Pharmacists Play Role in Impairment Care Planning

One in 9 adults in the United States aged 45 years and older reports confusion or memory loss, according to the CDC.¹

Cognitive impairment affects more than 16 million Americans, and this number is expected to grow as more baby boomers reach age 65.² Cognition is the range of mental processes that allows us to acquire, store, manipulate, and retrieve information; exercise judgment; and behave appropriately.

Essentially, this defines who a person is as an individual. Cognitive impairment is when an individual has difficulty concentrating, learning new things, making decisions that affect their everyday lives, and remembering.

The impairment can range from subjective cognitive decline to mild or severe impairment, but often these varied levels are difficult to distinguish and may go unnoticed for some time.

In 2020, it was estimated that 5.8 million patients over age 65 had Alzheimer disease, a form of severe cognitive impairment.³ That number is expected to reach 13.8 million by 2050.³ Although age is a nonmodifiable risk factor for cognitive impairment, there are many modifiable ones, including brain injury, cardiovascular conditions, certain medications or combinations of medications, hearing and vision impairment, hormonal

imbalances, poor lifestyle choices, and sleep disturbances. Although there is no cure for severe cognitive impairment, such as Alzheimer disease or dementia, some causes of mild cognitive impairment are related to health issues that may be treatable. Additionally, investigators believe future treatments to preserve brain function and slow or stop the progression of Alzheimer disease may be most effective when administered early, either at the mild cognitive impairment or preclinical phase.³ It is important to detect the signs of cognitive decline early and pursue appropriate treatment from a health care professional.

There are Medicare services that address cognitive impairment. In 2017, the Centers for Medicare & Medicaid Services (CMS) approved payment for a new current procedural terminology (CPT) code for cognitive impairment care planning services. These services include a comprehensive clinical visit and written care plan for eligible Medicare beneficiaries with a confirmed or established diagnosis of cognitive impairment. The code was revised from CPT G0505 to CPT 99483 in 2018.⁴ It was designed to improve detection, care planning, and coordination of care for patients with cognitive impairment (TABLE 1⁵).

The Alzheimer’s Association developed a cognitive impairment care planning toolkit that outlines important information for providers seeking to offer this service to patients. The toolkit explains recommendations and provides tools to meet the requirements of cognitive impairment care planning. To meet the required elements of CPT 99483, an independent historian must be present for the face-to-face visit. CMS estimates that about

50 minutes will be spent with the patient and/or caregiver or family, highlighting the complexity of the service. The care plan itself should be written in language that is easily understood by the caregiver and/or family. In addition, the plan should indicate who is responsible for each of the outlined action items and include a timeline for follow-up. The toolkit outlines the domains for the cognitive impairment care planning service (TABLE 2⁴).

During cognitive care planning, caregivers are involved by assessing their knowledge of cognitive impairment and their ability to assist in the caregiving responsibilities. In addition, caregiver stress and well-being are assessed to ensure their needs also are being met. In 2019, caregivers of individuals with Alzheimer disease or other dementias provided an estimated 18.6 billion hours of unpaid assistance, valued at $244 billion.³

Resources and support are provided, including assistance; assistive devices; caregiver, family, and patient counseling; home modifications; information; respite; and support groups. It is important for clinicians performing cognitive care planning to have information on federal, local, and state resources available for caregivers.

Caregivers and family members play an important role in recognizing cognitive decline and helping family members as they age. A caregiver is anyone who is involved in the following⁶:

• Acting as a designated on-call person to deal with problems that arise
• Buying groceries, cleaning the house, cooking, or doing laundry
• Handling crises for family members or making plans for their care
• Helping a family member get dressed, shower, and take medications
• Helping with feeding tubes, injections, physical therapy, or other medical procedures
• Making medical appointments and driving to the doctor and pharmacy
• Talking with care managers, doctors, and other health care providers to understand all necessary tasks
• Transferring someone in and out of bed

OTHER TOOLS

There are various tools that support cognitive care planning services for both caregivers and patients, including screening tools. Patients must receive a diagnosis of cognitive impairment prior to proceeding with care planning services for these conditions. Screening tools are used to detect early changes in cognition, and, depending on the results of such screenings, further evaluation may be warranted. Tools such as the AD⁸ Dementia Screening Interview, Mini-Cog, and Quick Dementia Rating System are commonly used to assess cognitive changes and are selected based on a variety of factors, including demographics, language, and target population age.⁷ With advancements in technology, practitioners also may use newer tools such as Cognivue Clarity, an FDA-cleared computerized cognitive assessment device, to assess changes in cognitive function. The Cognivue Thrive device, based on the same FDA-cleared technology, helps identify changes in cognitive performance from baseline if used regularly as part of routine screening.⁸

