“An ounce of prevention is worth a pound of cure.”

Benjamin Franklin

 

I was only 8 years old when I first became aware of what a heart attack can do. One of my favorite uncles was working one afternoon when he collapsed and was rushed to the hospital.  Within 5 hours of his attack he was dead.  I had seen my uncle the day before and there was no indication that he was in poor health.  Even my aunt said the attack came with no warning.  As one would expect, experiencing that at such a young age had a profound impact on me.  Not only did I mourn the loss of a man who I was very attached to, I was witness to the sadness his widow and other family members endured for decades after his death.

In 2016, I had the opportunity to participate in a pilot study that focused on Medicare preventive services.  Again, I witnessed how a cardiac event could come with little warning.  Halfway through the study, a 65 year old patient came in for his Welcome to Medicare visit (IPPE).  There were no red flags that showed up during the visit.  In fact, besides being a bit overweight, he seemed to be in excellent shape.  Luckily for him,  Medicare will allow an EKG to be performed at no extra charge during the IPPE visit.  The providers tended to order those for anyone who may be at risk for cardiac disease.  During the EKG the NP was disturbed by what she saw and immediately sent him to the Emergency Department.  The patient was quickly admitted and the next day had triple bypass surgery.  Apparently, he was on the verge of a massive heart attack that would have gone undetected until it was too late.

Both my uncle and the patient in our study are perfect examples of the 25% of heart attacks and strokes the CDC has deemed preventable. The patient who had bypass surgery was lucky because he was a participant in one of Medicare’s new preventive services.  For him, that service worked.  I can’t help but wonder if my uncle had been given access to preventive services if he would have survived and/or possibly avoided his heart attack altogether.

The bypass patient was not an anomaly. During our 2016 pilot study, we found hundreds of patients who were suffering from conditions that would likely lead to a coronary event.  Certainly, several were found through our Welcome to Medicare and Annual Wellness Visits but the pilot also incorporated a program Medicare calls their Intensive Behavioral Therapy for Cardiovascular Disease program (IBT CV).  IBT CV is an annual service designed to promote health literacy and identify patients who are at risk of cardiovascular disease.  Done correctly, it is a wonderful tool for primary care providers to screen for cardiovascular concerns but also to educate patients on how to minimize their risk.

Background:

Starting in 2011, Medicare began funding  Intensive Behavioral Therapy for Cardiovascular Disease.  (For patient literacy we renamed this program the Healthy Heart Visit.)  A practice can be reimbursed annually for providing a patient with health education and screening to determine their risk for heart disease.  The visit is billed as a 15 minute encounter and all Medicare patients are eligible.

Because of low RVU reimbursement however, few IBT CV visits have been done.  To help manage the low RVU, there are a variety of ways in which the visit can be done to maximize efficiency and improve patient outcomes.

Utilization/Workflow Recommendations:

For Fee-for-Service, MIPS and APM providers, the best option may be to combine this visit with the Medicare Annual Wellness Visit.  Although not recommended for the initial AWV (due to time constraints) it could be a valuable component to add to subsequent visits.

The behavioral counseling intervention for aspirin use and healthy diet should be consistent with the Five A’s approach that has been adopted by the USPSTF:  

  1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

Unlike the Annual Wellness Visit, the Healthy Heart Visit may not be done by a licensed professional without the provider seeing the patient.  That being said, we believe it is advantageous and appropriate to utilize the wellness team in IBT CV visits.  Regardless of whether or not the wellness team is involved, to be in compliance with Medicare’s regulations, the provider must ensure all 5 A’s have been met.  In the following example we have demonstrated how one may divide the 5 A’s up between the team and the provider.  

The Wellness Nurse/team may:

  • Assess (and document) current problems
  • Advise (provide health literacy education to patient)
  • Agree on a plan of action the patient can use to reduce risk

The provider can use the information gathered by the wellness nurse to:

  • Agree – Determine if the patient agrees with the goals and the plan of action,
  • Arrange follow-up services meeting the needs found during the assessment (EKG, Cardio Scan, medication modification, behavioral change etc)

Further screening such as lipid testing may be deemed necessary.  See Medicare’s requirements for reimbursing for the lipid panel here.

Health Literacy:

The Institute of Medicine’s report on health literacy showed an ominous trend toward very poor health literacy in this country.  It also demonstrated that low health literacy tends to correlate with greater risk of disease.  For these reasons, the Healthy Heart visit should incorporate health literacy into its goals.

