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CMS Requires Physicians to Enroll in PECOS by June 26

Posted 5/30/2012 Categories: healthcare reform, home health, PECOS, CMS

CMS has issued a new regulation that requires all physicians who order or refer home health services or supplies to be enrolled in Medicare – or have officially opted out – and registered in PECOS. This new regulation is part of a Final Rule that goes into effect on June 26, 2012. In order to enforce this rule, CMS has stated that it will turn on edits in the future that would deny claims for Medicare home health services or supplies from all physicians not enrolled.

To help physicians navigate this new CMS requirement, we’ve created a one-page guide outlining 5 Steps to PECOS Enrollment.

Frequently Asked Questions

1. What is PECOS?

PECOS stands for Provider, Enrollment, Chain and Ownership System. It is a database for physicians who have registered with CMS.

2. When does CMS plan to turn on the edits?

CMS has not issued an official date to turn on the edits but has stated they will provide advance notice.

3. What if I don’t bill for Medicare? Do I still need to enroll in PECOS?

In some circumstances, a physician may order and refer home health services, but not bill for Medicare. These physicians are still required to be enrolled in PECOS. CMS has identified several unique enrollment issues for certain physicians and has abbreviated their enrollment process. Physicians that fall under one of the following categories can either enroll in PECOS online or fill out and submit the form CMS-855-O:

  • Physicians employed by the Department of Veterans Affairs
  • Physicians employed by the Public Health Service (including Indian Health Services)
  • Physicians employed by the Department of Defense Tricare program
  • Physicians employed by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or Critical Access Hospitals(CAHs)
  • Physicians in a Fellowship
  • Dentists, including oral surgeons

4. What if I don’t want to be enrolled in Medicare?

In PECOS, you have the option to opt out of Medicare. This way, you will be able to continue ordering home health services for your Medicare patients.

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Understanding and Respecting Patient Goals of Care

Posted 5/2/2012 Categories: home health, palliative care, patient goals of care, cancer

One of the issues in health care nearest to my heart is the importance of skillfully communicating with patients and understanding and respecting their goals of care. This morning I read the most profound personal narrative on this subject that I have ever read, by Amy Berman, who faces a terminal breast cancer diagnosis.

“Thank goodness my oncologist wasn’t like that specialist. Instead of ignoring my wishes and goals, my doctor was embracing them and keeping me as informed as possible. She’d discussed the diagnosis, prognosis, and possible treatments, and she’d asked me about how I wanted to proceed. Together, the two of us chose a treatment regimen that would slow tumor growth, while protecting what was precious to me: my quality of life.

“Too many other patients have doctors like that specialist. A cancer-survivor friend told me that her oncologist once said, ‘I wish I could just treat the cancer; patients get in the way.’ Another friend, with stage IV cancer, was advised by her oncologist to skip a three-hour car ride to visit her new granddaughter because she’d miss a chemo appointment—one that would do nothing to change the fatal nature of her advanced disease.

“Why do these and so many other doctors miss that patients have their own needs and desires? William Osler, who’s been called the founder of modern medicine, understood. As he put it, ‘The good physician treats the disease. The great physician treats the patient who has the disease.’”

You can read the full article, “Living Life In My Own Way--And Dying That Way As Well,” over at Health Affairs.

Amy is a nurse and a senior program officer at the John A. Hartford Foundation (a foundation dedicated to improving care for older Americans). You might want to check out her blog at www.jhartfound.org/blog/. She is remarkably insightful and eloquent and one of the best ambassadors for palliative care I have ever encountered.

About the Author

Kevin Henning, MD, FAAFP, FAAHPM, is chief medical director of Amedisys Home Care and Hospice. He is a nationally recognized leader in hospice and palliative medicine.

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6 Steps for Discussing Goals of Care and Sharing Bad News

Posted 4/13/2012 Categories: home health, palliative care, patient goals of care, hospice, chronic care

The Burden of Illness and Goals of Care

It is no secret that Americans are living longer than ever. In fact the number of seniors has grown by a factor of 11 over the last century. By 2030, 1 in 5 Americans will be over 65. Unfortunately longer life is often accompanied by chronic illness. Thirty-percent of seniors have three or more chronic diseases, 80% of people over 80 have difficulty performing some activities of daily living. More and more Americans and their families must cope with the burden of chronic illness for months to years before death.

When facing the final years of life with its accompanying burden of illness, symptoms and functional decline most people begin to change their health care goals. Some patients are interested in rehabilitation and recovering strength. Others focus on avoiding hospitalizations so they can live at home with family members. Still others decide to avoid burdensome efforts aimed at prolonging life and want aggressive symptom management and care oriented toward comfort.

