Creating Strategic Alliances for Post-Acute Coordination of Care

Transcription

1 Creating Strategic Alliances for Post-Acute Coordination of Care Kathleen Yosko, PhD President/CEO

2 Wheaton Franciscan Health Care Sole Illinois property Free-standing facility 101 IRF beds 27 SNF beds Outpatient & Day Rehab Marianjoy Network Management Contracts with 3 Inpatient Rehabilitation Units 38 Bed Unit Academic Medical Center 200 SNF Beds within Acute Hospitals and Nursing Homes Marianjoy Medical Group 21 PM&R specialists 6 outpatient clinic sites

3 Impact of Market Consolidation on Referral Sources Referral Sources Now Three FY2014 Admissions By System 20% 17% 28% 35% Cadence Edward/Elm Advocate Others System consolidation dramatically alters our approach New systems (Cadence and Edward/Elmhurst) creates need to re-think resource allocations

4 Creating Strategic Alliances for Post-Acute Coordination of Care Understanding the Market and Regulatory Dynamics at Work Demonstrating the Value of Post-Acute Care Finding Referral Partners

5 Skilled Nursing Facility and Home Health Account for ~70% of PAC Spending Growth From Skilled Nursing Facility Growth of 163% (~14.8% /year) Home Health Growth of 145% (~13.1%/year) Overall IRF Growth of 55% (~5%/year)

6 Aggregate Medicare Spending by Sector Overall Spending 57.1% (~5.7%/year) Overall Post Acute Care 117% (~11.7%/year)

7 Assessment of Patient Outcomes of Rehabilitative Care Provided In Inpatient Rehabilitation Facilities and After Discharge Dobson/DaVanzo When patients are matched on demographic and clinical characteristics, rehabilitation in IRFs leads to lower mortality, fewer readmissions and ER visits, and more days at home(not in a hospital, IRF, SNF, or LTCH) than rehabilitation in SNFs for the same condition. This suggests that the care delivered is not the same between IRFs and SNFs. Therefore, different post-acute care settings affect patient outcomes.

8 The New Reality: Shifting from Volume to Value Fee for service No reward for quality No shared financial risk Acute inpatient hospital focus Stand-alone systems thrive Pay for value (efficiency) Quality impacts reimbursement Partner for shared financial risk Re-aligned incentives encourage coordination of care Scale increases in importance Adapted from AHA Future of Hospitals 2011

9 Stated Priorities of Health Care Reform (ie, What s Driving the Change?) Promote value and accelerate health care delivery system innovation Encourage high-value choices by consumers armed with better information about the quality and cost of care Improve overall function of health care markets Commonwealth Fund 2013

10 Population Health & Patient Management Three Basic Types of Patients High-Risk Patients (usually complex with multiple comorbidities) Goals Avoid high-cost services through lower-cost care management Rising-Risk Patients (conditions no in control, risk escalation) Goals Avoid rising acuity through prophylactic management of conditions Low-Risk Patients (majority of population) Goals Maintain population health and loyalty to the system Adapted from Advisory Board Company 2013

11 Inpatient Use Rates (per 1,000 population) Inpatient Rates Projected to Continue Decline Projections for National Inpatient Use Rates Loosely managed High admitting Moderately managed Medium admitting Well managed Low admitting What will the impact of these trends be on post-acute admissions? Source: Milliman, Kaiser State Health Facts, AHA Copyright 2011 Kaufman, Hall & Associates, Inc. All rights reserved

12 Currently Medical Rehabilitation Accounts for Only 1.2% of Medicare Spending

13 What About the Ongoing Assault on Post-Acute Care? President s Budget Priorities Full Implementation of 75% Rule Site-Neutral Payments Ongoing Market Basket Cuts RACS Increased Competition SNF Outpatient Diversion of Inpatient Referrals

14 So what does all this mean?

15 Implications of the Changing Landscape Importance of the Voice of the Customer/Referral Source Understand the goals/ scorecards of acute-care referral sources What are they reporting, and how can we help improve their outcomes on those measures? Identify potential referral source needs and demonstrate added value to their operations What can we do that they need? Align with organizations to create solutions to define the future How can we balance modeling for the future while minimizing risk?

