3 Patient C.D. Age 45 Was in good health and completely independent Admitted to BGSMC 11/30/ /18/12 At Banner Good Samaritan Rehab Institute 12/18/12-1/23/2013
7 HEALTH SYSTEM TRANSFORMATION Where we re at Where we re going Current Future Variable quality, expensive, wasteful Consistently better quality, lower cost, more efficient Pay for volume Pay for quality Pay for transactions Care based episodes Quality assessment based on provider and setting (process) Quality assessment based on patient experience (outcomes)
8 ACO BUNDLED PAYMENTS
9 Growth of Post Acute Services Each year more than 10 million Medicare beneficiaries are discharged from acute care hospitals into post acute settings. Grabowski, et.al
10 % FFS Medicare patients hospitalized received post acute care
11 40% of geographic variation in Medicare expenditures can be attributed to variations in post acute care expenditures mainly to variation in home health expenditures
12 2011 Post Acute Care Spending (in billions) IRF Home Health SNF
13 Medicare spending on post acute care has doubled in the past decade increasing from $26.6 billion in 2001 to $58 billion in 2010.
14 Many patients utilize more than one level of post-acute care PAC Setting 1 PAC Setting 2 PAC Setting 3 AH SNF Skilled Nursing Facility (SNF) HH OT Acute Hospital (AH) Home Health (HH) Inpatient Rehabilitation Facility (IRF) Outpatient Therapy (OT) AH HH OT HH OT Source: RTI International & American Hospital Association.
15 Examining Post Acute Care 20% of all Medicare beneficiaries hospitalized at least once a year - Admitted for a wide range of reasons including medical, surgical, functional diagnoses About 35% will be discharged to PAC: % SNF % Home Health % IRF % Outpatient/ambulatory therapy % LTCH Source: Gage et al, (2009). Examining postacute care relationships in an integrated hospital system, ASPE
16 The Changing of Incentives Medicare ALOS days SNF days/beneficiary up 3 times HH visits up 7 times Current Medicare ALOS 4.8
17 The growth in post-acute care utilization continues Total Medicare spending on post-acute care (billions) Year $1,400 $1,200 $1,000 $800 $600 $400 $200 $- Spending per beneficiary on post-acute care Total spending on post-acute care Per beneficiary PAC spending Source: CMS Office of the Actuary.
18 Patient functional ability affect care costs $35,000 Distribution of episodes & average Medicare episode payment by functional ability score for 30-day fixed-length episodes ( ) $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $ Low Functional Ability Score High Source: Dobson/DaVanzo analysis of research-identifiable 5 percent SAF for all sites of service,
19 Hospital Readmissions vary among post-acute settings Percent of 30-day fixed-length episodes with readmissions by first setting of post-discharge care 28% 17% 22% 20% 12% LTCH IRF SNF HHA Outpatient Rehab Sources: RTI International and Cain Brothers Analysis.
20 Post-acute care contributes to controlling hospital readmissions The highest percentage of readmissions comes from patients who did NOT receive post-acute care. 2.0% 3.1% 5.3% 14.4% 18.9% 56.2% Community Skilled Nursing Facility Home Health Emergency Department Inpatient Rehab Other Percent of readmissions by source, 30-day fixed length episodes, Source: Dobson/DaVanzo Analysis of 5% Sample of Medicare Claims Data ( ).
