1. CMS Kidney Disease Patient Education Benefit: Hit or Miss? Linda Shenton RN, MN, ACNP-BC, CNN-NP Nephrology Associates, P.A.

3. Objectives 1. Identify the basic structure of the CMS Kidney Disease Patient Education (KDPE) benefit. 2. Discuss key components of the CMS KDPE of particular interest to nephrology nurses. 3. Critique of the CMS KDPE benefit.

4. To provide KDE services “…tailored to meet the needs of the individual beneficiary involved, to provide opportunities to actively participate in the choice of therapy, and provide information regarding…” -Management of comorbidities (for the purpose -Management of comorbidities (for the purpose of delaying dialysis) of delaying dialysis) -Prevention of uremic complications -Prevention of uremic complications -Renal replacement options -Renal replacement options

5. Objective One Identify the basic structure of the CMS KDPE benefit.

6. Structure  Beneficiaries eligible for coverage  Qualified person  Limitations for coverage  Standards for content  Outcomes assessment

7. Beneficiaries Eligible for Coverage Medicare part B covered beneficiaries Diagnosed with Stage IV CKD (severe decrease in GFR; GFR value of 15-29ml/min/1.73m²) Referral from the physician managing the CKD

8. Qualified Persons Medicare Part B covers KDPE services by a ‘qualified person’ meaning a: Medicare Part B covers KDPE services by a ‘qualified person’ meaning a: -Physician -Physician -Physician assistant -Physician assistant -Nurse practitioner -Nurse practitioner -Clinical nurse specialist -Clinical nurse specialist

9. Non-qualified Persons? Quoting directly from the Medicare document: Quoting directly from the Medicare document: “ The following providers are not ‘qualified persons’ and are excluded from furnishing KDPE services: a hospital, CAH, SNF, HHA, or hospice located outside of a rural area or a renal dialysis facilities.” “ The following providers are not ‘qualified persons’ and are excluded from furnishing KDPE services: a hospital, CAH, SNF, HHA, or hospice located outside of a rural area or a renal dialysis facilities.”

11. Limitations for Coverage Medicare Part B covers KDE services. 1. Up to six (6) sessions as a beneficiary lifetime maximum. Session is 1 hour. In order to bill for a session, a session must be at least 31 minutes in duration. A session that lasts at least 31 minutes, but less than one hour still constitutes 1 session. 1. Up to six (6) sessions as a beneficiary lifetime maximum. Session is 1 hour. In order to bill for a session, a session must be at least 31 minutes in duration. A session that lasts at least 31 minutes, but less than one hour still constitutes 1 session. 2. On an individual basis or in group settings; if the services are provided in a group setting, a group consists of 2 to 20 individuals who need not all be Medicare beneficiaries. 2. On an individual basis or in group settings; if the services are provided in a group setting, a group consists of 2 to 20 individuals who need not all be Medicare beneficiaries.

12. Standards for Content The required content is divided into four categories. A. The management of comorbidities, including delaying the need for dialysis, which includes, but is not limited to, the following topics: 1. Prevention and treatment of cardiovascular 1. Prevention and treatment of cardiovascular disease disease 2. Prevention and treatment of diabetes 2. Prevention and treatment of diabetes 3. Hypertension management 3. Hypertension management

13. Standards for Content (cont.) 4. Anemia management 4. Anemia management 5. Bone disease and disorders of calcium 5. Bone disease and disorders of calcium and phosphorous metabolism and phosphorous metabolism management management 6. Symptomatic neuropathy management 6. Symptomatic neuropathy management 7. Impairments in functioning and well- 7. Impairments in functioning and well- being being

14. Standards for Content (cont.) B. Prevention of uremic complications, which includes, B. Prevention of uremic complications, which includes, but is not limited to, the following topics: but is not limited to, the following topics: 1. Information on how the kidneys work and 1. Information on how the kidneys work and what happens when kidneys fail what happens when kidneys fail 2. Understanding if remaining kidney function 2. Understanding if remaining kidney function can be protected, preventing disease can be protected, preventing disease progression and realistic chances of survival progression and realistic chances of survival

15. Standards for Content (cont.) 3. Diet restrictions 3. Diet restrictions 4. Medication review, including how each 4. Medication review, including how each medication works, possible side effects medication works, possible side effects and minimization of side effects, the and minimization of side effects, the importance of compliance, and informed importance of compliance, and informed decision making if the patient decides decision making if the patient decides not to take a specific drug not to take a specific drug

16. Standards for Content (cont.) C. Therapeutic options, treatment modalities and settings, advantages and disadvantages of each treatment option, and how the treatments replace the kidney, including, but not limited to, the following: 1. Hemodialysis - both at home and in-facility 1. Hemodialysis - both at home and in-facility 2. Peritoneal dialysis (PD), including intermittent PD, 2. Peritoneal dialysis (PD), including intermittent PD, continuous ambulatory PD, and continuous cycling PD, continuous ambulatory PD, and continuous cycling PD, both at home and in-facility both at home and in-facility 3. All dialysis access options for hemodialysis and 3. All dialysis access options for hemodialysis and peritoneal dialysis peritoneal dialysis 4. Transplantation 4. Transplantation

