Perceptions of the Medicare Care Choices Model Patricia Rowan, MPP - - PowerPoint PPT Presentation

INFORMATION NOT RELEASABLE TO THE PUBLIC: The information contained in this report is preliminary and may be used only for project management purposes. It must not be disseminated, distributed, or copied to persons unless they have been authorized by CMS to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Hospice Implementation and Beneficiary and Staff Perceptions of the Medicare Care Choices Model

Patricia Rowan, MPP (Abt Associates) Allison Muma, MHA (Abt Associates) Joan Teno, MD (OHSU) AcademyHealth 2019 Annual Research Meeting June 3, 2019

Abt Associates | pg 2

Acknowledgments

• This research was funded by the Centers for

Medicare & Medicaid Services (CMS) under contract to Abt Associates, contract #HHSM-500-2014-00026I

• The contents of this presentation are solely the

responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies

@patriciajrowan

Abt Associates | pg 3

Agenda

• Overview of the Medicare Care Choices Model

(MCCM) and participants

• MCCM implementation approaches

– Staffing structure – Marketing efforts – Delivery of MCCM services – Implementation challenges

• Beneficiary and hospice staff perceptions of MCCM

services received

@patriciajrowan

INFORMATION NOT RELEASABLE TO THE PUBLIC: The information contained in this report is preliminary and may be used only for project management purposes. It must not be disseminated, distributed, or copied to persons unless they have been authorized by CMS to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Overview of the Medicare Care Choices Model and the Evaluation Approach

Abt Associates | pg 5

Medicare Care Choices Model

• Current Medicare policy requires beneficiaries to

stop treatment of their terminal condition to receive hospice benefits

– This choice often results in beneficiaries electing hospice late in their disease trajectory

• MCCM tests the effect of allowing eligible

beneficiaries the option to receive supportive services from participating hospices (“MCCM hospices”) while continuing to receive coverage for treatment of their terminal condition through fee-for- service Medicare

@patriciajrowan

Abt Associates | pg 6

MCCM Hallmark Services and Payment

1. Care Coordination and Case Management 2. 24/7 Access to Hospice Team 3. Person-centered Care Planning 4. Shared Decision-Making 5. Symptom Management 6. Counseling

*Provided in addition to typical services like home and respite care.

• $400 per beneficiary per month payment

– $200 for first month if enrolled fewer than 15 days

@patriciajrowan

Abt Associates | pg 7

Abt Associates | pg 8

MCCM Beneficiary Eligibility Criteria

• Enrolled in Medicare fee-for-service Part A and Part B as

primary insurance for the past 12 months

• Diagnosis of terminal cancer, CHF, COPD, or HIV/AIDS
• Prognosis of six months or less documented with a

Certificate of Terminal Illness

• At least one hospital encounter in the last 12 months
• At least three office visits with any provider in the last 12

months

• Lived in a traditional home continuously for last 30 days

@patriciajrowan

Abt Associates | pg 9

Number of Beneficiaries That Were Referred to and Enrolled in MCCM, June 2017

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Abt Associates | pg 10

Participating Hospices, December 2017

Cohort 1 hospices (January 2016 – December 2020) Cohort 2 hospices (January 2018 – December 2020)

@patriciajrowan

Abt Associates | pg 11

MCCM Hospices Differ from All Other Hospices

• MCCM hospices are:

– Larger – More likely to be non-profit – More concentrated in the Midwest and Northeast – More likely to be facility-based

@patriciajrowan

Abt Associates | pg 12

Methods and Study Population

• In-person staff interviews at 18 MCCM participating

hospices

• Interviews with 20 Medicare beneficiaries and

caregivers receiving services through the model

• Survey of hospice leadership to gather basic

implementation and staffing information

– All MCCM hospices (N=113) were surveyed, and 83% (N=94) responded

• This presentation reflects the first report of the

evaluation, using data through December 2017

@patriciajrowan

MCCM Implementation Approaches

INFORMATION NOT RELEASABLE TO THE PUBLIC: The information contained in this report is preliminary and may be used only for project management purposes. It must not be disseminated, distributed, or copied to persons unless they have been authorized by CMS to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Abt Associates | pg 14

MCCM Staffing Approaches

• Majority of MCCM hospices reassigned existing staff for

MCCM positions, rather than hiring new staff

– For those hospices that did hire specifically for MCCM, the most commonly hired role was RN care coordinator

• Most common staffing approaches included:

– Designating an MCCM team made of an RN and social worker, with other disciplines from hospice teams as needed – Cross-training all hospice staff to also serve MCCM enrollees – Utilizing the palliative care team to serve MCCM enrollees – Having a single, designated RN care coordinator with other disciplines from hospices teams as needed