21 Post Acute Silos Site specific payment systems Site specific documentation
22 Artificial Boundaries LTACH 25 day LOS IRF 60% rule/3 hour rule SNF 3 day prior hospitalization
23 Post Acute Care Goals and Values Minimize medical complications Minimize readmissions Optimize function/mobilization Promote independent/community living Patient/caregiver education and support Safe, effective transitions of care Sick role learning/health role
24 Global Goals Need for full continuum of post acute services with clear usage criteria Effective transition of care management Aligned payment incentives
25 Medicare Criteria for Inpatient Rehabilitation Medically stable able to participate in intensive rehab Requires intervention of at least two therapies (PT, OT, Speech) Requires, can participate from at least three hours of therapy, five days per week Requires medical management of an experienced rehabilitation physician, and receives at least three face to face visits per week Requires an intensive, coordinated interdisciplinary team approach
26 Allowable IRF Medical Conditions Stroke Spinal Cord Injury Congenital Deformity Amputation Major Multiple Trauma Femur Fracture Brain Injury Neurological Disorders Burns Active polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies Systemic vasculidities with joint inflammation Severe or advanced osteoarthritis (osteoarthritis or degenerative joint disease) involving two or more major weight bears joints (elbow, shoulders, hips or knees, but not counting a joint with prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint Knee or hip joint replacement or both, during an active hospitalization immediately preceding the inpatient rehabilitation stay
27 Questionable Diagnoses Single extremity fractures Joint replacements without complications Debility/Deconditioning
28 Goals of Medical Rehabilitation Optimizing patient health Preventing medical complications Improving functional skills Restoring independence Promoting participation in society Education Optimize experience Achieve durability Promote efficiency
29 Critical Transition Needs Manage transitions Focus on palliative care goals Supported discharges Improved linkages with medical homes ASA International Stroke Conference San Diego February, 2014
31 About 4% of U.S. adults will have a stroke by 2030 (potential 20% increase) Costs to treat stroke may increase from $71.55 billion (2010) to $ billion Americans currently years old will have highest increase in stroke at 5.1% Stroke prevalence to increase most among Hispanic men by 2030 and the cost of treating stroke among Hispanic women is expected to triple AHA/ASA
32 Does Post Acute Care Site Matter? 222 patients Home Health vs SNF vs IRF IRF gains > SNF in Basic mobility Cognitive Daily activities Chan, et.al Archives PM&R 2013; 94: 622-9
33 Potential Added Value of Acute Inpatient Rehab Facilities: More intensive physician direction and intervention Physician specialty follow up More intensive and specialized RN care More intensive and specialized therapy Team/care coordination Psychosocial management Patient/family education Discharge/transitional planning Quality/Outcome focus
34 Generally stroke patients treated in IRF s have greater improvement and shorter stays than stroke patients treated at a SNF. Medicare Payment Advisory Commission Report to Congress March, 2011
35 There is strong evidence that organized, interdisciplinary stroke care will not only reduce mortality rates and the likelihood of institutional care and long term disability, but also may enhance recovery and increase activity of daily living independence. ASA
36 Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities and After Discharge DaVanzo, et.al.
37 IRF vs SNF Returned home two weeks earlier. Remained home two months longer. 8% lower mortality over 2-year period. 5% fewer ED visits. 5/13 conditions had fewer hospital readmissions.
38 Anybody who can be cared for at home should be cared for at home. Michael Reding, MD Burke Rehabilitation Hospital
39 Episode Based Care with disease specific focus
40 Value, focus and goals of different care continuum environments Determine appropriate mix of medical supervision and therapy intensity Understand and minimize risks of transitions Episode based case/care management and navigation
Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs) and After Discharge Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com
ACUTE INPATIENT REHABILITATION: MEETING THE NEEDS OF THE TRAUMA PATIENT St. Mary Rehabilitation Hospital Goals for today s presentation: Admission 1. Clarify the inpatient rehabilitation admissions process.
