Sec. 3. Advanced illness care and management model
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Section 1115A of the Social Security Act ( 42 U.S.C. 1315a ) is amended— in subsection (b)(2)(A), by adding at the end the following new sentence: The models selected under this subparagraph shall include the model described in subsection (h), which shall be implemented by not later than 1 year after the date of the enactment of the ; Patient Choice and Quality Care Act of 2017 . by adding at the end the following new subsection: The model described in this subparagraph is a model under which payments are made under title XVIII to applicable providers that furnish advanced illness care and management services, including care coordination and palliative care services, to eligible individuals with serious, chronic progressive, or advanced illness in order to test the use of targeted advanced illness management and early use of palliative care under the Medicare program.
Participation under the model shall be voluntary with respect to both eligible individuals and applicable providers. At least one applicable provider selected for participation under the model shall be a hospice program (as defined in section 1861(dd)(2)). The Secretary shall establish the model in such a manner as will permit the comparison of outcomes for eligible individuals participating under the model and eligible individuals who are not so participating. In addition to operating the model independently, the Secretary shall incorporate the model into existing models related to the Medicare program, such as models involving accountable care organizations, bundled payments, and value based purchasing arrangements, and other coordinated care models as the Secretary determines to be appropriate.
Under the model, the Secretary shall establish payment amounts for advanced illness care and management services that is targeted to eligible individuals with a serious, chronic progressive, or advanced illness. The payments may include payments under a fee schedule, capitated payments, bundled payments, value-based purchasing agreements, and other payment mechanisms determined appropriate by the Secretary. In this subsection, the term advanced illness care and management services means the following services, as appropriate for the individual's illness and stage of illness:
One or more face-to-face encounters between one or more members of the interdisciplinary team and the individual and, at the individual’s discretion, family caregivers, or, for an individual who lacks decisionmaking capacity under State law, the individual’s legally authorized representative. The provision of information about the typical trajectory of illnesses or conditions that affect the individual, including foreseeable care decisions that may need to be made at a future time when the individual is likely to be unable to make decisions due to temporary or permanent cognitive or medical incapacity.
Assisting the individual in defining and articulating goals of care, values, and preferences. Providing the individual with and discussing information about the benefits and burdens of relevant ranges of treatment options available to the individual, including disease modifying or potentially curative treatment, palliative care, which may be provided alone or in conjunction with disease modifying treatment, and, when the individual may be currently eligible or may become eligible for hospice care due to disease progression.
Assisting the individual in evaluating treatment options and approaches to care to identify those that most closely align with the individual’s goals of care, values, and preferences. Preparing, and sharing with relevant providers, documentation— that states the individual’s goals of care, preferences, and values, preferred decisionmaking strategies, and a plan of care that is concrete and actionable; and that is in State or locally recognized forms that are used for the purpose of assuring that providers can follow the plan across care settings, such as advance directives or portable treatment orders.
Referrals to providers, including medical and social service providers, who deliver care consistent with the plan. Providing culturally and educationally appropriate training for the individual and family caregivers to support their ability to carry out the plan. A multidimensional assessment of the individual’s strengths and limitations. An assessment of the individual’s paid and unpaid supports, including family caregivers. Comprehensive medication review and management (including, if appropriate, counseling and self-management support).
Visits to the patient in all sites of care (including the home, a hospital, and a nursing home) as needed to respond appropriately to problems and concerns. Additional services, consistent with the care plan, that the interdisciplinary team believes would assist the eligible individual and family caregivers in more effectively managing their health condition. 24-Hour access to emergency support in person or via telephone or telemedicine with the individual’s medical record and care plan available to the responder.
Care coordination and communication across health care and social service settings and providers, including involvement of the interdisciplinary team to evaluate quality and address concerns over time. Such other palliative and other services that the Secretary determines appropriate. In this subsection, the term applicable provider means a hospice program (as defined in section 1861(dd)(2)) or other provider of services (as defined in section 1861(u)) or supplier (as defined in section 1861(d)) that— furnishes services through an interdisciplinary team; and meets such other requirements the Secretary may determine to be appropriate.
In this subsection, the term eligible individual means an individual who— is entitled to, or enrolled for, benefits under part A of title XVIII and enrolled under part B of such title, but not enrolled under part C of such title; resides at home or in an institutional setting, whichever is consistent with their personal goals and preferences; and meets at least one of the following: The individual has the need for assistance with two or more activities of daily living (defined as bathing, dressing, eating, getting out of bed or a chair, mobility, and toileting) that is caused by one or more serious or life threatening conditions or frailty and that is not associated with an acute or post-operative condition.
The individual is diagnosed with a serious, chronic progressive or advanced illness that— has a strong negative impact on the individual's quality of life and functioning in life roles, independent of its impact on mortality; or is burdensome in symptoms, treatments or caregiver stress. The individual is diagnosed with— metastatic or locally advanced cancer; Alzheimer’s disease or another progressive dementia; late-stage neuromuscular disease; late-stage diabetes; late-stage kidney, liver, heart, gastrointestinal, cerebrovascular, or lung disease; or age-related physical debility.
The individual meets other criteria determined appropriate by the Secretary. Subject to subparagraph (B), in this subsection, the term interdisciplinary team means a group that— includes at least— one physician who is board certified in geriatrics, internal medicine, or family medicine; one physician, advance practice registered nurse, or physician assistant, who is a palliative specialist (defined as having a certification in hospice and palliative care) or who has at least one year’s experience providing hospice or palliative care; one nurse; and one social worker; may include a chaplain, minister, or pastoral counselor; may include other direct care personnel (including pharmacists, dieticians, physical therapists, occupational therapists, and psychotherapists); and meets requirements that may be established by the Secretary.
An applicable provider shall offer to the eligible individual (or the individual’s legally authorized representative when the individual has been found to lack decisional capacity) the opportunity to select either a chaplain affiliated with the applicable provider, a minister, or personal religious or spiritual advisor who can help to represent the individual’s goals, values, and preferences to serve as a core interdisciplinary team member at the individual’s (or legally authorized representative’s) request. .
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Sec. 3
Advanced illness care and management model
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