The Wis-PALTCM Mission Statement- - WAMD, The Wisc …



Newsletter for September 2019-Ron Schreiber, MD, CMD, president 1707ron@ Bob Smith, MD, CMD, immediate past-president rpsmith53@ Curt Hancock, MD, CMD, webmaster cwhancock@ T Rex Flygt, MD, CMD, newsletter editor Flygt@ Karen Miller, Executive Assistant KarenMiller.Rio@ News-from around our organizations and our members:Your Board of Directors met July 17-We heard a presentation from the Wisconsin Alzheimer’s Association.We reviewed and accepted the financial report.We chose to continue to use Impact as the association’s management company.We chose to continue to use the Wisconsin Medical Society as the accreditor of the educational program at the annual meeting.We testified before the state assembly earlier this year, and the state senate at mid-year, supporting legislation that would align the CNA training hours more closely with the federal minimum.We chose to table indefinitely forming a charitable foundation at the state level.We are advertising to replace our executive assistant Karen Miller on her proposed retirement.We plan to hold our 2020 meeting at the Holiday inn in Pewaukee.We voted to support legislation in the state senate to permit physicians’ assistants and nurse practitioners to authenticate do not resuscitate orders and to be one of two signers of the activation of powers of attorney for healthcare and living wills.Other News-from around our state and our partners. Annual meeting registration-downloadable PDF at Your association will hold its annual meeting at the Radisson in Madison October 11 and 12Friday, October 11-10 AM Board Meeting11 AM Registration and Exhibits11:55 AM Welcome, Ronald Schreiber MD, CMD, WAMD President12:00 PM Disaster Preparedness Timothy Vayder MD and Robert Deede RN1:30 PM The Geriatric Colon Eric Gaumnitz MD GI and Geriatrics2:30 PM Break and Exhibits3:00 PM Valvular heart disease: What the ECF provider needs to know ? ? ? ? ? ? ???? Dr. Cherian Varghese?4:00 PM Megarule Implementation and Hospital Readmissions Brian Purtell JDPreparation for Patient Driven Payment Model:?Jon Ollmann, North Shore SVP Operations5:30 PM Annual Meeting Ronald Schreiber MD, CMD, WAMD President 6:30 PM Reception – Appetizers and Drinks, Networking spouses and guest invitedSaturday October 12-6:30 AM Industry Breakfast Janssen Pharmaceuticals: The Compass Trial and ASHD and PAD, Sean Cannone, DO, CMD7:25 AM Welcome Comments: Pres. Kristin Severson DO7:30 AM Pharmacy Update Douglas Engelbert8:30 AM Mary Cohan MD Fellows Clinical Updates 3 Fellows, 20 min each, then 15 min panel9:45 AM Pat Virnig RN, DQA update10:30 AM Break and Hotel checkout11:00 AM AMDA Update Christopher Laxton, CAE, Executive Director AMDA12:00 PM Lunch in the TrenchesNational Issues facing Long term Care Christopher Laxton, CAE, Executive Director, AMDAPat Virnig RN, DQA, Megarule ImplementationRonald Schreiber MD Coding Ronald Schreiber MD, CMD, WAMD Past President1:00 PM ENT Emergencies and Urgencies in LTC Perry Phillips MD2:00 PM MD-Adv Practice-Therapies-Pharmacy CollaborationTanya Chapman, APNP3:00 PM Break (15 min)3:15 PM Infection Update 2019.? Chris Crinch MD4:15 PM Adjournment Kristin Severson DO PresidentSave the date for the DQA’s annual FOCUS conference November 20-21 in Wisconsin Dells. This year’s special session will is “Let’s Talk About It: Topics Too Important to Ignore” including sexual expression, abuse and resident rights. Teepa Snow will deliver the keynote address “Dementia 360.” Go to Save the date for AMDA’s annual conference in Chicago April 2-5.From the Trenches- questions about the meaning of PA/LTC life: PDPM Executive Summary for Physician and non-Physician Providers- Background: The TEFRA of 1982 created the Medicare A SNF benefit. The BBA of 1997 created the payment system we are now in, RUGS IV. In all PA/LTC settings, as in all of medicine, coding follows the money; in SNFs that’s been therapy billing minutes. The RUGS to PDPM change uses the MDS in a different way, and adds weight to ICD-10 codes in a new and different way. The change will do to SNFs what DRGs and ICD-10 did for the acute care facilities. We have experience with the change; we know ICD-10.Additional background: There are still three of five categories related to therapy (OT, PT, and ST) and a fourth related to nursing (using a lot of GG from the MDS); what is really new is the fifth (“non-therapy ancillary” or “NTA”), driven by mapping the 68,000 ICD codes to fifty conditions or services into ten categories creating a comorbidity score (a case-mix index). Payment is frontloaded, and is largely fixed based on the initial (day 5) MDS submitted by day 8, and not subject to further change without an additional change in condition.Now the meat: Although only a clinical provider (P or NPP) can diagnose, the hospital provider, clinical provider, and SNF provider may actually submit different diagnosis codes with their service. If you think about that for a minute, it’s not too strange: Consider a transplant patient hospitalized for UTI who goes to a SNF for rehabilitation a couple weeks later; the hospital may code for the UTI, but the SNF may not. The patient has had an organ transplant, but the clinical provider is not “treating” that, so she doesn’t bill that code (the transplant team does). The transplant team isn’t involved with the