Unfortunately many research studies show that physicians and other healthcare providers typically avoid discussing goals of care and prognoses with patients. Often it is because these conversations are difficult and involve sharing bad news. However, for patients in the last few years of life to receive the care they want that is consistent with their values and wishes, health care providers must be skilled at challenging conversations. In short, they must be expert communicators.

Many clinicians mistakenly believe that experience alone is sufficient to prepare them for discussing goals of care and sharing bad news. It is also easy to assume that simply lending a sympathetic ear or having compassion for seriously ill patients equips them with the ability to effectively communicate bad news. Although there is little research on this subject, studies suggest that physicians feel inadequately trained in sharing bad news, but after receiving structured training in the area, feel more comfortable engaging in these conversations.1

The Many Reasons We Avoid It

Besides lacking specific training in the area, medical professionals may avoid sharing bad news for a number of other reasons. We may feel personally responsible for a patient’s misfortune or feel that a poor outcome reflects a practice failure. Clinicians also often worry that sharing bad news will cause adverse reactions in patients, such as anxiety or despair. Finally, unresolved personal issues surrounding the death and dying process can also adversely affect a hospice professional’s ability to communicate bad news.

A 6-Step Protocol that Can Help

Although there is no evidence-based consensus on the best way to share bad news, experience suggests that structured communication is more effective than ad lib discussions. In his book, How to Break Bad News: A Guide for Health Care Professionals, Dr. Robert Buckman proposed a six-step protocol that many find helpful when embarking on a difficult conversation. His protocol uses the mnemonic, SPIKES, to help clinicians remember the content and order of the important steps, summarized below:

S—Setting

First, ensure the setting is conducive to good communication. Adequate privacy and comfort for the patient and family is essential. Limit distractions by turning off cell phones and pagers, and ask staff members to avoid interrupting the meeting. Invite appropriate loved ones to the conversation but, at the same time, respect the patient’s privacy and autonomy by excusing unwanted family members. Always remember to minimize any sense of power inequity by speaking to patients at their eye level.

P—Perception

Next, elicit the patient’s perception of the current problem. Psychological defense mechanisms, such as denial, can affect a patient’s capacity to understand the prognosis. Furthermore, when patients see multiple specialists it is easy for them to receive inconsistent or even conflicting information. It is unwise to begin sharing diagnostic or prognostic information without first knowing the patient’s current understanding of the circumstances.

I—Invitation

Before sharing bad news with patients, obtain an invitation to proceed. Patients who are in pain or experiencing other physical symptoms may want to postpone the conversation. The information will be better understood if the patient is physically and emotionally ready to receive it.

K—Knowledge

When it is time to share the specific bad news with the patient, share the knowledge in small chunks. It is tempting for clinicians to disclose everything they know about the patient’s condition at once. Sharing too much information at one time reduces the likelihood that a patient will understand and remember the details. Avoid using medical jargon. While this advice is self-evident, it is easy to forget that even what we think of as simple medical terms, like “malignancy” or “prognosis,” can be misunderstood by the patient or family member. Stop and check frequently for understanding.

E—Empathy

Once you have shared some information about the patient’s condition and checked for knowledge, it is time to begin to understand the impact on the patient. Avoid using trite phrases like “I understand” or “I know how you must feel.” Instead, simply ask how he or she is feeling. Reflect on the patient’s emotions and let the patient know that you understand how and why he or she feels that way. Although it is not necessary to literally assume the burden of the patient’s feelings, if the patient feels empathy, it can be disarming and reassuring. True empathy with the patient or family member can have a powerful impact on the therapeutic relationship. When patients feel they are heard and understood by their caregivers, they are more likely to trust them and follow their advice.

S—Summarize and Strategize

Learning difficult news can be overwhelming to patients and family members. Medical details, particularly when patients are seriously ill, are often complicated. Make sure you end the conversation by summarizing the information and discussing a future strategy.

Learning how to deliver bad news and discussing goals of care in a structured manner—so patients and their loved ones are ready to hear the information, understand it, and feel listened to and cared for—can better equip them to make decisions that are consistent with their values and the goals of care. In short, patients can get the care they want, where they want it.

About the Author

Kevin Henning, MD, FAAFP, FAAHPM, is chief medical director of Amedisys Home Care and Hospice. He is a nationally recognized leader in hospice and palliative medicine.

