Readmissions Management Through Partnerships: Physicians Hospitals Post- Acute Providers

Transcription

1 May 24, 2011 Readmissions Management Through Partnerships: Physicians Hospitals Post- Acute Providers Health Research & Education Trust of New Jersey New Jersey Hospital Association Kathleen M. Griffin, PhD, National Director, Post Acute and Senior Services and Jane Gorwin, RN, MA, Senior Home Health and Hospice Consultant, Health Dimensions Group 1

2 Topics Payment and Delivery Reforms Driving Partnerships Tactics for Partnership Development Pre-partner Due Diligence Tactics for Managing and Reporting on Readmission 2

3 Game Changer for Post-Acute Medicare Payment: Hospitals and Physicians at Risk for Post-Acute Care Hospital Readmission Penalties Value-Based Payment Bundled Payment Pilots Accountable Care Organizations 3

4 Why Post-Acute Care is Key to Bending the Cost Curve But rehospitalizations from post-acute is not good 4

5 30-Day Rehospitalizations High, but Worse for Medicare Patients Discharged to SNFs 19.6% of Medicare patients are readmitted within 30 days, and 28.2% within 60 days; only 10% of these readmissions are planned Jencks S et al. N Engl J Med 2009; 360:

6 Penalties for Hospitals with Excessive 30-Day Readmissions: October 1, 2012 Hospitals in quartile with highest rate or lowest improvement in rate of 30-day readmissions for heart attack, heart failure, and pneumonia will lose a percentage of total Medicare payments All 30-day readmissions with two exceptions (AMI with planned readmission for CABG or stent) Even if readmitted to another hospital 6

7 What are Readmission Penalties? FY 2013: Reduction of all Medicare payments for lowest quartile hospitals of up to 1% based on 30- day readmission rate for the three conditions FY 2015: Medicare payment reduction of up to 3% and the program will expand to include COPD, cardiac bypass, stents, and other vascular conditions for total of seven conditions and more Does not apply to critical access hospitals 7

8 How Does New Jersey Rank in 30-Day Readmissions? Not Well. 8

9 2012 Impact on Post-Acute Providers Preferred provider networks for hospitals/health systems: selection criteria Data proving low 30-day readmission rate; discharges to home; care transitions; care continuum Manage high-acuity patients with 24/7 physician/np access Appropriate use of palliative care and hospice Health systems with at-risk contracts with Medicare Advantage and insurers have created senior transitions programs: Health system s primary care physicians follow their patients into all post-acute settings, except for IRF 9

10 Bundled Episodic Payment: January 1, 2013 Pilot begins January 1, 2013; if spending reductions, expand at least by January 1, 2016 Payment either given bundle or via bids Payment to entity (the hospital) contingent on meeting quality indicators Functional status improvement Reduction in avoidable hospital readmissions Rates of discharge to community ED visits Rates of health care-acquired infections Efficiency, patient-centeredness, patient perception of care 10

11 Bundled Episodic Payment and Post-Acute Care Bundling = payment to a single provider entity of one amount for the full range of care during a hospitalization episode Episodic payment related to acute hospitalization: -3 through +30 days Hospitalization; rehospitalization; post-acute care; outpatient hospital services, including ED, physicians Initial focus on one or more of eight conditions 11

12 Why Bundled Payment Desirable for Bending the Medicare Cost Curve Hussey P., et al. N Engl J Med 2009;361: HIT denotes health information technology, NP: nurse practitioner, and PA: physician assistant 12

13 CMS Acute Care Episode (ACE) Bundled Payment Pilot Bundle includes all services related to the inpatient stay; five hospitals in pilot 28 Cardiovascular and 9 Orthopedic DRGs Demonstration length: Medicare fee-for-service beneficiaries Competitive bidding Gainsharing with physicians Shared savings with beneficiaries Planned expansion to 8 states, new sites in 2011, at least one pilot including post-acute care Key to margins will be management of readmissions 13

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15 Post-Acute Payment Methods for Bundled Payment Acuity adjusted episodic payment + shared savings Bundled payment: one health system example $10,000 = 30 days Capitation possible in long-term future, but today even physician groups with capitated lives pay preferred post-acute providers by episode (and manage patient stays) 15

16 Strong Future for Bundled Payment: Medicare and Insurers A means to learn risk-sharing and alignment via shared payment incentives requires superior readmissions management Length of bundling period may expand over time, driving providers toward population health management But to work, must address Stark issues and Conditions of Participation for post-acute providers 16