16 How Can Post-Acute Care Providers Demonstrate Value? Understanding the Voice of the Referring Customer

17 The Value* of Post-Acute Care Past Readmission Era (Now) ACO/Bundle Era (Next Week) Financial DRG driven LOS reduction DRG/LOS plus financial penalty Common bottom line with shared responsibility for cost Quality Site specific state and federal criteria, Marketing/lists In Post Acute setting, matters in so far as it impacts readmissions Impacts finances, efficiency, and market share Access More is Better The right provider can reduce readmissions Balanced by cost effectiveness Efficiency Ease of access, no impact on overall cost or efficiency Access + low readmissions Essential under global payment, readmissions become efficiency measure Reputation No impact No impact Linked based on satisfaction across entire episode of care Patient Satisfaction No tangible impact No impact Sites are interdependent (see reputation) Characteristics of Relationship ACH & PAC providers are silos with no shared incentives ACH now cares about PAC as a partner to reduce readmissions ACH now cares about PAC as a part of financial success Shared Measures None Readmission rates Cost, quality, patient sat. * Schmidt, O Malley, and Flynn AHA Presentation Jan 26, The Value of Post Acute Care: It Depends on When You Ask

18 Patient Function Patient s Post-Acute Care Journey Optimizing Gains at Most Appropriate Level of Care Outpatient Sub-Acute IRF Illness, Accident, Injury Post-Acute Days

19 Post Acute Provider Value Might Be Found in Goals of Partners 21 Med Reconciliation 2013 Advocate Value Report

20 Value of Post-Acute Care Patient-Centered Care Planning vs. Discharge Planning Post-Acute Coordination of Care Goals Acute Expedite patient stabilization & focus treatment on appropriate level of care after discharge Post-Acute Stabilize medically and avoid readmission to Acute Care setting Improve patient function and regain independence to greatest extent possible Return to referring network or medical home Evolving Role of Nurse Navigator

21 Innovations in Post-Acute Care

22 Continuing Assessment Record and Evaluation (CARE) Tool The Consolidated Payment Mechanism CMS mandated development of tool to measure clinical and functional status at: Acute hospital discharge Post acute care admission and discharge 3 year pilot project ended 2011 Analysis and reporting period currently underway Collects information on medical, functional, cognitive impairment, social/environmental factors Attempting to measure severity differences within medical conditions/predict outcomes Viewed as a precursor to a single Post-Acute Care payment system Impact Act 22

23 Current Delivery System Patient Acute Care Hospital LONG TERM HOSPITAL ACUTE REHAB HOSPITAL/UNIT OUTPATIENT REHAB HOME HEALTH CARE Nursing Home SNF HOME OUTPATIENT REHAB HOME HEALTH CARE HOME LTC/ ASSISTED LIVING ACUTE REHAB HOSPITAL/UNIT Hospital SNF OUTPATIENT REHAB OUTPATIENT REHAB HOSPITAL SNF HOME HEALTH CARE HOME HOME HEALTH CARE HOME Nursing Home SNF Nursing Home SNF LTC/ ASSISTED LIVING OUTPATIENT REHAB HOME HEALTH CARE HOME OUTPATIENT REHAB HOME HEALTH CARE ACUTE REHAB HOSPITAL/UNIT OUTPATIENT REHAB HOME HEALTH CARE Nursing Home SNF *AMRPA Revised 12/01/09 LTC/ ASSISTED LIVING HOME Long Term Hospital HOME KEY Nursing Home SNF LTC/ ASSISTED LIVING HOME HEALTH CARE OUTPATIENT REHAB Long Term Hospital ACUTE REHAB Hospital SNF HOME

