Promoting CVD Prevention in Your Practice: A New Medicare Reimbursable Service

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1 Promoting CVD Prevention in Your Practice: A New Medicare Reimbursable Service Richard Josephson, MD, MS, Professor of Medicine, Case Western Reserve University; Medical Director, CICU, UH Case Medical Center; Medical Director, CVP Rehabilitation, UH Case Medical Center Shirley Moore PhD, RN, Professor of Nursing, Case Western Reserve University; Director, Center of Excellence in Selfmanagement Research; Director, FIND Lab (Full INclusion of persons with Disabilities) Better Health Greater Cleveland relies on the presenter to obtain all rights to use and display copyright-protected information. Anyone claiming a right or interest in or to any posted information should contact Better Health immediately by calling

2 Acknowledgements Colleagues who helped prepare this presentation: Vanessa Maier, MD, MPH, Assistant Professor of Family Medicine, Case Western Reserve University; Attending Physician, University Hospitals Department of Family Medicine Joel Hughes, PhD, Associate Professor in the Department of Psychology, Kent State University Mary Dolansky, RN, PhD, Associate Professor of Nursing, Case Western Reserve University Grant funding: Ohio Partnership for Adherence through Collaborative Education (PACE), M. Dolansky and R. Josephson, Co-Principle Investigators

3 Counseling to Prevent CVD Conflict of Interest The presenters have no financial conflict of interest related to this presentation

4 Counseling to Prevent CVD Objectives o Describe the new Medicare reimbursable service for CVD prevention counseling o Apply evidence-based approaches to counseling patients for adherence & health behavior change o Develop an office improvement plan to include and bill for this new service

5 Counseling to Prevent CVD The New Billable Service and Code

6 Counseling to Prevent CVD New Code for Intensive Behavioral Counseling to Prevent CVD Primary prevention G0446 Primary care setting & practitioner(s) May be used annually May be used alone or with another E & M code Suggested time 15 Total RVU =0.74 wrvu=0.45

7 Counseling to Prevent CVD Code Covers Prevention of CVD in Primary Care Visit needs to include documentation: BP screening Appropriate daily aspirin use Heart healthy diet

8 Counseling to Prevent CVD Implementing G0446 Extend annual health maintenance visit Extend allocated visit time Bill G0446 in addition to other E & M codes May be used in conjunction with tobacco cessation codes Free standing visit-as prequel or f/u to annual health maintenance visit Non-physicians can render portion of service Diet instruction Consider macro or form/sticker to aide documentation

9 Counseling to Prevent CVD Background & Significance of New CMS Service

10 Counseling to Prevent CVD Intensive Behavioral Therapy for Prevention of CVD Aspirin use (81 mg/day or higher dose every other day) in patients whose CVD risk is higher than bleeding risk. Screening adults for hypertension annually. Behavioral counseling to promote a healthy diet for adults with or at risk for CVD.

11 Counseling to Prevent CVD Cardiovascular Disease Hypertension Coronary Artery Disease/Angina/MI Heart Failure Stroke Peripheral Arterial Disease Other forms of CVD exist, but are not necessarily relevant to this initiative

12 Counseling to Prevent CVD Absence of Proof is not Proof of Absence Aspirin is PROVEN to reduce (broadly defined) CVD events in men. Aspirin is PROVEN to reduce stroke in women. Aspirin is PROVEN to be of additional benefit in individuals at higher risk of CVD (e.g. hyperlipidemia). Aspirin bleeding risk is PROVEN to be increased with NSAIA use and h/o bleeding. General age guidelines: Men (?) years Women (?) years

13 Framingham Risk Score Counseling to Prevent CVD

14 Counseling to Prevent CVD Bleeding Risk Increases with Age

15 Counseling to Prevent CVD Accurate BP Measurements Patient should be seated, at rest for > 5 Appropriate cuff size Average > 2 measurements Hypertension > 140/90 Prehypertension /80-89 Hypertension vs Elevated BP Consider measurements on > 2 days

16 Counseling to Prevent CVD Healthy Diet Appropriate caloric intake/portion size Appropriate sodium content Appropriate Composition (e.g. DASH)

17 Counseling to Prevent CVD Healthy Diet Caloric intake Portion size, snacks, caloric-dense foods & drinks You can t manage what you don t measure Use reference materials, online resource Guesstimate 30 kcal/kg/day (basal) Sodium < 2.4 gm (1,000 mmol) daily Count high sodium portions, and decrease! DASH Favor fruits and vegetables Minimize processed foods, total fat

