How Carilion Clinic used workforce and coding techniques to overcome cost challenges in memory care

Nurse practitioners, physician assistants, therapy staff, and non-clinicians can perform some elements of dementia care diagnosis if trained to do so and properly supervised. Carilion Clinic believes it is important for professional staff within the clinic to garner additional skills to conduct the cognitive testing and perform geriatric screenings such as the Geriatric Depression Screen (GDS). Staff can be trained to conduct many other common geriatric screening tests including timed-up-and-go, standing reach, timed walk, grip strength, brown-bag medication reconciliation, and vision or hearing screening.

Typical trainings may include:

• Certified Dementia Practitioner Training (nccdp.org)
• Alzheimer's awareness videos and associated Alzheimer's testing via Alzheimer’s Association
• Continuing Education and in-services

Once staff are trained, Carilion Clinic task shifts within the care team to optimize the efficiency and workflow of their practice and allow everyone to work at top of their license. For example, nurses or non-clinical staff such as receptionists and schedulers can conduct tests and surveys either before or after the planned physician visit. Additional tasks may include providing follow-up education to patients and their caregivers about available community resources.

Patient journey at Carilion Clinic

1. The patient journey at Carilion Clinic starts with the front desk staff.

A nurse or social worker calls the patient’s family to confirm the appointment. They use a modified structured dementia screening tool called the AD8 to ask the family how the patient is doing at home (repetitive behaviors, difficulties with ADL's, can they care for themselves, etc.).

2. The patient then comes into the clinic, or the clinic physician will conduct a house call or video visit.

When the patient comes in, the nurse screens the patient, and the nurse or social worker/aid administers the cognitive testing and geriatric depression screening.

3. There is a huddle with the care team to discuss the intake information before the official exam with the physician.

This ensures that, in the actual exam, the doctor can effectively use their time to make a diagnosis and begin formulating a care plan.

4. Following the huddle and exam, the physician will chat with social worker about next steps and meet with the family.

The social worker handles counseling and support and services, and the physician will typically order up labs, imaging, medications, etc.

5. There is typically a follow up visit in six months on the status of the patient.

6. Patients/families are encouraged to contact the clinic in the event of major changes in status.

There is a lot of ambiguity around the payment procedures for cognitive assessments. This contributes to providers deprioritizing the evaluation of patients’ cognitive health. In 2018, Medicare established CPT code 99483 to reimburse physicians for cognitive assessments and care plan services. The Medicare national payment allowance (not geographically adjusted) for 99483 is $241 in non-facility settings. The challenge is that there are several codes that cannot be billed on the same date of service as 99483, including those for routine office visits, care plan oversight, psychiatric diagnostic evaluation, advance care planning, and home health care and hospice supervision. Carilion Clinic developed a checklist for how to know if providers should bill this CPT code in their dementia care program to receive correct and accurate payment for their services. See the figure below for the checklist.