New CMMI Primary Care Demo Could Pave Way for Hospice, Palliative Partnerships

Hospice News | By Jim Parker

A new primary care-focused payment model demonstration could create new partnership opportunities for hospice and palliative care providers.

The U.S. Centers for Medicare & Medicaid Services (CMS) has unveiled the Making Care Primary (MC) model, which will launch in July 2024 in eight states — Colorado, Massachusetts, Minnesota, New Jersey, New Mexico, New York, North Carolina, and Washington.

The agency intends for the 10-year demo to expand and enhance care management and care coordination. CMS plans to equip participating primary care clinicians with tools to form partnerships with specialists and to leverage community-based connections to address patients’ health and social needs.

This could include partnerships with hospice and palliative care clinicians.

“Palliative and hospice care are critical to a patient’s care journey. MCP participants will be required to form partnerships with clinicians of various specialty types, which will be referred to as Specialty Care Partners,” a CMS spokesperson told Hospice News in an email. “The final list of allowable specialty types for Specialty Care Partners will be released in the Request for Applications, but we anticipate that it will include hospice/palliative care.”

The program has three goals, according to CMS:

1) Ensure patients receive primary care that is integrated, coordinated, person-centered and accountable.

2) Create a pathway for primary care organizations and practices – especially small, independent, rural, and safety net organizations – to enter into value-based care arrangements.

3) Improve the quality of care and health outcomes of patients while reducing program expenditures.

Participating providers will be divided into three tracks based on their degree of experience with value-based care and alternative payment models. Home-based primary care providers are eligible to participate if they meet the program’s eligibility criteria, CMS confirmed to Hospice News.

Primary care operators that participate in the program will receive additional revenue to build infrastructure, make primary care services more accessible and improve coordination with specialists, CMS indicated.

The program will build upon previous primary care models, such as the Comprehensive Primary Care (CPC), CPC+, Primary Care First models, and the Maryland Primary Care Program (MDPCP), according to the agency.

“The goal of the Making Care Primary Model is to improve care for people with Medicaid and Medicare,” said CMS Administrator Chiquita Brooks-LaSure, in a statement. “This model is one more pathway CMS is taking to improve access to care and quality of care, especially to those in rural areas and other underserved populations. This model focuses on improving care management and care coordination, equipping primary care clinicians with tools to form partnerships with health care specialists, and partnering with community-based organizations, which will help the people we serve with better managing their health conditions and reaching their health goals.”

CMS Issues Memo to Hospitals About Requirement to Provide Information to Post-Acute Providers

On June 6, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a memo to hospitals to remind them of their obligation to provide all necessary information to post-acute providers (PACs) as part of the discharge process. “When a patient is discharged from a hospital, it is important to provide their post-acute provider and caregivers as applicable with the appropriate patient information related to a patient’s treatment and condition in order to decrease the risk of readmission or an adverse event,” CMS says in the memo.

CMS is especially concerned about missing or inaccurate information related to:

Patients with serious mental illness, complex behavioral needs and/or substance use disorder, especially information about patients’ underlying diagnoses and specific treatments that were implemented to help manage patients’ conditions while in the hospital, but discontinued prior to discharge

Medications, including an incomplete comprehensive list of all medications prescribed to patients during and prior to their hospital admissions. Common omissions also include diagnoses or problem lists, clinical indications, lab results and or clear orders for medications post-discharge, especially psychotropic medications, and narcotics.

Skin tears, pressure ulcers, bruising and lacerations, such as surgical sites, skin conditions noted upon admission and/or acquired during hospitalizations, including orders or instructions for cultures, treatments, and dressings

Durable medical equipment (DME), such as Trilogy, CPAP/BiPap or high-flow oxygen used for respiratory treatments and skin healing equipment, such as mattresses, wound vacuum machines for treatment of a variety of wounds

Patients’ preferences and goals for care, such as choices for treatment and advance directives for end-of-life care

Communications about patients’ needs at home or how their home environment may impact their ability to maintain their health and safety after discharge.

CMS says that failure to provide complete, accurate information upon discharge may put patients’ health at risk. The health and safety of other residents and staff may also be at risk. Incomplete and/or inaccurate information may also cause avoidable readmissions, complications, and other adverse events. Patients may also receive treatments that are unnecessary or inconsistent with their wishes.

CMS reminds state survey agencies, accrediting organizations, and hospitals in the memo that regulations of the Medicare Program require hospitals to “have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care.”

In addition, says CMS, “the hospital must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care.”

CMS concludes the memo by acknowledging that hospitals have discretion to develop their own policies and procedures to meet the above requirements. However, CMS makes the following recommendations to hospitals with regard to discharge planning:

• Collaborate with PAC providers by, for example, agreement on standardized processes
• Conduct case reviews of previous discharges to improve outcomes of future discharges
• Enable access to patient information in electronic health records (EHRs) by PAC providers so necessary information can be accessed to improve transitions.

Discharge planners/case managers should be prepared for increased scrutiny regarding these issues during surveys.

©2023 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

Brain Stimulation May Prove Helpful to Acute Stroke Patients, Pilot Study Suggests

University of California, Los Angeles

Highly targeted electrical stimulation to the brain showed promise as a new treatment for the most common type of stroke, according to a pilot study led by UCLA Health researchers.

