Quality Today
Primaris produces QualityTODAY, the premier source of healthcare quality improvement news in Missouri. QualityTODAY is published quarterly, sent to over 5,000 healthcare professionals and leaders statewide. E-mail Matt Heger (mheger@primaris.org) to get your copy or for reprint information.
Back Issues
SUMMER 2007 |
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Walking through the Welcome to Medicare Visit
Not your everyday physical
Since the dawn of Medicare, routine physical checkups had always been explicitly excluded from coverage. If America’s seniors had the foresight to get a checkup, it came out of their own pocketbooks.
Since January 1, 2005, that has changed. Now Medicare Part B will pay for the Welcome to Medicare visit, also called the Initial Prevention Physical Examination (IPPE). This is a one-time-only opportunity for new beneficiaries which must be completed within the first 6 months of their Part B coverage. Everyone working with new beneficiaries is encouraged to spread the word; utilization of this benefit has been low. The words
“Medicare will pay for” may be misleading. Beneficiaries will be responsible for paying 20 percent of the Medicare-approved amount after meeting the yearly Part B deductible. Since this will likely be their first Medicare-covered service, they may meet the entire Part B deductible at this visit.
Welcome to Medicare isn’t your everyday physical exam. Medicare is paying for seven very specific segments. Most physicians will need to modify their usual exam procedure to meet the requirements. The results of each requirement need to be documented as the physician completes the exam.
Medical/Social History
The first part of the exam includes a comprehensive review of the beneficiary’s medical and social history. The objective is to find risk factors that may be modified.
At a minimum, the Centers for Medicare & Medicaid Services (CMS) say the medical history should include history of illnesses, hospital stays, operations, injuries and treatments; known allergies; current medications, supplements and vitamins; and family history. Social history should include history of alcohol, tobacco and illicit drug use; diet; and physical activities.
To help the visit move smoothly, it may help to ask beneficiaries to come prepared. Bringing medical records, immunization records, medication lists and any other useful documentation could greatly enhance the visit’s value.
Depression Risk
Depression is one of the most common and most commonly untreated chronic conditions. Part two of the Welcome to Medicare visit includes a review of potential risk factors.
There is not a specific Medicare-recommended screening tool. The only stipulation is the rather vague notion that the method must be “recognized by national professional medical organizations.”1
The fastest and most effective screening may be a simple two-question approach, asking “During the past month, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past month, have you often been bothered by little interest or pleasure in doing things?” These questions are derived directly from the Diagnostic and Statistical Manual of Mental Disorders–IV description of a major depressive episode and, according to a University of California-San Francisco/Brown University study, may be just as effective as much longer methods of screening for depression.2
A reply of “yes” to either question warrants further investigation.
Functional Ability/Safety
Part three of Welcome to Medicare includes a review of functional ability and overall safety. At a minimum, this includes asking about hearing impairment, activities of daily living (ADL), potential for fall risks and home safety.
Again, the requirements are flexible and can be accomplished with a few questions or a screening questionnaire provided the screening materials are “recognized by national professional medical organizations.”1 Analyses such as the Berg Balance Scale or the American Geriatrics Society’s Up and Go Test may be used for assessing fall risk. This should be followed by questions about home safety; for example, are there adequate rails throughout the home, appropriate lighting or loose throw rugs, etc. For ADLs, tactful questions about the patient’s ability to perform everyday tasks such as doing housework, using the restroom, or taking medication are appropriate.
As with the depression screening, if the questions reveal any risk factors, ask additional questions.
Exam
Part four is fairly straightforward; a physical exam. The only requirements are height, weight, blood pressure and vision. For vision, a Snellen chart is suitable.3 Additional examination is allowed based on the medical and social history.
Electrocardiogram
One of the most important portions of Welcome to Medicare visit is the ECG. Whether it is performed in-house or by referral, it must be completed and interpreted before billing.
To avoid billing nightmares, when writing a referral, the order should read “Electrocardiogram as part of the Welcome to Medicare visit. Use codes G0366-G0368.”
Education, counseling and referral
Part six brings together the results of parts one through five. Review the results and offer education or referrals as needed, such as nutritional information if the beneficiary is overweight, smoking cessation pamphlets or referral to a cardiologist for an abnormal ECG.
Referral to other Medicare services
And finally, part seven essentially repeats step six. This time, however, Medicare wants the focus on covered preventive services. Part B has recently expanded coverage for preventive services and offers a dozen options in addition to the Welcome to Medicare visit. However, these services have been greatly underutilized.
