By James L. Robinson
In January 2016, the Centers for Medicare and Medicaid Services began to reimburse physicians for advance care planning conversations. That opportunity started CHRISTUS Santa Rosa of San Antonio on a journey to create a robust ACP program. The issue quickly became: where to house this initiative and would reimbursement work within the hospital setting?
Not so well, it turned out. Our hospitals are reimbursed by Medicare through a complex “bundled” payment method for services provided, which was not the method of reimbursement for ACP that CMS had in mind (although even that has changed recently). Incentives were written into the regulations that rewarded the physician for holding the conversations in the physician’s office during regular office visits, and most observers were consistent in the opinion that the preferred location for a conversation about end-of-life issues was the physician’s office.
However, those observers also noted that physicians often feel that they are not prepared to hold those patient conversations, nor do they generally have the time. Physicians, though perhaps aware of the opportunity, were not lining up to take on this additional task.
After many conversations within our Mission Integration department, the clear direction emerged for placing a chaplain in the associated CHRISTUS physician setting, on the physician’s payroll, as an advance care planning coordinator. In September 2017, the position was created within CHRISTUS Physician Group to serve two family medicine practices. The coordinator, a chaplain with five units of CPE, is a First Steps Certified instructor and is certified by the California State University program in palliative care for chaplains.
Patient visits in the physician’s office are generally scheduled in 15-minute and 30-minute slots, which, with multiple physicians, creates a fast-paced routine. After the physician visit, the opportunity to have a brief advance care planning conversation is presented to the patient. The conversation is then typically held in the exam room or in the coordinator’s office. For Medicare patients having their annual wellness visit, who comprise most of the coordinator’s patient load, the visit is free. For others, the normal Medicare co-pays apply.
After the visit with the patient, which is typically 20 to 30 minutes, the coordinator charts the visit in the physician electronic medical record as a “general procedure” with the CMS billing code attached to the documentation. The documentation notes who was present during the conversation, what was discussed, time of the conversation, and whether advance directives were completed. (CMS does not require advance directive documents to be completed in order for the physician to seek reimbursement.) That documentation and billing code become part of the normal office billing procedures. To date the two family medical practices that share the coordinator have billed for more than 250 advance care planning visits, which easily supports the costs of the coordinator.
What have we learned? First, “the conversation” in the physician’s office is quite different from “the conversation” in the hospital. Most patients are receptive to talking about advance directives. The physicians report that there has been 100 percent positive response. Occasionally, however, time is the commodity that is lacking in the outpatient setting. Patient appointments typically run late in the physician’s office and adding an extra 20 to 30 minutes to the patient’s experience can be an unexpected burden. Charting in the electronic medical record is quick, using a standard template that covers most of the required information.
Texas requires two witnesses to the advance directives, but one of those witnesses cannot be an employee of the patient’s physician. Therefore, we are generally unable to complete the advance directives in the office, but we stress the importance of sending the completed documents back as quickly as possible. We discuss the details of filling out the documents, who should have copies, and where copies should be kept. We also discuss travelling with documents and, for those interested, making a digital copy and storing on their phone.
The conversation in the physician’s office is more document-focused. It is a conversation about “the conversation,” and it is often the first time that a patient has encountered advance directives. For those patients who have completed advance directives, the outpatient setting is a good place to review them and to talk about who should have copies of the documents, including their physician.
The Jan. 16, 2018, issue of the Journal of the American Medical Association Internal Medicine carried a brief research letter by Aoife C. Lee, DMin, BCC, who described a similar initiative in Chicago with similar results. Her conclusion: “It is feasible and acceptable for a qualified chaplain to conduct ACP conversations in a medical office. … The physician’s introduction of the chaplain was vital to the initiation of an ACP conversation of a time limited office visit. … A crucial step has been taken by initiating the discussion of patients’ (end-of-life) preferences.”
James L. Robinson, is advance care planning coordinator for CHRISTUS Physician Group in San Antonio, TX.