UTI, so they don’t bill for that. Again, for the purpose of review: While each provider bills using the code they think is appropriate for their services, the acute and post-acute facilities can only use diagnoses made by the clinical providers. So in conclusion: While PDPM does not affect clinical provider work or billing directly, it may have a strong indirect effect on their work as nursing home providers (like hospital providers the last year or two) seek the most accurate ICD-10 codes. So how can we make the “coding query” as quick and painless as possible?Clinical providers will figure out pretty quickly what diagnoses the facilities are looking for, and get them into the medical record (if they’re not there already) as indicated, recursively reducing questions in the long run.Facility providers should use Epic Link (or whatever electronic health record system their clinical providers use) to find out the complete diagnostic list as rapidly as possible, and then in-basket their coding queries quickly and efficiently in a way that locks our answers into the record. Buildings that rely on paper workflows will be less accurate and timely.Who has the responsibility, authority, accountability for this? It’s about the MDS nurse and GNPFacility providers should use Epic Link wherever possible to find out the complete diagnostic list as rapidly as possible, and then in-basket their coding queries quickly and efficiently in a way that locks our answers into the record. Paper workflows will be slower and less efficient.As clinical providers figure out what diagnoses are needed, questions will decrease over time—we’re in suspense for August and September, we’re going to be working in the fourth quarter, and things will be better in 2020.Frequently asked questions-Who’s at the center of this? It’s about the MDS nurse and the first provider who sees the patient.What is an “active” diagnosis? Active diagnoses are those bearing a direct relationship to the resident’s current function, cognition, mood or behavior status, medical treatments, nursing monitoring, or risk at or up to seven days before admission.Who picks the “active” diagnosis? The buildingAre we vicariously responsible for the potential misuse of our diagnoses by facilities? NoWhat are some of the diagnoses we’re likely to be asked to add?Morbid obesity doesn’t matter much in the hospital or clinic; it matters now in PA/LTC. The cause probably does not matter.Mood disorders are frequently not explicitly diagnosed in primary care, or in non-psychiatry specialty care; it matters now in PA/LTC. The exact type probably does not matter.Amputations are frequently not carried on the problem list in primary care, or noted in the hospital; they matter now in PA/LTC. Diabetes mellitus is sometimes present, but not diagnosed; strange but true. Can I say “I don’t know”? --Yes; it is also permissible to say “I do know”If asked to characterize complicated fracture morphology, refer to the imaging report.If asked to characterize the kind of heart failure present, refer to the echo report: If the EF is low, it’s HFrEF; if the EF is normal or near normal it’s HFpEF. Acute or chronic—your call.If asked to characterize the kind of stroke present, refer to the imaging report. It will say acute (vs chronic), ischemic (vs hemorrhagic) and anatomic distribution; if the referring clinicians did not discriminate between atheroembolic and cardioembolic, nothing will be clearer from the bedside.Spontaneous and most fall-related fractures are pathologic; most other fractures are not pathologic.How certain do I need to be to make a diagnosis? A reasonable degree of medical certainty = more likely than not. That’s all.Other Reviews-publications from around the world of geriatrics and PA/LTCDoes My Patient with Multiple Comorbidities Have Heart Failure with Preserved Ejection Fraction, and Does It Matter?Dmitry AbramovThe Journal of the American Board of Family Medicine May 2019, 32 (3) 424-427; DOI: Dmitry AbramovFrom the Department of Cardiology, Loma Linda University, Loma Linda, CA.Find this author on Google ScholarFind this author on PubMedSearch for this author on this siteAbstract-Heart Failure with Preserved Ejection Fraction (HFpEF) is a common diagnosis and accounts for half or more of all cases of heart failure. Despite its high prevalence and significant morbidity, the pathophysiology of HFpEF remains incompletely understood. Patients diagnosed with HFpEF often have significant cardiac and extra-cardiac comorbidities. Given the availability of evidence-based treatments for common comorbidities, but not for HFpEF, the necessity of diagnosing HFpEF among symptomatic elderly patients with multiple comorbidities is unclear. This commentary raises the question of whether the search for the diagnosis of HFpEF should instead be refocused to the management of common comorbidities without necessitating the heart failure diagnosis.Introduction-Heart failure with preserved ejection fraction (HFpEF) comprises about half of the cases of heart failure in the United States.1 Despite its growing prevalence and significant morbidity, HFpEF remains incompletely understood and diagnosis in the community setting may be difficult. Widely used diagnostic criteria that incorporate clinical findings with laboratory values and echocardiographic parameters lack sensitivity