Constructivist Learning Theory dictates that information is gained based upon the patient’s past knowledge.  One cannot overload a patient with information and expect learning to take place.  Breaking cardiovascular health literacy down into small increments is the best practice.  

Building upon a patient’s prior knowledge should take place over time and Medicare’s funding of the IBT CV program annually allows for this.  We recommend each practice/provider determine what their 5 and 10 year goals and objectives are for their patient’s health literacy.  We offer the following as an example of developing goals and objectives for this visit:

Goal for IBT CV

The patient will have a working knowledge and understanding of how the cardiovascular system works and how their diet and lifestyle impacts their system.

Objectives for IBT CV

The objectives are specific and guide the actual visit.  Some objectives will change each year while others will stay the same.  Notice that the following examples have several objectives  These objectives should be guidelines and the subject matter should be honed down to very basic information.  Remember, the long term goal is to give patients a working understanding.  Giving them too much information at a time can actually prevent success.

Annually, objectives should expand the health literacy education and build upon the knowledge the patient gained the year before.  In our example, we have separated Medicare objectives from practice objectives.  It is imperative that the Medicare objectives be met in order to be reimbursed.  The practice objectives should support the practices’ long-term goal.

For IBT CV Medicare Objectives should always include the following: 

  • the value of aspirin use,
  • current cholesterol levels,
  • recognition of heart attacks and strokes,
  • how behaviors affect the cardiovascular system and
  • the importance of rapid response.”  

Objectives need a time frame. The following is an example of a 5 year plan:

  • Medicare Objectives Year One  The patient will be introduced to how using aspirin may reduce the risk of heart attacks and strokes, how cholesterol affects the body, how to recognize a heart attack and stroke, and that tobacco cessation, diet and an active lifestyle can reduce the risk of cardiovascular disease.
  • Practice Objective Year One  The patient will be introduced to basic concepts of cardiovascular health.

Year one is an introduction to the heart and brain.  You will cover a lot of material so keep your descriptions simple and to the point.  It is recommended that you acquire a heart model and in the first year demonstrate the basic biology of the heart and brain showing the arteries and vessels that get clogged.  Most patients are not aware that heart attacks and strokes occur in these tiny vessels.  Helping them understand how small the spaces are that are getting clogged may demonstrate how important it is for them to maintain a healthy diet with plenty exercise.

  • Medicare Objectives Year Two  The patient will understand the how using aspirin may reduce the risk of heart attacks and strokes, how cholesterol affects the body, how to recognize a heart attack and stroke, and that tobacco cessation, diet and an active lifestyle can reduce the risk of cardiovascular disease.
  • Practice Objective Year Two  The patient will understand that  diet can lead to high cholesterol, cholesterol can lead to cardiovascular disease and understand how to recognize a heart attack and stroke.

The emphasis for year two is  on cholesterol and lifestyle.  That being said, the wellness team will build upon year one’s introduction, show patients how the heart works reiterating how it is a muscle that needs constant exercise just like any other muscle in their body.  You will also return to the discussion from the year before regarding how aspirin use may be a benefit under certain circumstances and how to recognize a heart attack or stroke.  

  • Medicare Objectives Year Three The patient will understand the how using aspirin may reduce the risk of heart attacks and strokes, how cholesterol affects the body, how to recognize a heart attack and stroke, and that tobacco cessation, diet and an active lifestyle can reduce the risk of cardiovascular disease.
  • Practice Objective Year Three  The patient will have a greater understanding of how a heart attack and stroke happens, where it happens in the heart and brain and how to prevent it.

Building upon the knowledge your patient has gained in previous years, show patients the vessels outside the heart model and discuss how fat moves through the body demonstrating the importance of a healthy diet.  Discuss, in more detail how cholesterol works and the effects it can have on the body.

  • Medicare Objectives Year Four The patient will understand the how using aspirin may reduce the risk of heart attacks and strokes, how cholesterol affects the body, how to recognize a heart attack and stroke, and that tobacco cessation, diet and an active lifestyle can reduce the risk of cardiovascular disease.
  • Practice Objective Year Four  The patient will have a greater understanding of how behaviors such as tobacco use, lack of exercise and diet impacts cardiovascular health.

Building upon the knowledge gained in years 1 through 3, share with the patient how moderate exercise, diet and tobacco cessation can reduce risk for cardiovascular disease significantly.

  • Medicare Objectives Year Five   The patient will understand the how using aspirin may reduce the risk of heart attacks and strokes, how cholesterol affects the body, how to recognize a heart attack and stroke, and that tobacco cessation, diet and an active lifestyle can reduce the risk of cardiovascular disease.
  • Practice Objective Year Five The patient will understand how their mental health, specifically stress and depression, can impact their cardiovascular health.