References:

  1. Walter F. Baile, M.D. Cancer 1999;86:887–97
  2. Buckman, R. (1992). How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press.
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Hospice and Palliative Medicine Certification Exam Deadline: April 30

Posted 4/5/2012 Categories: home health, palliative care, hospice, chronic care

American Board of Medical Specialties (ABMS) certified physicians must act soon in order to earn a Certificate of Added Qualification in Hospice and Palliative Medicine.  The deadlines for registering for the final certification exam during the grandfathering period are:

  • Certified family physicians: April 30, 2012
  • Certified internal medicine physicians: May 1, 2012

The “grandfathering period” refers to the time early in the development of a field when physicians may qualify to sit for the certification exam on the basis of experience, even if they have not completed a 12-month ACGME-accredited fellowship program. The ABMS grandfathering period is from 2008 through 2012.

After this year, ABMS-certified physicians can only achieve board certification in hospice and palliative medicine through the completion of a hospice and palliative medicine fellowship.

Bodies of medical research show that hospice and palliative medicine can maximize both quality of life and, in many cases, even extend life expectancy through good medical management. Please consider taking time to learn more about palliative medicine and hospice – for your own professional development, for your practice, and for the patients and families you serve.

Preparing for the Exam

Prerequisites for application and further details on the examination can be found at the American Academy of Hospice and Palliative Medicine website.

To help physicians prepare for the HPM certification exam, “Improving Outcomes in Palliative Care and Hospice,” was developed by the Duke University School of Medicine. Supported by an educational grant from Amedisys, this advanced learning opportunity is one of the only accredited hospice and palliative medicine curricula in the industry. In addition to offering physicians the opportunity to enhance their knowledge of hospice and palliative medicine, up to 25 free CME credits are offered for completing the online curriculum.

ABMS Background

In 2006 the American Board of Medical Specialties (ABMS) created Hospice and Palliative Medicine (HPM) as a sub-specialty of ten co-sponsoring boards, including American Boards of Internal Medicine, Anesthesiology, Family Medicine, Physical Medicine and Rehabilitation, Psychiatry and Neurology, Surgery, Pediatrics, Emergency Medicine, Radiology, and Obstetrics and Gynecology.

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Medication Management Study Hopes to Reduce Readmission Rates

Posted 3/2/2012 Categories: chronic care, home health, medication management, readmission rates, research, adverse drug events

In our current health care system, medication management for patients with chronic conditions is a notoriously complex task. The complexity becomes acutely apparent when we examine hospital admission and readmission rates.1,2 Alan Forster’s study of 400 patients discharged home found that 66% of adverse events were related to adverse drug events, while procedure-related complications were a far second at 17%. In the same study, Forster notes that patient education regarding their medications and post-discharge medication monitoring were two areas that required systematic improvement.3

External Research

What else do we know about the challenges of medication management?  A review of 55 observational studies found that hospital-based physicians believe that information related to medications and reasons for changes to medications are two of the most important factors included in a discharge summary. However, the same study found that information related to medications is missing from the discharge summary up to 40% of the time.4 A study by David Budnitz examined emergency department visits for people over age 65 and found that in 2004 and 2005 there were over 177,000 emergency department visits due to adverse drug events.5 Finally, a small study by Eric Coleman found that patients with medication discrepancies (among pre-hospital, post-hospital, and an in-home assessment) had a 30-day hospitalization rate of 14.3% compared with 6.1% for patients without a medication discrepancy.6

There is some good news. Important advancements in care transitions management, including the Naylor and Coleman models, have shown promise in reducing readmission rates and adverse events.7,8 Unfortunately, these programs have their drawbacks as well, such as problems with staff recruitment and lack of comprehensive risk stratification methods.9 Perhaps an even greater barrier is the cost of implementing these programs, which require additional staff and resources.

At Amedisys

With over 11 million visits each year, we maintain a wealth of clinical information at Amedisys.  Internal analysis shows our average home health care patient is 82 years of age and on 12 medications.  Unfortunately, it is hard to get a completely accurate picture of how many admissions are related to medication management because some hospital admissions related to medications are documented as falls, bleeding and other complications.

Moving Forward

Information in hand, in 2011 we set out to examine the needs of our patient population and test a sustainable model for medication management. In collaboration with a team of scientists at the Purdue University College of Pharmacy, we developed a randomized controlled study that includes a representative sample of our home health care centers to rigorously evaluate a medication management intervention. For validity, it was important to us that the evaluation be conducted by external researchers.

