180 days of somebody being
(08:24):
enrolled in hospice.
So they actually looked at italmost 12 months total amount of
time to you know, really figureout what those savings were
when the break-even pointhappened.
And they looked at thosepatients across disease types so
they broke them into you knowsort of primary disease
categories and it was a really,really promising I shouldn't say
(08:47):
promising, it was a reallyexciting but discovery to
understand that even thoselonger lengths of stay are still
saving the Medicare program alot of money.
Where this ties into the guidemodel, of course, is that
dementia is one of thoseillnesses that has a very
unpredictable trajectory.
A lot of these patients maylive with the illness for eight
(09:09):
years, 10 years, and the guidedemonstration model is expected
to go until 2032.
So after implementation in 2024, it's going to run for eight
years.
Part of the reason for that isbecause of that long, if you
will runway towards the end oflife that dementia patients have
.
So it'll be a reallyinteresting opportunity to
provide support for thosecaregivers to make sure that, as
(09:31):
patients and their caregiversneeds change, that the level of
care can be adapted to whereverthey are in that illness process
and not tied to prognosis, likethe hospice benefit is.
Jennifer (09:42):
Right and that totally makes sense to me to
structure it that way.
We know that without any kindof a framework, many individuals
that are living with dementiahave really fragmented care.
They're doing that churn thatER hospital, maybe back out to
(10:05):
home health, maybe out to astint and a sniff and come back
out to the community.
It's that huge churn and thenthey're back and they're back
and they're back.
And when I look at this model,it's really focused on that
coordination piece, thatdecrease of fragmentation piece,
and there's building of healthequity into the model as well,
(10:30):
which we know that CMS is reallyfocused on sprinkling health
equity in everything that theydo these days.
But in your experience withcaring for individuals living
with dementia, that underservedpopulation is probably a huge
consideration.
What are your?
How can you talk to us aboutthat?
Rory (10:54):
Yeah, I'm really excited that there is this health equity
component to the guide model,because one thing we know in
general is that traditionallymarginalized communities or some
of those underservedpopulations, historically do not
have a great uptake of thehospice benefit.
So this is an opportunity towork with folks as you mentioned
(11:15):
upstream, but programs thatdesign opportunities to engage
members of their community whoare in those traditionally
marginalized groups, we may beable to see them having better
supports and hopefully betteroutcomes throughout the entire
eight or 10 years that they'reliving with this illness and, as
you mentioned, dementiasometimes disproportionately
(11:37):
affects people in thosepopulations black families,
families that are Hispanic orLatino.
So it's really interesting thatthis health equity component is
built in and CMS has.
Cms has mentioned that this isgoing to be part of the way they
analyze almost all of theirmodels moving forward, so that's
really really exciting.
(11:58):
As it pertains to the guidemodel, this is also something
that's interesting there will bea health equity adjustment as
in a payment adjustment.
Jennifer (12:07):
That's really exciting.
Rory (12:09):
Yeah, so it's going to be based on beneficiaries, health
equity scores, and those aregoing to be determined by social
, certain social risk factors,and that's going to depend on
the proportion of thatpopulation that makes up a
program's patient panel.
But if you, if there's, likethe National Area Deprivation
(12:30):
Index and the State AreaDeprivation Index, patients who
have low income subsidies, maybefor Medicare Part D, or they're
duly eligible, if you're aprogram that's serving a lot of
those patients, there would bean adjustment to your payment in
addition to the per beneficiaryper month payment that already
comes within the model.
(12:50):
So there is an incentive forprograms to ensure that their
entire community is wellrepresented in the program and
to find ways to engage membersof their community that may
historically not have beeninterested in hospital
circulated care because ofcultural miscommunications,
misconceptions around whathospice is or does.
Jennifer (13:14):
Yeah, I see this as a possible game changer in the
pathway or the flight path tohospice.
You know, if we're engaged witha family in this model and we
know that right now there isn'tany kind of a cure for different
types of dementia, alzheimer'setc.
There would be a bettertransition to end of life care
(13:38):
in a Medicare model.
So I see that as a total plus.
Rory (13:43):
Right and of course the model is also focused on keeping
folks out of nursing facilitiesif possible.
You know, of course, if it'sappropriate and needed, they're
not going to say no, you can'tgo to a nursing facility.
But we know patients andfamilies for the most part don't
want to spend their days,especially their end days, in a
nursing facility.
(14:03):
So what's exciting is thatmaybe by better use of the
respite approach, helpingprovide some relief to those
caregivers, providing us what'sLorde looking for stipend for
respite that will help keepthose caregivers, give them that
(14:24):
great that they need so thatthey can come back and continue
to take great care of theirloved one.