The study is the first in humans to test the feasibility of using a targeted type of electrical current, called high-definition cathodal transcranial direct current stimulation (HD C-tDCS), to treat acute ischemic stroke, which occurs when a clot blocks blood supply to part of the brain and accounts for approximately 85% of all strokes. Stroke is a leading cause of death and disability in the United States.

Many patients are not candidates for the two main treatments currently available for acute ischemic stroke: clot-dissolving drugs and a device that reaches into the bloodstream and yanks out clots. Even among those who are eligible for those treatments, just an estimated 20%–30% are disability-free three months after their stroke.

In their new study, published June 21 in JAMA Network Open, UCLA Health researchers tested HD C-tDCS as a novel therapy for acute ischemic stroke, in which a series of electrodes are strategically placed across the scalp to deliver a weak inhibitory form of electrical current to the part of the brain suffering from low blood flow.

This form of noninvasive stimulation has been used to treat certain neurological and psychiatric conditions, and the researchers had noted the electrical currents appeared to have an effect on the brain's blood flow. The researchers theorized it may be possible to use HD C tDCS to enhance blood flow to parts of the brain impacted by stroke and protect the threatened brain tissue, known as the penumbra, from irreversible injury.

The pilot study involved 10 acute stroke patients who presented to the emergency department or were admitted at neuro-intensive care and stroke units, were ineligible for currently available treatments, and were within 24 hours of stroke onset. Seven patients were randomized to receive active HD C-tDCS treatment, and three received "sham" stimulation. Using hemodynamic brain scans that acute stroke patients receive upon arrival, the researchers located the stroke area with low blood flow to where the HD C-tDCS treatment was delivered.

"This treatment was aimed at being as targeted and as individualized as possible, only to the area of the brain that has low blood flow or is suffering from stroke," said the lead researcher on this innovative project, Mersedeh Bahr-Hosseini, MD, a vascular neurologist at UCLA Health. "With this high-definition form of C-tDCS, we were able to refine this electrical field to focus it just on this area."

The first set of patients, which included 3 patients in the treatment arm and one in the sham group, received 20 minutes of 1 milliamp of stimulation. In the remaining patients, the dose was escalated to 2 milliamps for 20 minutes.

Researchers were able to efficiently provide the treatment in emergency settings, and patients tolerated the treatment.

Bahr-Hosseini said the most exciting finding was that in patients receiving HD C-tDCS, a median of 66% of the penumbra—the threatened brain tissue surrounding the core of the stroke—was rescued in the first 24 hours after stroke, compared to 0% in the sham group.

According to the hemodynamic brain scans performed soon after treatment, patients who received HD C-tDCS showed signs of improved blood flow that was greater in patients receiving 2 milliamps compared to 1 milliamp. In contrast, the blood flow decreased in sham group. "That was also very exciting, because it showed a possibly true biological effect of the treatment," she said.

Researchers are planning a new multi-site study with Johns Hopkins, Duke University, and the University of Pennsylvania, to gather more data on the treatment's safety and efficacy. The next study will also include patients who are eligible for the clot-dissolving drugs, known as intravenous thrombolytics.

Traumatic Brain Injury Should be Recognized as Chronic Condition, Study Argues

By American Academy of Neurology

People with traumatic brain injury (TBI) may continue to improve or decline years after their injury, making it a more chronic illness, according to a study published in the June 21, 2023, online issue of Neurology.

"Our results dispute the notion that TBI is a one-time event with a stagnant outcome after a short period of recovery," said study author Benjamin L. Brett, Ph.D., of the Medical College of Wisconsin in Milwaukee. "Rather, people with TBI continue to show improvement and decline across a range of areas including their ability to function and their thinking skills."

The study involved people at 18 level 1 trauma center hospitals with an average age of 41. A total of 917 people had mild TBI and 193 people had moderate to severe TBI. They were matched to 154 people with orthopedic injuries but no head injuries. Participants were followed for up to seven years.

Participants took three tests on thinking, memory, mental health and ability to function with daily activities annually from two to seven years post-injury. They also completed an interview on their abilities and symptoms, including headache, fatigue, and sleep disturbances.

When researchers looked at all test scores combined, 21% of people with mild TBI experienced decline, compared to 26% of people with moderate to severe TBI and 15% of people with orthopedic injuries with no head injury.

Among the three tests, researchers saw the most decline over the years in the ability to function with daily activities. On average, over the course of 2 to 7 years post-injury, a total of 29% of those with mild TBI declined in their abilities and 23% of those with moderate to severe TBI.

Yet some people showed improvement in the same area, with 22% of those with mild TBI improving over time and 36% of those with moderate to severe TBI.

"These findings point out the need to recognize TBI as a chronic condition in order to establish adequate care that supports the evolving needs of people with this condition," Brett said. "This type of care should place a greater emphasis on helping people who have shown improvement continue to improve and implementing greater levels of support for those who have shown decline."

A limitation of the study was that all participants were seen at a level 1 trauma center hospital within 24 hours of their injury, so the findings may not apply to other populations.