HealthStat Rx, a specialty pharmacy, was chosen as the medication management partner for the evaluation and is providing telephonic services using pharmacists and pharmacy technicians.  In broad terms, our medication management intervention is designed to promote better understanding of medication therapies, increase medication compliance, reduce the incidence of adverse drug events and lower readmission rates. Our intervention includes the following components.

  • Assessment: A traditional home health start-of-care evaluation, including medication review, is performed by an Amedisys nurse or therapist.
  • Medication Therapy Review: A telephonic comprehensive medication review by Healthstat Rx to identify and communicate any potential medication-related problems and review the appropriateness of medications prescribed. 
  • Personal Medication Record / Medication Action Plan: Healthstat Rx pharmacists develop a medication treatment plan to optimize patient adherence and drug therapy; document care and communication with primary care provider; and provide verbal and written education on all medications to the patient and Amedisys providers. 
  • Follow Up:  Telephonic communication with the patient by Healthstat Rx and in-person communication from Amedisys clinicians in the home is used to monitor safety and effectiveness and review adherence to the medication regimen. 

Three Amedisys home health care centers in North Carolina, West Virginia and Tennessee were randomly chosen to participate as beta sites and test the operational effects of the intervention.  In the winter of 2011, the beta sites completed their testing.  Though no conclusions can be drawn from the small sample of patients (n=69), the results were encouraging.  Although more patients in the intervention group were on five or more medications, the number of hospitalizations for the intervention group was lower than our usual care control group.  In addition, emergency department visits were 3% for the intervention group as compared to 19% in the control group.

Building on these results, we expanded the study with Purdue and HealthStat Rx in early 2012.  Forty of our home health care centers were randomly selected to participate.  In each care center, 28 patients will be randomly assigned to usual care or to the medication management intervention.  Initial results are expected in early summer with dissemination of the findings to begin in fall of 2012 (subscribe by email or RSS feed to keep up with the findings). 

We hope to see a successful medication management intervention that translates into less confusion and frustration for our patients and their caregivers, and fewer adverse drug events.  Knowing that patients are especially vulnerable during the transition from an acute care hospitalization to home, we also expect our hospital partners to be interested in how the medication management intervention can improve hospital readmission rates for patients discharged to home health care. Reducing readmission rates would mean better patient care and satisfaction, lower costs for Medicare and other insurers, and a significant step toward an improved continuum of care.  

References

  1. Vincent Mor, Orna Intrator, Zhanlian Feng and David C. Grabowski. The Revolving Door Of Rehospitalization From Skilled Nursing Facilities. Health Affairs, 29, no.1 (2010):57-64.
  2. Stephen F. Jencks, Mark V. Williams, and Eric A. Coleman. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009;360:1418-28.
  3. Alan J. Forster, MD, FRCPC, MSc; Harvey J. Murff, MD; Josh F. Peterson, MD; Tejal K. Gandhi, MD, MPH; and David W. Bates, MD, MSc. The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital. Ann Intern Med. 2003;138:161-167.
  4. S. Kripalani, F. LeFevre, and C. O. Phillips, et al., “Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care,” Journal of the American Medical Association, vol. 297, no. 8 (February 28, 2007), pp. 831-841.
  5. Daniel S. Budnitz, Nadine Shehab, Scott R. Kegler, and Chesley L. Richards. Medication Use Leading to Emergency Department Visits for Adverse Drug Events in Older Adults. Ann Intern Med. 2007;147:755-765.
  6. Eric A. Coleman, MD, MPH; Jodi D. Smith, ND; Devbani Raha, MS; Sung-joon Min, PhD. Posthospital Medication Discrepancies: Prevalence and Contributing Factors. Arch Intern Med. 2005;165:1842-1847
  7. Mary Naylor, PhD; Dorothy Brooten, PhD; Robert Jones, PhD; Risa Lavizzo-Mourey, MD, MBA; Mathy Mezey, EdD; and Mark Pauly, PhD. Comprehensive Discharge Planning for the Hospitalized Elderly: A Randomized Clinical Trial. Ann Intern Med. 1994;120:999-1006
  8. Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for post-hospital care from the patient’s perspective: the care transitions measure. Med Care. 2005;43(3):246–55.
  9. Navigating Care Transitions in California: Two Models for Change. California Healthcare Foundation Issue Brief. September 2008.

About the Author

Julie L. Lewis is the vice president of health policy and government relations at Amedisys. She assists Amedisys in the continued development of a patient-centered, value-driven agenda for effective chronic disease management and end-of-life care that focuses on the quality and sustainability of the U.S. health care system.

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