17 Value-Based Purchasing 10/01/12, But Proposed Efficiency Measure for FY 2014 Value-based purchasing for hospitals FY % reduction in hospital Medicare payments $850,000,000 to reward best performers Quality indicators process, outcomes, and satisfaction FY 2014 proposed measure Hospital responsible for Medicare costs for 90 days after hospital discharge Excessive costs = less Medicare payment 17

18 Accountable Care Organizations: January 1, 2012 ACO Population Physician Groups or Physician- Hospital Organizations are participantsshare savings if reduce Medicare A & B costs Contract with select post-acute providers Serve 5,000+ Medicare fee-forservice beneficiaries Savings through primary care prevention, avoiding institutions Adapted from Premier, Inc. 18

19 ACO Proposed Rule: Payment via Shared Savings Current average per-capita spending for Medicare beneficiaries in market area determined from claims for past three years; spending target is determined by CMS Medicare beneficiaries attributed to ACO retrospectively If actual spending lower than target, savings are shared if quality targets are also achieved ACO Launched Projected Target Actual Shared Savings Adapted from Brookings Institute 19 19

20 Post-Acute Providers and Hospital Readmissions: The Bottom Line Fewer hospital days, fewer post-acute institutional days, more home care = lower costs (so long as patient outcomes are good) Proving your ability to manage high-acuity patients via readmissions data and patient discharges to home will be critical Post-acute providers at every level become today s community hospital without surgical suites and high-tech diagnostics 24/7 physicians/nps in all post-acute institutions manage patient crises within the post-acute setting, not ED or hospital Procedure rooms in LTACHs and subacutes Facilityists for your general subacute; specialists for your centers of excellence Care continuum for seniors no one falls through the cracks 20

21 A New Factor: CARE Report Due June 2011 Continuity Assessment Record and Evaluation (CARE) piloted at 199 PAC sites; report due to CMS June 2011 Web-based measurement: At acute hospital discharge At admission to PAC (SNF & HHA) At discharge from PAC Measures: Health status: Diagnoses, procedures, medications, allergies, skin integrity, and physiologic factors Prior use/pre-morbid status Functional status/physical issues Social and environmental factors Changes in severity Cognitive status Idea is that CARE tool will predetermine best post-acute setting. PAC providers concerned that study group too small to yield valid results, but no single PAC voice to provide input to CMS 21

22 CARE The Goals CARE project goal is to provide an electronic, standardized patient assessment instrument that will: Identify patient characteristics and needs Rapidly communicate key information between providers, consistent with the Institute of Medicine s six critical aims Serve as a continuity of care record to support clinical excellence Optimize efficiencies available through information technology advances Move CMS toward an electronic health record 22

23 Health Systems Four Strategies for Managing Post-Acute Continuum Health systems use four major strategies for managing post-acute care quality and costs 23

24 Strategy 1: Own Most or All of the Continuum; Add Care Transitions Program NJ Examples: Meridian, Solaris, Saint Barnabas Other Examples: Centura (CO), Sentara (VA), Spectrum (MI), Lee Memorial (FL), Fairview Health (MN) But post-acute venues that include skilled nursing and home health typically supplemented by preferred partnerships with other skilled nursing facilities and home health agencies to cover health system s market MSO strategy when new post-acute assets added via hospital mergers or acquisitions: centralize back office services, care pathways, physician coverage partners pay a fee to MSO 24

25 Strategy 2: Create Post-Acute Continuing Care Networks (CCNs) Steps: Establish criteria for membership and qualify interested providers, e.g., requisite staff, medical coverage, experience; clinical pathways and effective discharge planning; ability to manage transitions and hand-offs; work toward interoperable IT and decision support systems Require ongoing reporting of patient outcomes and satisfaction Patients still have choice, but aware that health care system has qualified the CCN members May have separate CCNs for various post-acute venues Examples: Summa Health System (OH), The Methodist Hospital (4-hospital system) (TX) 25

26 Strategy 3: Joint Venture Post-Acute Venues Typically, single purpose or combo building on hospital land New interest in continuing care hospital mentioned in ACA under bundled payment pilot Ownership percentage based on value of contributions (hospital = land; post-acute provider = cash, start-up sweat equity) Post-acute provider manages; fee based on meeting financial and quality targets; financial targets will change under bundling Examples: Baylor (TX), Summa (OH), Texas Health Resources (TX) 26