Building upon the knowledge gained over the past 4 years introduce the patient to how stress and depression can impact their cardiovascular health.

Documentation Needs:

This visit should be considered a cumulative visit for patients with additional health literacy elements integrated annually.  To ensure you are able to demonstrate to Medicare that you have consistently met the requirements for IBT CV, we recommend you create an organized, consistent documentation process.  The following outlines elements you should include in your documentation process:

  1. The documentation process should include proof that all Medicare’s requirements are being met during the visit.
  2. The practice should create a template to ensure all 5 A’s are documented upon the completion of the Healthy Heart visit. 
  3. The patient’s plan of action should be saved in their chart to ensure the provider can review periodically to determine if patient is following through with their plan.  
    • If patient is receiving Chronic Care Management services, the Healthy Heart Plan of Action should be integrated into their care plan and monitored by the CCM nurse.
  4. The literacy covered with the patient should be included in the documentation as well.  

Federally Qualified Health Centers:

Federally Qualified Health Centers are unique and have more flexibility in expanding this service for their Medicare patient than other types of primary care.  Unlike Fee for Service, FQHCs are reimbursed at a PPS rate.  This is a basic rate for all approved CPT codes.  The Healthy Heart (IBT CV) visit is an approved PPS code.

The reimbursement for FQHCs allows them to offer a bit more to their patients than what a regular Fee for Service practice can.  FQHCs also have the restriction that prevents them from being able to implement more than one visit per day with a patient.  This means if the practice intends to bill for both services, the AWV and the Healthy Heart must be done on separate days.  To ensure patients are getting the most value out of their return visit the FQHC should offer a bit more to this visit than what may be done in other types of primary care practices.

Examples of Ways to Improve the Healthy Heart Visit:

  • Evidence-Based Cardiovascular Risk Calculators:  Incorporating evidence based cardiovascular risk calculators are a perfect example of how the practice can improve this visit for patients.  Many of these calculators come highly recommended from organizations such as the American Association of Family Physicians.  Each practice should review the calculators they believe to be most appropriate for their population.
    • Note:  Which ever calculator the practice uses, we recommend choosing one that advises the patient how to reduce their risk for disease (such as lifestyle changes.)
  • Increased Health Literacy:  If the practice plans to spend extra time with the patient they should consider increasing the level of health literacy provided each year.  Atrial fibrillation and Congestive Heart Failure can be discussed in more detail for patients with those issues.
  • Readiness Scale:  With the increased time, it may also be advisable to determine the level of readiness that patient has for lifestyle changes.  A readiness scale could be valuable in assessing if the patient is ready to modify his/her behavior to implement lifestyle changes.  If a scale is incorporated, it may be advisable for the provider or care management staff to continue monitoring the patient’s readiness over the year.

Quality Measures Met:

The following is a sample of quality measures that may be met during this visit:

MEASURE NAME UDS
2016
HCCN
New
MPCA
Clinical
Quality
Award
2016
Health
Home
PC SPA
Chronic
Disease
Collab.
CDC
HEDIS MU
COM
Medicare
ACO
Humana BCBS
PCMH
BP Control (HTN and DM) X X X X X X X X X
Adult Weight Screening and Follow-up X X X X X X X X
CAD Lipid Therapy X X X
IVD Use of Aspirin X X X X X
LDL Control (Adult, DM, IVD) X X X X X
IVD Complete Lipid Panel X

Conclusion:

Regardless of what type of primary care provider you are or how many Medicare patients you see, incorporating Medicare’s Intensive Behavioral Therapy for Cardiovascular Disease can have a significant impact on the health of your patient population. It is important to remember that prevention of chronic conditions like heart attack and stroke have a real impact on the lives of our patients.  In the example of my uncle or the man whose heart attack was prevented during our pilot, incorporating preventive services means the difference between life and death. For every attack we prevent we improve our patient’s chances for survival as well as their long term quality of life.  That makes these services worth the effort.

IHM offers expert consultation services to help practices develop wellness programs, and also has AWV software available for practices needing a template for their Annual Wellness Visits .  You may also contact IHM at 816-866-5688 or by email at info@informthepatient.com .

For previous preventive service blogs see the following:

Basic Introduction to the Medicare Annual Wellness Visit

Depression is a Serious Medical Concern Especially During The Holidays

Building Your Primary Care Weight Loss Program For Medicare Patients