24 Likely Scenario: Acute Bundle with Post Acute Silos Acute Care Bundle Shared Savings Bundle or FFS IRH/U Freestanding SNF LTACH Hospital Based SNF $ Home Health Care Outpatient Rehab LTC/ Assisted Living HOME

25 Alternative Approach Continuing Care Hospital (CCH) Language in PPACA PART 3-ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS SEC ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID INNOVATION WITHIN CMS. "(1) IN GENERAL.-The CMI shall test payment and service delivery models in accordance with selection criteria under paragraph (2) to determine the effect of applying such models under the applicable title (as defined in subsection (a)(4)(b)) on program expenditures under such titles and the quality of care received by individuals receiving benefits under such title. "(B) 0PPORTUNITIES.-The models described in this subparagraph are the following models: "(xiii) Improving post-acute care through continuing care hospitals that offer inpatient rehabilitation, longterm care hospitals, and home health or skilled nursing care during an inpatient stay and the 30 days immediately following discharge.

26 Better Scenario: Continuing Care Hospital (CCH) Concept Patient Acute Care Hospital Referral Readmissions LOS CCH (IRF, LTCH, Hospital based SNF Levels of Care + X Days Freestanding SNF Home Health Care Outpatient Rehab HOME Case Mix Adjusted CCH Rate CCH Site Neutral Virtual or Real CCH Bundle For Readmissions: Share Payment Reduction *AMRPA Revised 12/01/09 Freestanding SNF Home Health Care HOME Outpatient Rehab LTC/ Assisted Living

27 CCH Benefits to Patients and Providers Patient-Centered Organizes care around the patient s needs and not the individual provider in the postacute care (PAC) setting Quality-Focused Enhances quality of care by eliminating boundaries among the current hospital-based PAC providers and implementing common quality standards, outcome measures, and accountabilities Efficiency Reduces overall costs of PAC delivery while improving the cost benefit, and cost effectiveness of PAC services. Eliminates or consolidates many of the onerous Medicare regulations currently in place (eg, 60% rule, medical necessity documentation) Stability Reduces the various PAC silos that currently exist Maintains consistency across the PAC continuum of care *AMRPA Revised 2013

28 Patient Function Patient s Post-Acute Care Journey Optimizing Gains at Most Appropriate Level of Care Outpatient Sub-Acute Continuing Care Hospital IRF Illness, Accident, Injury Post-Acute Days

29 Building Referral Relationships

30 Evolving Relationship With Acute Care Referral Sources Physicians and Case Managers Bonding Initiating -Physician consultations at Acute Care -Share patients -Current model to direct patients to inpatient rehabilitation Experimentation -Clinical data sharing -Shared intellectual resources -Focus on understanding limits and scope of services Intensifying - Joint team participation across levels -Share IT resources/ access -Focus on standardizing care across levels Integration - Full clinical integration -Common assessment and quality monitoring -Focus on integrating levels of care into a continuum - Long-term contractual relationships -Shared risk -Focused on defined valuebased integration Adapted from Knapp s Relationship Model

31 Defining Our Role Making The Value Tangible

32 Important Considerations to Create Value Reduce What else can be reduced well below industry standards? Eliminate What do we take for granted that should be eliminated? VALUE Create What can be created that the industry doesn t offer? Adapted from Kim & Mauborgne s Blue Ocean Strategy Raise What can be raised well above the industry standards?