27 Strategy 4: Management Agreement with Multi-Venue Post-Acute Organization to Manage All Post-Acute Patients Post-acute manager manages hospital discharges to most appropriate, lowest cost post-acute venue May be paid bundled rate (e.g., $10,000 per postacute user) Payment contingent on quality outcomes and achieving thresholds for rehospitalizations First step typically Joint Operating Committee clinical pathways, trust Examples: Kindred, Kissito 27

28 Selecting Your Partner(s) 28

29 How One Large Health System Selected Partners for a SNF CCN Create network of external SNFs that receive training/services from TMH so that the SNFs accept admission and provide quality care for medically complex patients discharged from TMH; within this network, SNFs agree to admit percentage of difficult-to-place patients, e.g. Medicaid pending, behavioral issues 1. Qualify at least one external SNF near each of The Methodist Health System outlying hospitals and a number of SNFs near TMH for a quality network based on State Survey reports, Medicare quality indicators and TMH defined quality measures 2. For the group of SNFs in the quality network, TMH can provide the following services: On-site staff training and call-in nurse mentoring Respiratory therapists to manage patients immediately after the SNF admission and to train SNF nursing staff on suctioning and other RT procedures Promotion of the SNF as part of the quality network 3. SNFs would provide quality network: Ongoing nurse training and adequate nursing staffing for medically complex patients Admission acceptance 7 days/ week Willingness to accept certain percentage of difficult-to-place patients from TMH Formal report on patient progress to attending physician when patient is discharged from Medicare Part A in SNF Source: Catherine Giegerich,

30 Why Readmissions from SNFs? #1 reason for hospital admissions from SNFs = limited on-site capacity to deal with medical issues #2 reason = physicians more comfortable with hospital services: stat labs, x-ray, nurse competencies To Hospitalize or Not to Hospitalize? Medical Care for Long-Term Care Facility Residents. Kaiser Foundation, October

31 Initial Assessment and Selection Quality Indicators & Site Visits Selection Process Public quality reporting Selected key indicators Site visit to confirm Acquired pressure ulcers Unanticipated weight loss Restraint usage Dehydration Rate of community discharges Staffing levels State investigations Tenure of administrator Tenure of nursing director Medical director qualifications Source: Catherine Giegerich,

32 Building a Communication System and Relationship Network meetings Central contact Affiliation agreement Visits Keeping up with staff changes Intranet site Transitions newsletter Staff meetings Classes s Compliments and complaints Hard-to-place patients Letters of agreement Source: Catherine Giegerich,

33 Monitoring that Spans Settings Meaningful quality information Site visit findings Readmissions monitoring Complaint tracking Volume by facility TMH-paid care assistance Patient-family surveys How well were you prepared for discharge? How satisfied were you with the SNF facility? Source: Catherine Giegerich,

34 Source: Catherine Giegerich,

35 Source: Catherine Giegerich,

36 How Post-Acute Providers Pick Winning Partners Identifying hospital-health system winners 1. Scale: multiple sites, market share, financials 2. Physician alignment: Owned, PHO, Network of Independents 3. Robust, accessible primary care: PCMHs 4. EMR across settings 5. Evidence-based practices 6. Experience with shared risk payment: insurers, Medicare Advantage plans 7. Investment in care management: discharge, transitions 36

37 Selecting Health System Partners: Market Overlap 37

38 Selecting Health System Partners: Data Talks Top Discharges to SNF Mt. Sinai Medical Center in Manhattan 30-Day Hospital Readmission Rates 38

39 Getting in the Door Demonstrate your 30-day readmission rates by condition and plans to continue to decrease Partner with hospitals to meet burning needs, especially concerns about readmission penalties FY2013: pneumonia, AMI, CHF; and reduce excess LOS for all conditions discharged to post-acute Customize programs to hospitals Heart Attack Heart Failure 19.4% 25.8% 12% 15% Pneumonia 19.6% 11% 39

40 Getting a Seat at the Table Joint Operating Committee arrangement with specific hospitals to create clinical pathways or explore program development: JOC agreement provides initial framework for working together, sharing data and resources to create the pathways JOC also would begin exploring EMR inter-operability Opportunity for sharing goals and progress 40

41 Tactics for Measuring and Reducing Rehospitalizations 41

42 Tracking Readmission Data Implementing practices to track readmissions and avoidable admissions to acute hospitals will be critical into the future Two types of diagnoses: 1. Diagnoses where there is a larger portion of preventable hospitalization then there is across all diagnoses What are your most common acute bounce backs? 2. Diagnoses where there is some type of care that a post-acute provider can furnish that will reduce the number of hospitalizations? What are you capable of doing? 42

