CMSHealthDisparitie

Limb Preservation after Katrina (LiPAK)

The Limb Preservation after Katrina (LiPAK) study aims to reduce the incidence of diabetes complications that might result in limb amputation if left untreated.  The study will accomplish this by motivating beneficiaries to take self-care action steps that will preserve the quality of their lives.  Eighty-one African American Medicare beneficiaries diagnosed with diabetes have already learned to effectively examine their own feet for early detection of neuropathy. Thirty-two percent of those trained reported that their own physicians had not conducted such a comprehensive foot exam within the past year. 

The Centers for Medicare & Medicaid Services (CMS) intends LiPAK to positively impact the lives of 500 African American Medicare diabetic beneficiaries in the Greater New Orleans area.  Many of these diabetics were forced into short-term homelessness and sought shelter in other states after Hurricane Katrina, but have now returned to Louisiana. This special study is designed to improve their health and lives by educating them in proven diabetes self-management techniques.  The study also focuses on reducing the risk of limb amputation by ensuring that 21 New Orleans primary care practices serving these medically disadvantage patients conduct the recommended comprehensive foot exams.

Quality improvement specialists from eQHealth Solutions deliver diabetes self-management education via the University of Chicago’s Diabetes Education Empowerment Program (DEEP). Special foot care training for LiPAK participants has been added to the curriculum and includes a self-testing activity modeled after the Lower Extremity Amputation Program (LEAP). LEAP, which was developed at the HRSA National Hansen’s Disease Program, introduces participants to an easy-to-use screening implement (a 5.07 monofilament) that tests skin and tissue sensitivity.   The monofilament is calibrated to apply 10 grams of force when pressed against the bottom of the patient’s foot.  A HRSA study reported that 87% of the patients who participated in the LEAP program obtained the same sensitivity reading as physician-conducted testing. LiPAK beneficiaries are encouraged to share their self foot exam results with their health care providers.  In this manner, communication between Medicare beneficiaries and providers is increased.

Quality improvement specialists also conduct quarterly follow ups with the beneficiaries. By using stepwise interaction methodology, they help beneficiaries stay engaged with self-care activities over time.   

To date, seven classes have been held in the Greater New Orleans area and eight-one beneficiaries have participated in the DEEP curriculum. Fifteen primary care physicians have agreed to work with the project by referring patients to local classes as well as increasing foot exams and other quality indicator utilizations such as HbA1c and Lipid blood testing. For more information please visit louisianaqio.eqhs.org/physicians.htm

Section 409 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Medicare Modernization Act) (Public Law 108-173) authorizes a five-year demonstration for rural Medicare beneficiaries.  The basics for the demonstration are as follows:

 Care models for patients without “appropriate caregivers” who reside in rural areas

• Provides care within a hospice facility at the appropriate level of care
• Routine Home
• Continuous Care
• General Inpatient
• NOT respite care because they lack an appropriate caregiver
• Majority Medicare patients
• Rural hospice facility must have 20 or fewer beds that offers, within its walls, the full range of hospice services
• Sites must undertake the Quality Assessment and Performance Improvement (QAPI) Program
• Report data on all patients (not just demonstration patients)
• Two waivers available
  • 20% inpatient cap
• Requirement to provide care in the community
• Sites agree to develop programs to increase care to priority populations
• Demonstration Timeframe:  October 1, 2005 through September 30, 2010
• The demonstration tests whether hospice services provided by a rural hospice that does not need to meet the cap on inpatient care days or provide hospice services outside of the facility results in wider access, improved hospice services, benefits to the rural community, and a sustainable pattern of care.
• The demonstrated was awarded to the Sanctuary Hospice House (SHH) located in Tupelo, Mississippi and Haven Hospice (formerly Hospice of North Central Florida) headquartered in Gainesville, Florida.

 Sanctuary Hospice House (SHH)

Operations

• Medicare Certification received Dec 2005
• One freestanding facility is located in Tupelo, Mississippi
• Originally organized and established to deliver hospice care only in its 16 bed facility

 Quality Program

• Just being established at start of the demonstration
• Falls tracking; some compliance auditing for charts

Waver status for demonstration

• Both waivers requested and granted
• To date has not used the 20% inpatient care waiver (March 10, 2009)

Goal to work with priority population even as a new hospice

Haven Hospice (HH)

Operations

• Established hospice more than 25 years ago
• Multiple locations in North-Central Florida; Based in Gainesville
• The Average Daily Census (average daily count of patients) is over 600
• Participating inpatient units Chiefland (16 beds) and Palatka (12 beds)

Quality Program

• Robust quality and compliance program
• Data collection via chart audits, and client surveys (e.g., families and physicians)
• Focused studies and performance improvement on areas of concern
• QAPI-ready

Waiver status for demonstration

• No waivers requested

Developing cultural understanding to work with priority populations.

Recognitions that Both Sites Independently Identified to Increase Care to Priority Populations

• Recognized that groups need to be approached differently based on cultural sensitivities
• Goal to engage in dialogue about hospice
• Need to develop rapport one-on-one
• Meet at places familiar to the group
• Church is an ideal setting
• As comfort level increases engage with the hospice in other settings – note early benchmark goal
• Recognized that it is a long-term project in order to see results

SHH’s Approach

Engaging the African American Community:

• Request to speak at churches with large black populations
• Attend church lunches
• Recruit volunteers from the African American community
• Chief Volunteer Chaplain is African American

Engaging the Hispanic Community:

• Attend Latino Mass
• Work with them on fundraising
• Note smaller community and slower process to make gains

HH’s Approach

• Have the church host information in their building:
• Health fairs
• Volunteer training for hospice services

• Rural areas require the need for word of mouth training:
• Literacy issues
• Access to information
• Train staff and volunteers on how to effectively conduct word of mouth campaigns

• Person to person:
• Civic clubs
• Community groups

Benchmarks to Date (March 10, 2009)

• Increasing minority volunteers appears to increase self-referrals to hospice

• Cultural Sensitivities:
• Discuss hospice services, such as pain management
• Do not discuss dying.  It is tantamount to giving up in these communities
• Engage the concept of family as it relates to hospice
• Hospice staff cannot be perceived as taking the place of family since family is there to provide care
• Trust must be earned. 

• Families that have been served are their best referral sources
• Word of mouth is key
• Multi-prong approach is required

Contact Information:

Cindy Massuda
Project Officer
Centers for Medicare & Medicaid Services
Office of Research, Development and Information
Rural Hospice Demonstration, 410-786-0652
Cindy.massuda@cms.hhs.gov