17. Standards for Content (cont.) D. Opportunities for beneficiaries to actively participate in D. Opportunities for beneficiaries to actively participate in the choice of therapy and be tailored to meet the needs the choice of therapy and be tailored to meet the needs of the individual beneficiary involved, which includes, but of the individual beneficiary involved, which includes, but is not limited to, the following topics: is not limited to, the following topics: 1. Physical symptoms 1. Physical symptoms 2. Impact on family and social life 2. Impact on family and social life 3. Exercise 3. Exercise 4. The right to refuse treatment 4. The right to refuse treatment 5. The impact on work and finances 5. The impact on work and finances 6. The meaning of test results 6. The meaning of test results 7. Psychological impact 7. Psychological impact

18. Outcomes Assessment “Qualified persons that provide KDE services must develop outcomes assessments that are designed to measure beneficiary knowledge about CKD and its treatment. The assessment must be administered to the beneficiary during a KDE session, and must be made available to CMS upon request. The outcomes assessments serve to assist KDE educators and CMS in improving subsequent KDE programs, patient understanding, and assess program effectiveness of…” “Qualified persons that provide KDE services must develop outcomes assessments that are designed to measure beneficiary knowledge about CKD and its treatment. The assessment must be administered to the beneficiary during a KDE session, and must be made available to CMS upon request. The outcomes assessments serve to assist KDE educators and CMS in improving subsequent KDE programs, patient understanding, and assess program effectiveness of…”

19. Outcomes Assessment (cont.) 1. Preparing the beneficiary to make informed decisions about their healthcare options related to CKD. 1. Preparing the beneficiary to make informed decisions about their healthcare options related to CKD. 2. Meeting the communication needs of underserved populations, including persons with disabilities, persons with limited English proficiency, and persons with health literacy needs. 2. Meeting the communication needs of underserved populations, including persons with disabilities, persons with limited English proficiency, and persons with health literacy needs.

20. Objective Two Discuss key components of the CMS KDPE of particular interest to nephrology nurses.

22. Components  Required content  Presentation of content  Outcome assessment tools

23. Required Content  Diabetes The most common cause of CKD world-wide The most common cause of CKD world-wide  Hypertension More than 50 million Americans have hypertension requiring treatment More than 50 million Americans have hypertension requiring treatment  Cardiovascular Disease 10-20 times greater mortality in patients on dialysis 10-20 times greater mortality in patients on dialysis

25. Required Content cont.  Anemia Develops as early as stage 2 Develops as early as stage 2 Contributes to development of LVH, CHF & Contributes to development of LVH, CHF & ischemic heart disease ischemic heart disease  Bone and Mineral Disorder Begins as early as stage 3 Begins as early as stage 3  Diet and Fluid Restriction

27. Required Content cont.  Options: Hemodialysis Hemodialysis Peritoneal dialysis Transplant Hospice Hospice

28. Presentation of Content Things to consider:  Depression  Short attention span  Education level  Denial  Family support  Literacy

29. Outcome Assessment Tools  Do not reinvent the wheel: ANA, ANNA, NKF, RPA all have patient education information guidelines, assessment tools and programs that can be adapted to most topics. ANA, ANNA, NKF, RPA all have patient education information guidelines, assessment tools and programs that can be adapted to most topics.

30. Outcome Assessment Tools

31. Nephrology Nursing Journal, Mar/Apr2010, Vol. 37 Issue 2, p143-148, 6p, 1 chart Chart; found on p146

32. Outcome Assessment Tools (cont.)  Reading Level  Written vs. pictorial  Oral  Multiple choice

33. Objective Three Critique of the CMS KDPE benefit. Critique of the CMS KDPE benefit.

34. Hit  Funding for any patient education  Extensive content requirements  Nephrology driven service  Adjusting reimbursement per RPA  NP/CNS/PA involvement

35. Miss  Excluding RN’s from participation  Insufficient number of sessions  Sessions too long for patient population attention span

36. Close…but no cigar  Starting education at CKD stage 4  Increased reimbursement but excludes incident to billing for NP, CNS, PA

37. Bibliography AHRQ Stakeholders’. 2008. Executive Summary of Medicare Coverage of Kidney Disease Patient Education Services. Rockville, MD. American Nephrology Nursing Association. www.annanurse.org www.annanurse.org Counts, Caroline. (2008). Core curriculum for nephrology nursing. 2008-01. Counts, Caroline. (2008). Core curriculum for nephrology nursing. 2008-01. Department of Health & Human Services. 2009. Pub 100-02 Medicare Benefit Policy. Washington, D.C. National Kidney Foundation. www.kidney.org www.kidney.org Nephrology Nursing Journal. Mar/Apr2010, Vol. 37 Issue 2, p143-148. Renal Physicians Association. www.renalmd.org www.renalmd.org