43 Tracking and Preventing Readmissions from Skilled Nursing Facilities 43

44 Tracking Readmission Data: Key Factors Associated with Hospitalizations from SNFs Nursing staffing levels, nurse skill set, and turnover Implementation of assessment and management protocols Physician/APRN coverage and support Stat labs, pharmacy, x-ray Geography What is your current factor assessment in these areas? 44

45 Tracking Readmission Data: Risk Identification Can Be Key Predictor Evolving a risk factor checklist during preadmission or immediately thereafter can help prioritize care or patient management to avoid a hospitalization Focus on key patient indicators 45

46 Tracking Readmission Data: Establishing Rehospitalization Data Tool Tool should be focused on tracking high-risk candidates for rehospitalizations and actual hospitalizations Data should be gathered across multiple points to support analysis and improvement: Date and time of transfer Reviewing nurse staff and specific discharger SNF LOS prior to transfer Actions taken to avoid Outcome Lessons learned 46

47 Tracking Readmission Data: Daily and Monthly Tool Components Daily tool: detailed focus on patient emergent issue, situation management and outcome Supports root cause analysis and problem resolution Monthly tool: data roll-up for previous month s activity Identifies overall readmission trend; can be modified to support specific trend analysis by diagnoses Can identify clinical skill set deficits, specific nursing unit trends 47

48 Daily Tool Patient Name/ID Number 48

49 Monthly Tool 49

50 Tracking Readmission Data Implementation Integrated as key component of patient care management protocol Employed in the evaluation of any patient considered for hospital admission Ideally employed in-situ to capture most reliable and meaningful data avoid GI-GO May additionally require implementation of evidence-based tools for patient assessment and management 50

51 Methodologies and Processes to Reduce Rehospitalizations: SNFs Short-term Rehab Defined cardiopulmonary rehab program Pre-admission assessment and hospital discharge planning Medication reconciliation with PCP for admission meds Established protocols/standing orders On-site Advanced Practice Nurses 24/7 RN staffing RN hourly rounds Rapid response teams SBAR Process (Situation-Background-Assessment-Recommendation) Tele-monitoring 51

52 INTERACT2: Evidence-Based Tool INTERACT2: Interventions to Reduce Acute Care Transfers Series of educational and clinical tools designed to reduce the number of avoidable transfers from nursing homes to hospitals. Two key focus areas: 1. Improve the early identification and evaluation of changes in residents' status that could lead to hospitalizations 2. Improve communication about these changes Available Online: 52

53 Tracking and Preventing Readmissions from Home Health Agencies 53

54 Tracking Readmission Data by Home Health Key factors associated with hospitalizations from home health: Unaddressed complex, patient chronic conditions Minimal focus on poly-pharmacy effects with functional status in elders Lack of consistent medication reconciliation Fragmented communication Lack of cohesive patient-centered plan of care based on integrated clinical pathways 54

55 Tracking Data Elements ID status (across system) Age Gender Education level Race PCP Hospitalist/s Payor Discharge principal diagnosis Cost of care Reimbursement Co-morbidities at DC LOS CNS/PA/GNP Readmission to ER Readmissions to acute Medication discrepancies Education provided PCP visit within 7 days postdischarge Standing orders/protocols initiated Labs ordered 55

56 Home Health Compare: State/National Averages How Often Home Health Patients Admitted to Hospital 27% Average 29% Average Home Health has its challenges! 56

57 Home Health Compare More Statistics How Often Home Health Care Teams Taught Patients (or Caregivers) About Their Drugs 88% Average 85% Average Implication: Definite room for improvement and relates to medication reconciliation 57

58 Methodologies and Processes to Reduce Rehospitalizations: Home Health Integrated patient care/clinical paths Evidence based Part of EMR and documentation systems Well-defined transitional care elements Front loading patient contact at SOC Tele-health: remote monitoring for complex patient populations 58

59 Home Health Best Practices to Reduce Rehospitalization Assess for Risk Front Load Visits Improved Patient Outcomes Self Management Plans, Teaching Document Pt. Teaching and Response Daily Telemonitoring Comprehensive Cardiac Assessment Source: VNS, Newport and Bristol Counties, Rhode Island, April

60 Polypharmacy Related Tools to Better Assess Purpose, Impact of Medications CURE PREVENT COMPLICATIONS RELIEVE SYMPTOM VITAL IMPORTANT OPTIONAL NOT INDICATED PATIENT'S NAME DOCTOR NAME DATE Source: Polypharmacy in the Elders Presentation, University of Kansas Medical Center 60