which may result in underdiagnosis. HYPERLINK "" \l "ref-2" 2 Overdiagnosis based on vague symptoms and nonspecific diagnostic parameters may likewise be problematic. The concern of over- and underdiagnosis is further compounded by the lack of evidence-based treatments for those diagnosed with HFpEF. Patients with HFpEF tend to be older, with multiple cardiac and noncardiac comordbitities.3 This begs the question of whether diagnosis of HFpEF remains critical to optimize the care of predominantly older patients with multiple comorbidities.Heart failure has been defined as the inability of the heart to generate adequate cardiac output or the ability to generate adequate cardiac output only in the setting of elevated filling pressures.4 The standard clinical diagnostic criteria for HFpEF includes heart failure symptoms (such as dyspnea, orthopnea, paroxysmal nocturnal dyspnea) and elevated filling pressures (predominantly Wedge pressure) at rest or with exercise.5 Elevated filling pressures may be clinically estimated through measurement of jugular venous distention. Confirmation of elevated filling pressures, and therefore the heart failure diagnosis, can be obtained through invasive right heart catheterization. The history and physical examination-derived signs and symptoms suggestive of heart failure may be difficult to ascertain, and their correlation with invasively derived filling pressures has largely been based on studies of acutely decompensated or end-stage patients with reduced ejection fraction.1, HYPERLINK "" \l "ref-6" 6 Recently, permanently implanted pulmonary artery monitors have been used to help evaluate central filling pressures as a supplement to the physical examination,7 although the utility of such devices as part of the diagnostic evaluation of heart failure may be limited.Current diagnostic criteria for HFpEF from the American College of Cardiology and American Heart Association include clinical signs or symptoms, ejection fraction ≥50%, and evidence of diastolic dysfunction.1 Patients meeting heart failure criteria with ejection fraction of 41% to 49% can be classified as having heart failure with borderline or midrange ejection fraction, which is more clinically similar to HFpEF than to heart failure with reduced ejection fraction.1,8 Diagnostic criteria for HFpEF from the European Society of Cardiology are similar, and include signs and symptoms, ejection fraction of ≥50%, elevated B-type natriuretic peptide values and echocardiographic evidence of structural abnormalities or diastolic dysfunction.9While seemingly straightforward, the application of these criteria to the community setting is fraught with limitations. These diagnostic criteria have been criticized for low sensitivity, HYPERLINK "" \l "ref-2" 2 and the reliance on echocardiographic evaluation of diastolic dysfunction may neither accurately evaluate cardiac relaxation abnormalities nor contain sufficient sensitivity or specificity to detect a clinical course consistent with HFpEF.10 Although exact criteria for grading of diastolic dysfunction have changed over time,11 diastolic abnormalities on echocardiography are common in community cohorts of patients with comorbidities such as obesity, hypertension, diabetes and coronary disease,12 and have poor correlation with heart failure symptoms.12, HYPERLINK "" \l "ref-13" 13 In addition, only minimal abnormalities in diastolic parameters (including a high prevalence of normal diastolic function, normal left atrial size, and normal wall thickness) are noted in cohorts with symptomatic HFpEF.10 Echocardiographic diastolic parameters may primarily estimate ventricular filling pressures, HYPERLINK "" \l "ref-11" 11 rather than necessarily providing an explanation for their elevation.Clinical trials and day-to-day care of patients with HFpEF highlight the high burden of comorbidities associated with this condition. Common noncardiac comorbidities include older age, chronic kidney disease, and lung disease. Common cardiac comorbidities include diabetes, hypertension, coronary artery disease, obesity and atrial fibrillation. As dyspnea is a common symptom in patients with many of these comorbidities, and given the notable limitations of the diagnostic algorithms, how are clinicians to identify which of these patients may have HFpEF?In light of these limitations, some have proposed scoring systems to help identify patients with HFpEF among those being evaluated for dyspnea5; identifying that the biggest predictors of elevated filling pressures (and therefore the HFpEF diagnosis) among patients with dyspnea are advanced age (>60 years old), obesity (Body Mass Index >30 kg/m2) and atrial fibrillation. Other factors having a smaller association with elevated filling pressures include elevated pulmonary artery systolic pressure, treatment with multiple antihypertensive medications, and abnormal diastolic parameter of E/e'.5 Having the 3 risk factors of advanced age, obesity, and atrial fibrillation was associated with a greater than 90% likelihood of meeting criteria for the diagnosis of HFpEF based on elevated filling pressures.5 Importantly, elevated B-type natriuretic peptide, dilated left atrium, ventricular hypertrophy, or abnormal ventricular strain—all key parameters associated with diastolic dysfunction—had either smaller or no independent