So that again is a game changerfor the entire palliative care
field, because respites reallyonly ever been available to
folks in world of hospice.
So I'm eager to see how that onein particular shakes out.
Jennifer (14:41):
As am I.
So, Roy, let's say that I'm ahome health or a palliative care
or even a home care provider.
Why should I be interested inparticipating in this model?
Rory (14:55):
Well, in addition to the fact that, as we know,
palliative care the way thereimbursement is structured
currently with a Medicare Part Bbilling, is generally not
sustainable for a lot ofprograms.
This is an opportunity to haveanother revenue stream.
And, of course, we're not herejust to talk about revenue, but
it is important to have a PDPMmodel for your members based on
(15:17):
their level of acuity or theircomplexity in their illness and
whether or not they have acaregiver.
There's different tiers ofpayment.
This is a huge opportunity tohave some revenue coming into
your program to better supportthese patients with dementia.
So if you are a palliative careprovider or if you're a home
health agency that finds thatyou see a lot of patients with
(15:38):
dementia in your patient panel,there's an opportunity to
partner with other folks in yourcommunity to serve these
patients.
If you don't have a specificdementia program or maybe your
program is fairly robust butyou're missing a couple of
things that CMMI is looking for,you can partner with other
(15:59):
members in your community.
Whether that's a geriatricpractice, assisted living maybe
you have some need a place tohave folks go for respite
there's a whole host ofopportunity for your palliative
or home health practice topartner with folks in the
community to develop this reallyrobust service.
So I'm really hoping that a lotof agencies or organizations,
(16:21):
physician practices that providehome health or palliative care
are interested in looking,interested in participating in
the model, because I think it'sgoing to be the rising tide.
You know, graces all votes.
I'm really hoping that thatwill improve care for a lot of
folks across the community.
Jennifer (16:38):
Yeah, I agree, and I think we need to have as many
folks in the pool as possible inorder to get a really good feel
for how this might work.
And we know that adjustmentscan be made to a demonstration
as it moves forward, and youknow CMS has done that before
and I'm sure they would do thatas we move forward as well with
(17:00):
this demo.
You mentioned partners, and I'mglad you did that, because
another partner in thisparticular model could be CHAP,
because we do have dementiaprogram practice standards and
we develop those with theassistance of experts in the
(17:22):
field and they're very practical, they're very easy to
understand and they cancertainly help an organization
that already might have dementiaprogram outlined, or if an
organization is just thinkingabout getting going with
something, I think they could beapplicable to that organization
(17:43):
as well.
So I mentioned two pathways.
Can you talk a little bit aboutthe two pathways of the model?
Rory (17:52):
Yeah.
So what is wonderful about thisnew model is that there are
these two pathways.
If you are an organization thathasn't established program, you
can pretty much get startedafter they can submit an
application this fall.
They're not ready, they're notreleased yet, but they're coming
out soon and you can prettymuch get started in July of 2024
.
If you are an organization thatis not quite fully fleshed out
(18:16):
in terms of your dementia caremodel but you're interested in
participating in this program,you can also submit this
application.
But you may be slotted into thenew program and you have a year
, basically a year's runway toget your program fully fleshed
out according to the guidelinesof the model.
It gives you some time to maybebolster your technology suite,
(18:39):
maybe partner withcommunity-based organizations
that fill in the gaps in yourprogram.
So those are sort of the twomain tiers a runway for an
established program that's readyto go in July and then a year's
startup that you can get yourprogram off the ground with.
So it's really exciting.
Jennifer (18:59):
I really think an organization, no matter what it
is, that they focus onparticipation in a model like
this helps expand their qualityfootprint, so to speak.
I think organizations thatdon't do things outside of their
scores are not proving theircomplete value, if you will.
(19:25):
So we know that, as people areaging out, that dementia is one
of those things that could bepossible in their array of
diagnoses that they may have.
And we have a whole slew ofbaby boomers that are going to
be aging now.
It doesn't mean that every babyboomer is going to have
(19:46):
dementia, but the odds ofpercentage increase are there
that these providers upstreamwill be caring for individuals,
as we have high percentages ofboomers aging out coming to them
for various services.
Again, I'm going to put you onthe spot and say what are your
(20:12):
thoughts about the value oforganizations really thinking
about this, you know, from avariety of different
perspectives.
Rory (20:24):
You mentioned quality and you mentioned the boomers and
you mentioned all of thesedifferent things, and I think
this model is a huge opportunityfor palliative care, because a
lot of times we've describedpalliative care providers as a
quarterback, Somebody who cankind of look across the field
and see what's going on with thepatient and their family and,
you know, just kind of steer I'mgonna mix metaphors here steer
(20:47):
the ship.