61 Medication Tracking Sheet - Sample 61

62 VNS Telemonitor Process One Example Intake Supervisors Central Station Staff MDs Fax MD form with check off Info on monitor available to be faxed Ask D/C planners, MD to order it Tell referring individual about monitor Check off on worksheet Indicate monitored patients on hospital list Enter Eval for MO order for Cardiac, Pulmonary patients Apply green Evaluate for HomMed sticker to admit paperwork Goals Get MO orders with referrals Communication between RN and Central Station Monitor frequency of visits; ensure 1-2 visits are decreased (monitor pays for itself) Expect HomMed installs to be done on admit Aim for 2-5 monitors in use by each case manager Review admits, keep in mind patient diagnosis to be monitored Oversight of effective use of monitors; recourse when rules are not followed Monitor staff compliance: once pt. identified, staff must explain why monitor is not used Case conference as needed Call pt. to confirm admit, discuss use of HomMed Disease Management 2-5 monitored patients per case manager Set up, teach monitor guidelines Disease management successful interventions written in newsleter P.I. rel. to frequency of visits, frontloading, avoiding ER/Hosp Present at team meetings Determine barriers to use Review installs which RNs are doing it Agency Benefits to ACOs Recover costs of monitors Use monitors to reduce rehospitalizations and improve pt outcomes Never have less than 40 in use Present monitor positively to patients/mds Written detailed reason for not installing monitor Plug in monitor, then teach on next visit Frontload visits in first 2 weeks and at end of episode Frontload visits = 5 RN visits in 2 weeks Use readings to determine need for visits and patient s status Use as a case mgt tool Focus on Benefits Improve quality of care Help patients manage illness All staff must be able to install Able to manage a bigger caseload with monitor Improve communication Overcome barriers related to using monitors Fax reports Ask for new referrals Must be aware of VS parameters MDs will call us to request monitoring Source: VNS, Newport and Bristol Counties, Rhode Island, April

63 Facts about Dying in America Why Palliative Care Has a Bigger Role to Play More than 2.4 million individuals die in the United States each year; nearly 75% of these people are more than 65 years old 65+ population consumes one-third of health care spending and one-half of physician time Approximately 27% of Medicare costs are for the last year of life, unchanged from 20 years ago Approximately 10% of all health care expenditures are spent on 1% of patients who die 63

64 Where We Die Nearly 50% of people die in hospitals, many in a critical care setting Rate of dying in the hospital varies by geographic location Hospital utilization, reimbursement for hospice services, and number of physicians predict hospital deaths (not patient preference) Hospice enrollment most predictive of death at home (versus institution) Functional decline predicts death in nursing homes 64

65 Methodologies and Processes to Reduce Rehospitalizations: Palliative Care/Hospice Earlier identification of chronic disease decline within each care setting Evidence-based criteria Palliative care bridge program to follow and intervene between home health and hospice levels of care Integrated/shared team between palliative care and hospice Determine causes of ED visits and increased rehospitalizations 65

66 Defining Specific Goals for Reduction in Readmissions and ED 5-day Readmissions 15-day Readmissions 30-day Readmissions Readmissions by diagnosis by X% HH patient readmissions by X% Readmissions for patients discharged to SNF by X% ED admissions for indigent patients for CHF by X% ED visits for HO patients by X% 66

67 Defining Additional Specific Goals 95% of patients seen by PCP within 5 days of discharge 95% of home health patients on tele-health managed in home (no ED or hospital admission while monitored) Increase hospice length of stay by X% to match industry best practice benchmarks by terminal condition 67

68 More Solutions that SNF, Home Health, and Hospice Offer in Health Care Reform? 68

69 Planning for Reductions in hospital readmission rates and penalties Accountable care organizations and bundled payment Payment and Delivery System Changes Increased care coordination Data-driven PAC decisions More home health technology More effective use of hospice Hospital-physician-post-acute partnerships essential Greater home health-hospice electronic information and connectivity Evidence-based care protocols Fewer home health visits Bundled PAC payment, financial risk/gain sharing, capitated payments Risk/gain sharing with suppliers, manufacturers, physicians Home health and hospice have leading roles 69

70 Effective Transitions of Care are Key: What Model is Right for You? Care Transitions Intervention BOOST: Better Outcomes for Older Adults Interact II: Reduce SNF transfers to hospital RED: Reengineered Discharge Geriatric/Disease Care Management Medical Home on Wheels 70

71 A Final Thought The real voyage of discovery consists not of finding new lands but of seeing the territory with new eyes. Marcel Proust 71

72 Questions? 72

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