“Prevention has never been more important than it is today,” said Secretary of Health & Human Services Michael Leavitt. “Until we learn to approach prevention and staying healthy with the same rigor we do treatment, we’re not going to get ahead of our health-care problems.”
For a listing and more information about Medicare’s preventive benefits, visit www.cms.hhs.gov/PrevntionGenInfo/.
Citations:
- Centers for Medicare & Medicaid Services. “The Guide to Medicare Preventive Services.” May, 2005. 1-11. www.cms.hhs.gov/MLNProducts/ downloads/PSGUID.pdf. Accessed July 25, 2007.
- Whooley MA, Avins AL, Miranda J, Browner WS. “Case-finding instruments for depression: Two questions are as good as many.” J Gen Intern Med 1997;12:439-45.
- Card RO. “Getting Paid: How to Conduct a ‘Welcome to Medicare’ Visit.” Family Practice Management. April, 2005. www.aafp.org/fpm/20050400/ 27howt.html. Accessed July 23, 2007.
Quality is never accidental
Primaris Quality Awards
Quality is never accidental. It takes intelligence, adaptation, innovation and willingness to change. To recognize these qualities, the Primaris Quality Awards are presented annually. It is our way of sharing your great work so others can replicate the process.
Awards are given to a single organization from four categories: home health agencies, hospitals, nursing homes and physician offices. Their stories…
Home Health
Wright Memorial Hospital Home Health and Hospice, Trenton
Teamwork, open communication, constant awareness and always finishing step one before moving to step two – these are a few ways Jacquelyn Walker’s team delivers some of the best home health care in the nation, all with fewer than ten staff members on the average day.
“Communication is number one,” said Walker, the clinical supervisor of Wright Memorial Hospital Home Health and Hospice. “You have to follow through to make sure the patients’ needs don’t get lost.”
And it is paying off. According to Centers for Medicare & Medicaid Services (CMS) data, this small, rural home health agency performs in the top 20 percent of agencies nationwide.
To honor their commitment to constant improvement and proven results, Wright Memorial Hospital Home Health and Hospice was named as the winner of the Primaris Home Health Quality Award on Wednesday, April 25.
Their strategy included front-loaded visits, open communication among staff and constant awareness of their quality improvement data through review of OBQI reports. In addition, they implemented a Friday-call policy, ensuring every patient had some form of contact with staff before the weekend. This allowed them to identify and intervene in situations that may have resulted in emergent care or hospitalizations over the weekend.
With this strategy, Wright Memorial’s acute care hospitalization rate dropped from 25.2 percent to 15.8 percent; nearly half the national average. Their emergent care, oral meds, ambulation and dyspnea scores all showed relative improvements of 40 percent or greater. Every one of their publicly reported quality measures is better than the state and national averages.
“Wright Memorial is not just leading the state, but the nation. This translates to better care for their patients. That’s helping people bathe themselves. It’s helping them move around their homes without assistance. It’s staying out of the hospital, breathing easily and, ultimately, getting to a point where they don’t need home care,” Royer said. “Their accomplishments are impressive to say the least.”
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Hospital
St. John’s Mercy Medical Center, St. Louis
When a team of health care experts reviewed candidates for the Primaris Hospital Quality Award, St. John’s Mercy Medical Center came out on top.
“Quality is essential to the healing environment of St. John’s Mercy,” said Denny DeNarvaez, president and CEO of St. John’s Mercy Health Care. “The remarkable commitment and collaboration among our physicians, nurses and other co-workers results in exceptional care for the patients we serve.”
The hospital receiving this award must rank among the highest in the state in quality of care on measures designated by the Centers for Medicare & Medicaid Services (CMS). Quality Award winners also demonstrate openness to their community through public reporting and show a true dedication to quality improvement through actively participating in Missouri quality improvement projects and collaboratives.
St. John’s Mercy Medical Center performed above the national average in 20 of 21 nationally reported measures of clinical care. In addition, St. John’s Mercy Medical Center worked intensively with various quality improvement projects. This included national campaigns, such as the Institute of Healthcare Improvement’s 100,000 Lives Campaign, as well as statewide efforts.
“While such projects pay off by improving care, they also require an investment of time and staff. By making these commitments, St. John’s shows that administrators and staff understand the value of constantly evolving care,” said Richard A. Royer, Primaris CEO.