You know I had a quarterback inand now we're on a boat
Quarterback on a boat.
Exactly.
You can drive your boat as aquarterback, because there's a
lot of things that are gonnaimprove the quality of life for
patients that sometimes maybeyour primary care doc, even
though the intention when thoseroles were created was for that
person to be the quarterback.
(21:07):
That hasn't always borne outthe way I think it was intended.
So you may have folks who havea lot of different illnesses.
They may be seeing a number ofdifferent specialists.
They could be on a bunch ofdifferent medications.
Maybe not all of them areworking well together.
So some of that quality datareporting that CMMI is looking
for in this model is going to beaddressed.
(21:30):
You know there's gonna bethey're looking at high risk
medication use and so hopingthat beneficiaries are able to
get rid of some of thosemedications that might actually
be causing them problems.
Of course they're gonna belooking at the quality of life
and that's gonna be beneficiaryself-report or caregiver
self-report.
They're gonna be looking atcaregiver burden.
(21:50):
We know that caregivers areincredibly stressed out.
Arc Angels, the organization,has what they call a distress
thermometer that you can, as acaregiver, type a bunch of your
feelings into about certainquestions that they ask and
it'll tell you your distresslevel and it's really helpful to
realize if you're in the red,you know, maybe that's the time
that you need to be looking intoa respite situation for your
(22:13):
loved one.
And then, of course, you knowcertain care delivery metrics
and social determinant of help.
All of those things fall intoimproving quality.
So I think that there is againa lot of reasons for palliative
care organizations to want Ithink they should want to
participate in this.
I think it's gonna be reallywonderful for folks.
Jennifer (22:34):
I hope so, and I'm kind of of the mind that you
know, if you didn't step up tothe plate and try, at least try
to participate.
Put your name in the ring,maybe get selected.
Maybe you don't.
Don't gripe on the back endright About how you're not
getting paid for this, as shouldit move forward into a
permanent arrangement, all right.
(22:57):
So let's say I'm anorganization and I'm trying to
make that decision whether I'minterested in throwing my hat in
the ring or not.
What are some factors that Ican consider to help me make
that decision?
Rory (23:11):
One thing I really like about this model excuse me is
that your organization does nothave to have all of the
components of the model in orderto be selected.
This model is reallyencouraging organizations to
partner with other folks in thecommunity to flesh out those
gaps.
So if you take a look at your,you take a look at the model
(23:34):
fact sheets that are availableon CMMI's website.
They have a one-pagerinfographic that's really
helpful.
You can basically say you knowwhat, I'm 80% of the way there.
So figure out where that 20%your organization is missing and
then figure out who in yourcommunity has those capabilities
whether that's a technology ormaybe it's 24 seven coverage, or
(23:56):
maybe you don't have a greatpartner right now for respite,
but you know a nursing facilityor an assisted living who might
be a good partner that you canestablish relationships with
those organizations and thencome into the model together as
almost like a new co.
That allows you to yeah, thatallows you to provide all of the
(24:18):
services that the model isasking for.
So I would say that hospice, orI would say to palliative care
programs, just because you don'thave all of the elements of the
model does not preclude youfrom participating.
Figure out who in yourcommunity you can work with and
make some phone calls and makesome new friends.
Jennifer (24:34):
It's definitely a partnership community model, for
sure, and I love to see thatbecause I think you know most
people want to stay in situ.
They want to be there for aslong as they can, if not up till
they take their last breath.
So, oh my gosh, Rory, thanks somuch for sharing all of your
expertise with us today.
(24:55):
Do you have any final thoughtsfor our listeners?
Rory (24:59):
I think my final thought really would be I would just
strongly encourage, as I justsaid, encourage folks to go to
CMMI's website, take a look atthe material that they have
there and try to put anapplication in when that becomes
available later this fall.
Jennifer (25:14):
Great, and I know we're gonna provide some links,
Many of them that you suppliedfor us.
We'll have that available toour listeners as well, and thank
you again, Rory.
You're just a plethora ofinformation.
Rory (25:29):
Thank you for inviting me to speak about this, Jennifer.
I'm really happy to have doneso.
Jennifer (25:33):
Thanks.
We'll talk again, I'm sure, andthanks to all of you for taking
time out of your day to pluginto CHAPcast From me and the
entire CHAP team.
Stay safe and well, and thanksfor all you do.
Upbeat music playing.
Popular Podcasts
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Therapy Gecko
An unlicensed lizard psychologist travels the universe talking to strangers about absolutely nothing. TO CALL THE GECKO: follow me on https://www.twitch.tv/lyleforever to get a notification for when I am taking calls. I am usually live Mondays, Wednesdays, and Fridays but lately a lot of other times too. I am a gecko.