18 Counseling to Prevent CVD Science of Adherence

19 Counseling to Prevent CVD Clinicians Can Make a Difference with Brief Counseling for CVD 80% of adults have a usual source of health care services, thus providers have a tremendous reach Most individuals trust their health care providers advice The patient-provider relationship is longitudinal, occurring over an extended period of time

20 Counseling to Prevent CVD Clinicians Can Make a Difference with Brief Counseling for CVD Brief advice and counseling by providers is feasible and can be effective in improving health behaviors Research shows small, but significant impacts of physician advice/counseling on smoking cessation, improved dietary counseling, and physical activity Artinian, NT, et. al., Circulation, 2010; U.S. Preventive Services Task Force, 2010; Brunner, E, et.al., The Cochrane Library, 2009; Goldstein, MG, et.al., Am J Prev Med, 2004

21 Counseling to Prevent CVD The Evidence is Clear that Health Behavior Can be Changed Thus, CMS is providing reimbursement for prevention counseling for several diseases, CVD among them Given the short time for the CMSreimbursed counseling session for CVD risk, it is important to use contemporary, evidence-based approaches

22 Counseling to Prevent CVD The 5 A s Assess the risk behavior Advise change Agree on goals and action plans Assist with treatment Arrange follow-up Makoul, G. et.al., J Gen Intern Med, 2006; Kahn, EB, et.al., Am J Prev Med, 2002; Ockene, IS, et.al., Arch Intern Med, 1999; Whitlock, EP, et. al., Am J Prev Med, 2002; Kimberly, SH, et. al., Am J Public Health, 2003

23 Counseling to Prevent CVD Effective Approaches to Improve Health Behavior Change 1. Implement the 5A s 2. Adopt a patient-centered approach attend to the patient s needs, beliefs, values and preferences 3. Increase patients self-efficacy (confidence about being able to change behaviors successfully) 4. Gain shared agreement on specific, measureable, attainable, proximal behavior change goals

24 Counseling to Prevent CVD Effective Approaches to Improve Health Behavior Change (cont.) 5. Help patients establish self-monitoring of targeted behavior(s) paper or web-based diaries or mobile applications 6. Help patients receive feedback on progress toward goals using in-person, telephone, and/or digital methods 7. Schedule regular follow-up to assess success, reinforce progress, problem-solve barriers

25 Counseling to Prevent CVD Effective Approaches to Improve Health Behavior Change (cont.) 8. Help patients to arrange social support 9. Use a multiple-component approach that combines two or more of the above strategies Adapted from: Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults: A Scientific Statement from the American Heart Association

26 Counseling to Prevent CVD Use Patient-Centered Communication Strategies Avoid commanding language Ask open-ended questions and express empathy (take an active interest in the patient s perspective) Learn what action steps an individual is willing to take

27 Counseling to Prevent CVD People Come with Wide Ranges of Ability to Communicate and Use Language To create accessible communications for people with Sight or Hearing impairments: Large print brochures and instructions Magnifiers Audio recordings Video recordings ASL Translation Voice Enhancers Free consultations/services for adapting patient education materials for persons with impairments in sight, hearing and mobility: FIND Lab (Full INclusion of persons with Disabilities) at the School of Nursing at Case Western Reserve University

28 Counseling to Prevent CVD Special Cases: Psychosocial Considerations Depression Anxiety Cognitive Impairment Health Literacy

29 Counseling to Prevent CVD Assess: Depression Must be addressed prior to behavior change e.g., PHQ9 Anxiety Interview should reveal Cognitive Impairment MMSE is not sensitive enough Health Literacy Assume low health literacy

30 Counseling to Prevent CVD Advise Clear, specific, personalized behavior change advice What does this look like when there is significant depression, anxiety, cognitive impairment, or low health-literacy?

31 Counseling to Prevent CVD Develop practice systems that are supportive to health behavior change Establish practical tools in your office to assess health behaviors of patients i.e., fields in electronic medical records; brief assessments; use of mobile apps Use connective technologies that link the practice team into the patient s tracking transmissions Develop systems addressing when and how to apply higher-intensity counseling

32 May be a need for additional assessments/treatments Further assessment (e.g., neuropsychology) Pharmacological (e.g., SSRI s) Counseling (e.g., CBT) Social support (e.g., caregiving) Refer to Health Educators, Nurses, Dietitians, for more intense counseling Consider designing group appointments

33 Counseling to Prevent CVD Thank you COUNSEL2preventCVD.org

34 Counseling to Prevent CVD For Discussion How is your office practice addressing CVD risk factor counseling? Do you have systems for deciding who needs low intensity (brief) vs. high intensity counseling? Systems for documenting the counseling that is done? Have you considered group appointments?

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36 Shared Medical Appointments Marianne Sumego, M.D. Director Cleveland Clinic Shared Medical Appointment

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