33 Intensity of Services Patient-Centered Post Acute Care Continuum Nurse Navigator Acute Care Inpatient Rehab Sub-Acute Rehab Outpatient PM&R consultation to help expedite patient stabilization Coordination of care helps with LOS management Assists in focusing patient treatment goals to aid a seamless transition to the most appropriate post-discharge level of care Maintain medical stability to avoid readmission to Acute Care setting Focus is on intensive rehabilitation with an interdisciplinary team Requires that patient receive three hours of therapy daily (PT/OT/SLP) Includes nursing and neuropsych care as need under the management and oversight of a physiatrist Patients must be medically stable Patients participate in less rigorous therapy regimen (~ 2-3 hours a day, up to 5 days a week ) Therapies available: include PT/OT/SLP Physician management offered as needed, 24 hour nursing on-site 3-night acute care hospital stay required for Medicare reimbursement Services for patients that are able to leave home to attend therapy Day Rehabilitation is intensive, interdisciplinary outpatient rehabilitation Treatment managed by a physician and includes PT/OT/SLP Usually 3-5 hours a day/3-5 days a week Outpatient Therapy is single or multiple discipline care PT/OT/SLP 1-3 days a week 5-7 days days post acute days post acute 20+ days post acute Time

34 Patient-Centered Model for Continuing Care Hospital Services Acute: Focused on care planning and transition of care PATIENT IRF: Intensive rehab and medical care focused on regaining function Sub-Acute: Less intensive rehab and RN care Outpatient: Focused on completing goal attainment and return to normal living

35 Integration Between Acute and Post Acute Care Will Be Critical to Survival Quality Efficiency Financial Access Reputation Relationship Characteristics Patient Satisfaction Shared Measures * Adapted from Schmidt, O Malley, and Flynn AHA Presentation Jan 26, The Value of Post Acute Care: It Depends on When You Ask

36 Marianjoy Strategies For Demonstration of Value Strengthen and formalize relationship with primary referral sources Identify priorities of referral sources Achieve operational excellence through efficiencies and standardization of processes Maintain high levels of satisfaction and clinical quality Take next steps in process of redefining post-acute care in our market place

37 How Marianjoy Defines Itself to Referral Sources Acute Care Coordination Inpatient consultation and coordination of care to assist with early mobilization of patients following accident, illness, or injury Early involvement shown to reduce acute LOS and improve overall outcomes Acute Inpatient Rehabilitation Focused on intensive rehabilitation with an interdisciplinary team physician-led team of specialty nurses and therapists (PT/OT/SLP) Supports patient s medical stability to avoid acute readmission t Sub-Acute Care and Support Provided both at Marianjoy main campus or across a broad network of SNF providers Day Rehabilitation and Comprehensive Outpatient Services Services for patients able to leave home to attend therapy Varying levels of treatment intensity based on patient needs Specialized programs designed to focus on everyday activities Addition of Nurse Navigator

38 The Types of Value We Can Provide Goals of Post-Acute Care Treatment Providing the appropriate Intensity of care based on patient s need Clinically integrate with acute-care referral source to insure consistency across continuum Education Assist patients and family members in understanding condition and care Manage patient and family expectations for recovery Return Assist patient s to gain the highest level of function possible Facilitate their return to original primary care network

39 Opportunities for Coordination of Care Fast-Track Admission/Consult Process Alignment of acute protocols for early PM&R consultation Early identification of patients likely requiring PAC admission Clinical Integration During PAC Communication of patient progress (ie, shared quality monitoring and reporting) Provider integration of protocols for patients with chronic disease (eg, Diabetes, Pain, Medication Monitoring & Management) Patient-center education customized for individual needs Post-Discharge Follow Up Care Assignment/Alignment with primary care physicians Coordination of specialty follow-up visits and therapy needs

40 Conclusions and Steps to Support Future Success Monitor the ever-changing landscape of Health Care Reform Follow legislative and judiciary action Meet with Acute Care partners and evolve an inclusion strategy Establish a stronger relationship focusing on the added value PAC can bring to the changes facing Acute Care providers Know their scorecard and define how you can help them achieve their goals Develop cost structures which reduce costs and maximizes outcomes At the end of the day outcomes costs will likely define the value equation Be involved nationally through AHA/AMRPA and Trade Association Activities Provides a voice for your concerns and ideas Acute care providers are relying on your insights

41 Questions?