- Uncontrolled diabetes. Focus efforts into uncovering the reasons behind the noncompliance. Find out if there is depression or a history of abuse -- these patients need very close attentive trust building, focused attention towards on their low self-esteem and low energy for self-care. Partner with community resources such as the hospitals diabetes Center to maximally help your patient learn self-care on diet. These patients need to be seen in the office monthly until they come under control. These are typically patients who miss appointments-- staff will make a special effort to reschedule them if they miss an appointment. Instruct your staff that this is a special patient who needs extra attention.
- Treat obesity multi-disciplinary.. Take advantage of the Medicare medical nutrition benefit for diabetes obesity and chronic renal disease The Mediterranean diet and dash diet approaches have been shown to improve quality-of-life cognition health and reduce the metabolic effects of diabetes. Consider using Topamax starting at 50 mg daily and increasing to 100 mg daily after two weeks to help control appetite--. Use half the dose with advanced renal insufficiency.
- Reduce injuries by focusing on fall risk assessments, urinary incontinence screening, osteoporosis treatment. The Medicare screening wellness visit includes recommendation for a fall risk assessment such as the timed up and go test. Also screen extensively for female incontinence which can lead to falls. Recommend scheduled toileting at midnight and 3 AM to reduce nighttime falls. Screen for bone loss particularly at the spine to reduce compression fracture risk. Treat with bisphosphonate for five years with calcium and vitamin D prior to using injectable medications. There is no cost benefit or mortality benefit to use of injectable osteoporosis medication compared to orals.
- Review and implement our ACO criteria for postacute care facility type. Don't let the case managers determine level of care. Beware of hidden networks of skilled nursing facilities and nursing home based LTACs. Bottom line--If the patient does not need daily specialty care visits, the patient does not need to be in an LTAC.
- Narrow the network postacute care – home health, skilled nursing by adhering to high value partner vendors. Carefully but thoroughly educate your office staff regarding the use of homecare services especially limitation of services to approved vendors.
- Take back control of diabetic and vascular foot disease – don't let the specialist independently make the decisions on type of care, location, or treatment, especially the wound care specialist based in a Hyperbarics center. Push for outpatient management using oral antibiotic regimens once infected tissue has been debrided surgically. Please review our peer reviewed LPACO protocol for managing diabetic and vascular feet infections.
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1. Schedule and perform Medicare Annual Wellness exam, G code ______ on EVERY Medicare primary care or specialty principal care patient annually.
2. Schedule and perform Medicare Annual Wellness exam, G code ______ on any Medicare beneficiary in the ACO who has not been to the office in 9 or more months. 3. Discuss and document Advanced Directives such as The 5 Wishes or LAPOST. Evaluate recurrent hospital admission patients for hospice when appropriate. 4. Schedule every hospital, rehab, or SNF discharged patient for a TCM office visit within 14 days to meet TCM requirements or 30 days maximum (won't qualify for TCM but meets MSSP quality goal). 5a. Re evaluate home health re-certifications for medical necessity and cost-benefit; utilize home health agencies with high quality scores, lower LOS and low hospital re-admit rate. Consider alternative outpatient programs such as senior senior day centers or partial hospitalization behavioral health programs. 5b. Re evaluate home health for dual eligible patients who concurrently are enrolled in Medicaid Home based care waiver program; most should not need. 6a. For SNF discharges, direct referrals to high performing SNFs under the care of a collaborating physician for improved oversight and length of stay. Schedule specialist outpatient visits during the skilled stay. 6b. For complex discharges,closely evaluate admission criteria to determine the most cost effective location for care: LTAC, SNF with outpatient services, home with home health, home with outpatient services. 7. When appropriate evaluate observation hospital patients for early discharge and close office follow-up within several days. 8. Reduce emergency room visits by making same day or next day office appointments with any available provider (including other LPACO clinics) or one of the patients specialists where appropriate. 9. For non adherent patients, probe for unmet psychiatric needs, social needs, history of mental or physical abuse and counsel / refer appropriately. 10. Focus on fall prevention, incontinence, poor vision, home safety, medication adherence, DVT prophylaxis, aggressive screening and treatment of osteoporosis. |
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