In addition to excellent care on CMS-reported measures, the hospital has nearly eliminated ventilator-associated pneumonia cases.
St. John’s Mercy Medical Center has also worked over the past few years to lower door-to-balloon time for ST-segment elevation myocardial infarction patients who present at St. John’s and need primary PCI. Since September 2005, they have been at or below 100 minutes and continue to strive to lower the door-toballoon time to 90 minutes.
This year marks the second consecutive year the award has been given to a member of St. John’s Mercy Health Care. Last year’s award was given to its Washington, Mo., hospital, St. John’s Mercy Hospital.
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Physician Office
Esse Health, St. Louis
Approximately 300,000 Missourians live with diabetes. Because the chronic disease requires careful attention, improvements in management deserve special celebration.
For that reason, a group effort to successfully manage the disease has earned recognition for physicians at Esse Health. On April 30, Primaris presented the St. Louis-based, independent physician group with the Primaris Physician Office Quality Award.
Esse Health was selected for its integration of electronic medical records (EMR) to improve care management of its patients with diabetes through a Disease Management Team. Esse’s Disease Management Team used its system to collect data for all of its diabetic patients, allowing for the monitoring of large groups of patients as well as individuals. In addition, the group established the Practice Standards, a set of diagnosis criteria and treatment protocols that includes checks and prompts to ensure that nothing is overlooked when a diabetic patient visits. Patients were also provided a Diabetic Health Report to help track their health.
“The Diabetic Health Report has improved our patients’ awareness of their own diabetes goals, and they can now become more active participants in their health care,” said Esse Health physician Dr. Kathleen Brunts. “Our patients have seen substantial improvement in their blood sugar, blood pressure and weight.”
Although most physicians have yet to add electronic records to their practice, Esse was an early adopter of the technology, starting to utilize them in the late 1990s.
“Only a fraction of Missouri physician offices have made the switch from old paper and pen records. Esse Health’s system shows the potential that others are missing,” said Richard A. Royer, CEO of Primaris. “Esse was quick to adopt technology – carrying wireless laptops that allowed better care for patients – and they are quick to put it to its best use, managing care.”
Because effective diabetes control requires a large degree of patient compliance, Esse also started what it calls “group visits.” During these visits, patients learned more about controlling diabetes as a group. Nearly all that regularly attended the meetings have shown significant improvement in controlling their diabetes.
With the diabetes management system in place, Esse plans to replicate the care management system for other chronic diseases.
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Nursing Home
Parkview Healthcare Facility, Bolivar
When affecting culture change became a competition for a coveted plastic trophy, residents, staff and administrators at Parkview Healthcare Facility all took home the cup.
Parkview, of Citizens Memorial Healthcare, was designed in 1992 with a pod-structured floor plan to foster communities of care, but it didn’t begin to fully live up to this vision until 2005. It was then that staff and administrators began working to create “neighborhoods”—units composed of a nurse manager, 15 staff members and as many as 30 residents.
These culture changes were taken to the next level with the help of a Primaris consultant who helped implement teams in each neighborhood devoted to reducing falls and high-risk pressure ulcers, assessing and managing pain, and keeping staff consistent in each neighborhood, said Tim Francka, Parkview’s administrative director of long term care.
With these “neighborhood” teams in place, improving quality became a competition with staff competing for a traveling trophy inscribed “best of the best.”
In 2006, education and new protocols were added for staff. Assessments were added to Parkview’s electronic documentation system, allowing care staff to continuously graph the healing process of pressure ulcers—the home’s main target for quality improvement.
They assigned a nurse to measure, document, photograph and report pressure ulcers on a weekly basis; posting of data increased accountability for pressure ulcer care across the whole facility. In a year’s time, high-risk pressure ulcers dropped from 13.33 percent —close to national and state averages—to a scant 3.33 percent. Francka said he attributes this dramatic reduction to culture change more than anything else.
Throughout 2006, staff developed plans to phase-in significant changes in regard to resident choice, furthering the community feeling for their residents. For example, a March 2006 staff plan for “Gentle Waking” allowed residents to choose when they awoke and when they ate breakfast. As a response to resident feedback, a flexible lunch was added and a “Bathing without a Battle” program allowed residents to choose the type and time of their bath.
In recognition of care quality and innovative efforts to promote and advance continual improvement, Parkview Healthcare Facility in Bolivar was awarded the Primaris Nursing Home Quality Award on July 6.