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PTAC Backs Model Aimed at Better Living for Seniors

WASHINGTON — For 2 years, the Physician-focused Payment Model Technical Advisory Committee (PTAC) has struggled to differentiate between care delivery models and payment models. On Monday, the panel greenlighted a proposal that Grace Terrell, MD, CEO of Envision Genomics and PTAC vice chair, called a “social care model.”

The Community Aging in Place — Advancing Better Living for Elders (CAPABLE) is intended to improve “functional ability” for older adults with chronic conditions and functional limitations. The model was submitted by the Johns Hopkins School of Nursing in Baltimore, and the Stanford Clinical Excellence Research Center (CERC) in California.

PTAC ultimately voted 7-0 to recommend the model, and more specifically to recommend testing the model “to inform payment model development” in ways specified by the group in a to-be-written letter to the Secretary of Health and Human Services (HHS).

Terrell and two other members initially voted to refer the model to HHS “for attention” — the option between a full recommendation and a rejection.

“This was really very different and not all of it was fleshed out yet … that was what we said in our voting … but if [voting only for attention from HHS] was going to stop it in its tracks, then absolutely, I would vote in the other direction, which is what I did,” Terrell told MedPage Today.

Seeking Solutions

Fee-for-service Medicare does not typically cover certain interventions included in the new payment model such as at-home modifications. But during the meeting, Terrell pointed out that countries that spend more on social care and less on healthcare have better health outcomes.

Sarah Szanton, PhD, ANP, of Johns Hopkins’ nursing school, said she has patients who greet her at their front doors “on their hands and knees” because they cannot walk and don’t have wheelchairs. Others have “dropped their keys from the second floor window,” having no other way to let her into their homes, she said.

The CAPABLE model proposes a three-person care team of an occupational therapist (OT), a registered nurse (RN), and a “handyman” or “handyworker,” Szanton explained.

Eligible participants include Medicare beneficiaries with at least two chronic conditions who must also have difficulty completing at least one activity of daily living.

The clinicians and the participants together identify concrete functional goals; the OT offers “assessment, education and interactive problem-solving,” notes the written CAPABLE proposal. The time-limited intervention (4-5 months) includes 10 home visits in all — six from an OT and four from an RN — each of which will last about 60-90 minutes.

In addition, the OT will also oversee the handyworker and assign specific home repairs and modifications, such as installing assistive devices (up to $1,300).

‘Stream of Innovation’

“CAPABLE fits squarely in the stream of innovation of not just looking at diseases, but looking at the total health of people,” Szanton said. She shared the case of a veteran participant with end-stage renal failure, chronic pain, and an entirely “flat affect.” The only time he left the house was for dialysis, she said.

As a participant in the program, he wanted to improve his pain and to be able to stand-up while shaving, as shaving while seated was messy. He also said his favorite activity was sitting on his back stoop and listening to birds, but he couldn’t reach his stoop in his wheel chair without help, Szanton noted.

This participant’s care team worked with him to improve his pain, his strength, and his balance, Szanton said. Grab bars were installed around his sink so that he could shave standing up. Grab bars also were put in at the back entrance of his home. Because of his improved strength and balance, he could reach the stoop without help.

“He no longer has a flat affect. He has a twinkle in his eyes,” said Szanton.

If this person had come to her office for a 20-minute primary care visit in his previous state — disengaged and depressed — “I wouldn’t have thought I could do much for him,” she added. “But after an intervention like this, he’s more engaged, he’s more able, he feels more dignified, and then primary care can do more for some of his other … issues.”

Model Limitations

The PTAC preliminary reviewers — and later the full committee in a vote — found that of the 10 criteria for evaluating new models, CAPABLE fell short on three:

  • Payment methodology
  • Integration and care coordination
  • Health information technology (IT)

For payment methodology, the CAPABLE group suggested a partial bundled payment with a “partial upside” that could in time shift towards a fully-capitated model. Szanton stressed that they would consider “a graduated kind of payment in terms of the frailty and complexity of the participants” — in other words, risk-adjusting the model.

As for care coordination, Kendell Cannon, MD, of CERC, acknowledged that the OT/RN/handyworker care team would serve as more of an “adjunct” to the primary care physician. But Szanton noted that their activities will still support the primary care provider’s work.

For example, if one of the home modifications includes paying for a refrigerator to store a patient’s insulin, that helps the provider to keep the patient’s diabetes under control, she said.

For health IT, Szanton told MedPage Today that that component of the model does need more thought, “I think it’s going to end up varying by the site.”

Shortcomings aside, PTAC members called the proposal innovative, and praised it for improving patient safety and enhancing patient’s quality of care.

During an initial vote, the model failed to win a majority, and would have been referred to HHS “for attention.” After additional discussion over the definition of a “physician-focused payment model,” three votes were swayed, including Terrell’s.

Members noted that HHS regulations specify that models can be provider-focused, and do not necessarily need to be physician-focused.

Two members recused themselves from the meeting, including PTAC chair Jeffrey Bailet, MD. Bailet has been a senior executive at Blue Shield of California, which he said “has been and continues to be a multi-year financial supporter of [CERC],” although he was not involved in the CAPABLE model.

Kavita Patel, MD, vice president of payer and provider integration for the Johns Hopkins Health System, also did not participate. She spoke briefly by phone, noting that she was not involved in the model development.