predictive ability to diagnose elevated filling pressures.This focus on comorbidities as the key contributor to pathophysiology of HFpEF raises significant questions about our current understanding of what it means to impart onto a patient the heart failure diagnosis. Dyspnea is a ubiquitous and subjective symptom in older individuals, HYPERLINK "" \l "ref-14" 14 and is particularly common in patients with comorbidities including obesity and atrial fibrillation. Dyspnea may also be multifactorial, and not primarily caused by elevation in intracardiac filling pressures.15 Elevated filling pressures, even in the presence of dyspnea, may not always reflect heart failure, as every patient with end-stage renal disease on dialysis is not generally considered to have “heart failure” before a dialysis session.Instead of focusing on the diagnosis of HFpEF, (ie, attempting to determine whether dyspnea is cardiac in origin or whether echocardiographic abnormalities are relevant to the clinical presentation), perhaps a better approach would be to return to the diagnosis and management of key cardiac and extracardiac comorbidities3 that are common in elderly patients with limitations to functional capacity. It should be acceptable to diagnose and manage conditions associated with fluid retention, such as anemia, obesity, diabetes, kidney disease, or atrial fibrillation without invoking the heart failure diagnosis. Each of these comorbidities is a significant stand-alone diagnosis, associated with its own symptoms (often dyspnea), diagnostic criteria, and evidence-based treatments.3 Whether these comorbidities contribute to fluid retention through: their association with diastolic abnormalities, other ventricular myocardial abnormalities, their own unique pathophysiologies, or a combination of these remains unclear. Diuretics are the mainstay treatment of symptoms of volume overload regardless of etiology, and can be used to control symptoms regardless of whether the patient is diagnosed with HFpEF, is suspected as having HFpEF, or is presumed to have volume overload from a noncardiac etiology. Among patients with HFpEF, the diuretic spironolactone is primarily effective at lower ejection fractions (<50%), and the benefits among patients with higher ejection fractions are less certain.16While the search for underlying pathophysiology continues, there is increasing evidence that comorbidities are the most prominent contributors to symptoms among patients labeled as having HFpEF. If symptomatic comorbidities require another name or label, perhaps a better one is “comorbidity associated heart failure” or even “comorbidity associated diuretic dependence.” Employing terminology to more closely correlate with etiology based on subpopulations of HFpEF patients may simplify the diagnosis of a widely encountered clinical syndrome and help guide management in a way not currently possible with HFpEF.May the diagnosis of HFpEF become more clinically relevant if ongoing trials of novel therapies, including sacubitril valsartan, empagliflozin, and others demonstrate improvement in clinical outcomes? The answer to that question has yet to be determined, as these medications may yield similar benefit in high risk primary prevention populations without the necessity of a HFpEF diagnosis. While diagnosing specific diseases that have previously fallen under the HFpEF umbrella such as Amyloid or Fabry's cardiomyopathy are increasingly critical as treatments become available, the benefit of diagnosing comorbidity associated HFpEF remains unclear. In addition, while diagnosing HFpEF may carry prognostic implications, the associated adverse prognosis may result more from a particularly advanced comorbidity burden rather than primary cardiac pathology or heart failure itself.In conclusion-Diagnosing HFpEF in the community may not be easy or even clinically relevant, and the answer to the question of, “does my patient with multiple comorbidities have HFpEF?” may be less important than using available treatments to improve the quality of life of symptomatic patients.To see this article online, please go to: . References omitted to shorten the copy and pasteAdvertisementSupported byReflections-The Wis-PALTCM Mission Statement-It will be the purpose of this organization:To promote quality and compassionate medical care for patients of all ages in post-acute and long-term care.To establish better communication among physicians serving as medical directors and other providers.To promote better communication between medical directors and (a) other post-acute and long-term care professionals, (b) various long-term care associations, and (c) officials of various government agencies.To represent medical directors in defining their roles and equitable compensation.To serve as a conduit between AMDA and the WAMD membership.To conduct continuing education programs, emphasizing the area of geriatrics and post-acute and long-term care.To promote a better understanding by the public of issues concerning the post-acute and long-term care facilities and residents.To support evidence-based treatments and best practice policies to manage post-acute and long-term care facilitiesWis-PALTCM: The Wisconsin Association of Medical Directors 5329 Fayette Ave., Madison, WI? 53713 ................
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