@patriciajrowan

Abt Associates | pg 15

MCCM Staff Training

• All MCCM hospices visited held an initial training for

a group of staff identified as the core MCCM team. This initial training was supplemented with:

– Reference guides or ‘quick tips’ outlining the differences between MCCM, hospice, and palliative care (where

• ffered)

– Presentations, team meetings, or literature shared with staff – Resources posted on the MCCM portal and CMS-facilitated webinars integrated into staff training sessions – Role playing activities where staff could try out caring for MCCM enrollees

@patriciajrowan

Abt Associates | pg 16

Efforts to Generate Beneficiary Referrals

• Hospices target their marketing efforts primarily to

physicians, nursing staff, social workers, discharge planners, and palliative care teams located in physician offices, hospitals, and other settings

– Majority of MCCM referrals come from oncologists and internal medicine physicians

• Key marketing messages included:

– Help with disease and symptom management – Support in making complex medical decisions – Additional beneficiary and caregiver support – 24/7 access to trained hospice staff

@patriciajrowan

Abt Associates | pg 17

Organizational Features Associated with Effective Implementation of MCCM

• Centralized processing of referrals to any service
• ffered by the hospice
• Leveraged health system participation to confirm

MCCM eligibility and educate referring providers

• Clear communication channels among well-defined

MCCM teams with streamlined decision-making authority

• Use of experienced staff and referral relationships

from existing palliative care programs

@patriciajrowan

Abt Associates | pg 18

Implementation Challenges

• Most MCCM hospices we visited for case studies

believe the costs of providing MCCM services may exceed the $400 PBPM

– Although few hospices are explicitly tracking their expenses

• Other implementation challenges included:

– Coordinating with home health agencies – Securing durable medical equipment – Coordinating medications with prescribers

@patriciajrowan

Perceptions of MCCM Among Stakeholders

Abt Associates | pg 20

Hospice Staff Perception of Positive Enrollee Impacts of MCCM

0% 20% 40% 60% 80% 100% Support for beneficiaries and their caregivers Timing of referral to hospice Coordination of care among the referring physician and MCCM staff Disease and symptom management Advance care planning Clarification of patient preferences that result in a DNR order Transitions from the hospital or other inpatient setting Clarification of patient preferences that result in a DNH order Percentage of Hospices Cohort 1 Cohort 2

@patriciajrowan

Abt Associates | pg 21

Perceptions of Hospice Staff & Leadership

• Many interviewees felt that MCCM could reduce

Medicare expenditures through fewer ED visits and/or hospitalizations and support earlier entry to hospice

• Hospice staff expressed increased professional

satisfaction as a result of participation in the model

• Low MCCM payments caused hospices to rely more
• n telephone encounters, and fewer in-person visits

than some hospice staff preferred

@patriciajrowan

Abt Associates | pg 22

Perceptions of Referring Providers

• Appreciated added layer of

supportive services MCCM provides

• Added support through in-home

services and care coordination for patients receiving treatment

– Keeping patients at home and preventing trips to the ED or hospitalizations

• Improved communication

between enrollees and providers

• Reduced stigma of hospice

“For me, the most important thing is that I can get information about the patients. I struggle to educate about symptoms and they’re not always able to do it on their own, so when MCCM calls and someone is checking on my patients, that’s great. Care coordination is very important in primary care.”

• Referring Physician

@patriciajrowan

Abt Associates | pg 23

Perceptions of MCCM Enrollees

• MCCM enrollees and their

caregivers were universally satisfied with MCCM

• MCCM improves quality of life and

gives enrollees and their caregivers “peace of mind”

• After-hours access to hospice staff

prevented ED use

• Hospice staff helped advocate for

enrollees

“That extra set of hands, eyes to access the situation is such a relief on the caregiver-to know, especially with lung cancer, I don’t have to wait six weeks to go back to the doctor and someone can check on her, to know how she’s doing.”

• Caregiver to an MCCM

enrollee @patriciajrowan

Implications for Policy and Practice

Abt Associates | pg 25

Implications for Policy and Practice

• Hospices interested in offering similar services

benefit from knowing which emerging organizational features are associated with effective model implementation

• CMS has used this research to tailor technical

assistance to participating hospices

• Our results fill a research gap in the published

literature on the first-hand experiences of Medicare beneficiaries receiving supportive services at the end

• f life

@patriciajrowan

Patricia Rowan, MPP, PMP Abt Associates Patricia_Rowan@abtassoc.com @patriciajrowan