1 The Essential Role of the Rehabilitation Nurse in Facilitating Care Transitions A White Paper by the Association of Rehabilitation Nurses Executive Summary Copyright 2013 Association of Rehabilitation
American Hospital association November 2010 TrendWatch Maximizing the Value of Post-acute Care Today, patients often require a diverse array of services to treat major health episodes, manage chronic disease
West Penn Allegheny Health System System Compliance Department Medical Necessity and Billing for Inpatient Rehabilitation Lessons Learned from an Inpatient Rehab Unit Billing Audit 2006 HCCA Compliance
CONTINUE THE CARE 2011 Quality and Social Responsibility Report Driving Integrated, Cost-Effective Care Across the Post-Acute Continuum Year in Review: Delivering on Quality, Value and Innovation in Patient
Chapter 3 Section 3.08 Ministry of Health and Long-Term Care Rehabilitation Services at Hospitals Background DESCRIPTION OF REHABILITATION Rehabilitation services in Ontario generally provide support to
WRITTEN TESTIMONY OF PETER W. THOMAS, J.D. COALITION TO PRESERVE REHABILITATION KEEPING THE PROMISE: SITE OF SERVICE MEDICARE PAYMENT REFORMS HOUSE ENERGY & COMMERCE HEALTH SUBCOMMITTEE On behalf of the
2013 Quality and Social Responsibility Report Creating Solutions in Post-Acute Care Through Patient-Centered Care Management CONTINUE THE CARE Providing Care Management and Improving Outcomes Across the
Southwestern Ontario Stroke Rehabilitation Action Planning Day November 28, 2006 Summary Report Moving to Best Practice Prepared by: Deborah Willems Southwestern Ontario Stroke Strategy January 29, 2007
1 Chronic Conditions Among Older Americans Chronic Illness on the Rise How Much Do We Spend on Chronic Conditions? A Closer Look at Selected Chronic Conditions 9 Chronic Conditions among Older Americans
ACUTE INPATIENT REHABILITATION 2013 ANNUAL REPORT INTRODUCTION It is my privilege to present the 2013 Annual Report for Regions Hospital Rehabilitation Institute s acute inpatient rehabilitation services.
Statewide Rehabilitation Service Plan 2009 2017 November 2009 The National Library of Australia Cataloguing-in-Publication: Author: South Australia. Dept. of Health. Statewide Service Strategy Division.
GAO United States Government Accountability Office Report to the Chairman, Committee on Finance, U.S. Senate August 2004 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITIES High Medicare Payments in Florida
National Stroke Association s Guide to Choosing Stroke Rehabilitation Services Rehabilitation, often referred to as rehab, is an important part of stroke recovery. Through rehab, you: Re-learn basic skills
Program Facts Program Facts The Program provides injury/illness-specific programs that offer patients care needed to regain the abilities to perform daily tasks, restore basic life skills, reclaim cognitive
1488 SPECIAL SECTION: SPECIAL COMMUNICATION Access to Postacute Rehabilitation Melinda Beeuwkes Buntin, PhD ABSTRACT. Buntin MB. Access to postacute rehabilitation. Arch Phys Med Rehabil 2007;88:1488-93.
Executive White Paper Series April 2015 In Cooperation With: This white paper series is produced by the LINK Conference, whose mission is to accelerate productivity and innovation in long term care and
SUBMISSION TO: Department of Health and Children and Health Service Executive Working Group for the development of: National Policy/Strategy for the Provision of Rehabilitation Services January, 2009 National
THE ARTS CHILD POLICY CIVIL JUSTICE EDUCATION ENERGY AND ENVIRONMENT This PDF document was made available from www.rand.org as a public service of the RAND Corporation. Jump down to document6 HEALTH AND
STANDARDS FOR ASSESSING MEDICAL APPROPRIATENESS CRITERIA FOR ADMITTING PATIENTS TO REHABILITATION HOSPITALS OR UNITS Prepared by: Medical Inpatient Rehabilitation Criteria Task Force John L. Melvin, MD,
Mount Sinai Rehabilitation Center 2014 Outcomes Mount Sinai Rehabilitation Center 2014 Outcomes TABLE OF CONTENTS A Message from the Chair... 3 About Our Programs. 4-5 Inpatient Rehabilitation. 6-12 Outpatient
Draft SHP for Acute Inpatient Rehabilitation Services.01 Incorporation by Reference. This Chapter is incorporated by reference in the Code of Maryland Regulations..02 Introduction. A. Purposes of the State
WWLHIN Rehabilitation Services Review Transitioning to a System of Rehabilitative Care in Waterloo-Wellington Final Report of the Rehabilitation Review Committee to the WWLHIN May 2012 Table of Contents