Other tools, such as the Mini-Cog and Montreal Cognitive Assessment Test, can assess instrumental activities of daily living, behavioral and neuropsychiatric symptoms, caregiver identification, and safety, as well as assist with end-of-life planning. All these components support the development of a care plan to address the needs of caregivers and patients.⁷

ROLE OF THE PHARMACIST

When pharmacists engage with patients with cognitive impairment, whether in the beginning or final stages, they can promote optimal care in numerous ways. They can partner with physicians and other qualified health care professionals (QHPs) to offer collaborative clinical services, such as cognitive impairment care planning. Because CMS does not recognize pharmacists as billing providers, this collaboration allows pharmacists to function as auxiliary personnel under the supervision of the provider.9 In an analysis conducted from data collected in 2017, family practice and geriatric medicine providers, internal medicine providers, neurologists, and nurse practitioners were the health care professionals who most commonly used cognitive impairment care planning services for traditional fee-for-service (FFS) Medicare beneficiaries.3 Although the service must

be furnished by the physician or other QHP, pharmacists may complete many of the required assessment elements.⁴

Providers may benefit from pharmacist collaboration to help address more of the eligible patient population. Use of the cognitive impairment care planning service by providers is low (TABLE 3^3,10) and just 0.06% of FFS Medicare beneficiaries had this service completed in 2017. These statistics do not align with the estimated number of Medicare beneficiaries who are eligible for this service based on a diagnosis of cognitive impairment. This is an opportunity for pharmacists to fill a gap in care, help providers evaluate and treat their patients with cognitive impairment, and use their knowledge of medications and modifiable risk factors to improve care.

TRENDS IN CARE PLANNING

When CMS introduced cognitive impairment care planning services as a separately billable service, uptake was slow for the first few months.¹¹ However, use increased steadily throughout the year. Cognitive care planning presents a unique opportunity for pharmacists to apply their knowledge of common chronic disease states and medications that contribute to the progression of cognitive decline.

Collaborating with providers allows pharmacists to serve as a support for caregivers by connecting them to necessary resources and to enhance care for patients and their cognitive health. This is an opportunity for pharmacists to participate in a major public health initiative. By introducing another health care expert to the team, pharmacists help fill the gap in the use of these services and can counsel patients on modifiable risk factors to promote a population that focuses on cognitive health.

JESSICA SINCLAIR, PHARMD, is the director of education and research outcomes for Rx Clinic Pharmacy in Charlotte, North Carolina, and an instructor at the Avant Institute of Clinicians in Charlotte.DESIREE GAINES, PHARMD, is the health and wellness director for Rx Clinic Pharmacy.

REFERENCES

• Know someone with memory loss? CDC. Updated September 2018. Accessed January 28, 2021. https://www.cdc.gov/aging/data/infographic/cognitive-decline.html
• Incidence and prevalence of the major causes of brain impairment. Family Caregiver Alliance. March 2001. Accessed November 30, 2020. https://www.caregiver.org/incidence-and-prevalence-major-causes-brain-impairment
• 2020 Alzheimer’s disease facts and figures. Alzheimer’s Association. Accessed January 26, 2021. https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
• Cognitive impairment care planning toolkit. Alzheimer’s Association. Accessed November 25, 2020. https://www.alz.org/careplanning/downloads/care-planning-toolkit.pdf
• Physician fee schedule. CMS. Updated January 7, 2021. Accessed January 26, 2021. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched
• Alzheimer’s disease and caregiving. Family Caregiver Alliance. Accessed November 25, 2020. https://www.caregiver.org/alzheimers-disease-caregiving
• Alzheimer’s and dementia resources for professionals. National Institute on Aging. Updated March 26, 2020. Accessed November 25, 2020. https://www.nia.nih.gov/health/alzheimers-dementia-resources-for-professionals#screening
• Cognivue Clarity. Cognivue. Accessed November 25, 2020. https://www.cognivue.com/product-tour/cognivue-clarity/
• Centers for Medicare & Medicaid Services, HHS §410.26. Accessed January 26, 2021. https://www.govinfo.gov/content/pkg/CFR-2014-title42-vol2/pdf/CFR-2014-title42-vol2-sec410-26.pdf
• Advance care planning among Medicare fee-for-service beneficiaries and practitioners: final report. US Department of Health & Human Services. October 1, 2020. Accessed November 11, 2020. https://aspe.hhs.gov/basic-report/advance-care-planning-among-medicare-fee-service-beneficiaries-and-practitioners-final-report
• Hargraves J. Examining the adoption of a new Medicare billing code for cognitive assessments: a slow but steady uptake. Health Care Cost Institute. May 15, 2019. Accessed November 11, 2020. https://healthcostinstitute.org/hcci-research/examining-the-adoption-of-a-new-medicare-billingcode-for-cognitive-assessments-a-slow-but-steady-uptake