4/27/2015. LeadingAge Michigan 2015 Annual Conference Dearborn, MI Monday May 18th, Jon Golm, President

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1 LeadingAge Michigan 2015 Annual Conference Dearborn, MI Monday May 18th, 2015 Jon Golm, President Aging Improving Enriched Post Discharge Services, LLC Outcomes Mike Logan, SVP/COO Wellspring Lutheran Services Realistic Learning Objectives Learn to identify the key elements of a successful patient discharge experience and extension of care post discharge. Learn how to incorporate key clinical outcomes data into a successful value proposition strategy within a bundled payment environment. Understand the benefits of extending the patient engagement experience post discharge in order to increase your overall market share. Health Service Delivery Present Primary Care Chronic Care & Post-acute Care Preventative Health & Wellness Acute Care 3 1

2 Health Service Delivery Future Primary Care Chronic Care & Post-acute Care Preventative Health & Wellness Acute Care 4 FY15 Budget Proposal Penalizes SNFs for high rates of preventable readmissions beginning in FY 2017 up to a 3% reduction. In 2012, acute care hospitals are penalized 1% of their base Medicare rate for not preventing preventable re admissions % penalty % penalty Equalizes payments for certain conditions treated in IRFs and SNFs. For example, hip replacement, knee replacement and pulmonary care beginning in FY Implements Bundled PAC Payment in 2018 for at least HALF of the PAC services. What does this mean? ACOs will be the primary payor source for PAC providers. ACO case management employees will be monitoring their PAC patients and provide care coordination. Increases authority and role of Independent Payment Advisory Board resulting in payment cuts when Medicare spending escalates. 5 Care Delivery Today 35% of Medicare Hospital Discharges are referred to Post acute care providers for additional care. 41% Skilled Nursing Facility 37% Home Health Agency 10% Inpatient Rehab Facility 10% Outpatient Rehab 2% Long term Acute Care Hospital 48% of Post acute care patients receive no further services after their initial post acute care. 29% of Post acute care patients are transferred to another Post acute venue for additional care (e.g., Outpatient Rehabilitation, Home Health). 23% of Post acute care patients are re admitted to the hospital. Source: Gage et al RTI International Examining post acute care relationships in an integrated hospital system, ASPE,

3 Senior Care Resources Senior Care Resources, LLC is an affiliate of LeadingAge Michigan and represents a unique network of aging service providers who have agreed to work collaboratively to formulate an innovative model of care that achieves the IHI Triple Aim. Member participants include skilled nursing facilities, homes for the aged, assisted living facilities, continuing care retirement communities as well as home care and hospice organizations. Primary Strategic Goals Serve as an exclusive health plan contracting agent in order to secure complete provider agreements that meet the approval of the SCR Board of Managers; Develop collaborative relationships with the health plans and health systems; Develop and share best practices for care management, care coordination, quality improvement and cost effectiveness; Develop a uniform set of quality and cost metrics and standards; Collect and analyze data to help providers to demonstrate the effectiveness of their services 7 Learning Objective #1 Post acute Care Relationships will Unravel and Narrow Post Acute Care under Health Reform 8 The Field of Aging Services is Evolving Health Wants Health Needs Preventative Post acute Care Active Adult 55+ Senior Services Acute Care Continuing Care Retirement Communities Program of All Inclusive Care of the Elderly (PACE) State Medicaid program Naturally Community Occurring Based Services Retirement Community Senior Wellness Tele Health & Center Home Technology Home Health Adult Day Services Skilled Nursing Care Palliative Care Outpatient (Hospice) In Patient Services Rehab Services In Patient Acute Care Geriatric Care Independent Manager / Case Living Respite Care Intermediate Sub Acute Care Management Wellness Care Services Programming Assisted Living Dementia Care Dementia Care Housing AL SNF w/services Long Term Acute Hospitalization Source: Ziegler Capital Markets Group 9 3

4 ACO Coordination of Care Must define care coordination processes across and among primary care physicians, home health providers, personal care providers, family members, pharmacy providers and DME providers Pharmacy & DME Skilled Rehab Patient HCBS PCP 10 Benefits of a Successful Discharge Experience Lower re hospitalization rate Family/patient peace of mind Higher patient satisfaction Brand positioning Opportunity to increase referrals Competitive advantage Challenges of Integrating a Successful Patient Discharge Experience Human resources Collaboration Software Consistency Automation/Data Flow/Real Time Affordability 4

5 McLaren/Wellspring Strategic Partnership MCLAREN REFERRAL ACCEPTANCE RATE % % 2015 YTD 75% RETURN RATE TO MCLAREN HOME HEALTH 25 % MCLAREN PATIENT ORIGIN COUNTIES INSURANCE STRATEGIC PARTNERS OUT OF NETWORK INSURANCE CARRIERS Saginaw County Tuscola County Genesse County Medicare Advantage Blue Cross Advantage Medicare Plus Blue AARP BCBS of Michigan Meridian Health Plan Humana United Healthcare Priority Insurance PATIENT EXPERIENCE: PATIENT EXPERIENCERATING: DID STAFF ACCOMMODATE YOUR INDIVIDUAL PREFERENCES? 98% DID THE STAFF ASSIST YOU WITH YOUR TRANSITION BACK HOME? 100% PLEASE RATE THE QUALITY OF CARE YOU RECEIVED ON A 1 5 SCALE? (5 IS HIGHEST QUALITY) HOW DO YOU RATE YOUR OVERALL SATISFACTION ON A 1 5 SCALE? (5 IS HIGHEST QUALITY) WOULD YOU RECOMMEND THE FACILITY? 5 59% 4 41% 5 50% 4 43% 3 7% Yes 91% No 9% Common Problems Little to no contact with rehab patients once they return home Minimal ongoing data on post discharge rehab patients Unaware of recovery progress and issues that may cause rehospitalizations Referral sources are expecting cooperation in reducing rehospitalizations, even after they have left your facility 75% of hospitals penalized last year for readmission rates 5

6 PATIENT EXPERIENCE: PATIENT EXPERIENCERATING: DID YOU UNDERSTAND YOUR DISCHARGE INSTRUCTIONS (INCLUDING MEDICATIONS, DME)???? DO YOUHAVEALLOFYOURMEDICATIONSTHATWERELISTEDON YOUR DISCHARGE INSTRUCTION FORM???? DID THE FACILITY MAKE THE FIRST PRIMARY PHYSICIAN PHONE CALL???? HAS A HOME HEALTH NURSE MADE THEIR FIRST VISIT YET???? HAVE YOU FALLEN???? HAVE YOU HAD INCREASED PAIN???? ARE YOUR HANDS OR FEET SWOLLEN???? ARE YOU HAVING DIFFICULTY BREATHING???? Meet Agnes Acute Care Hospitals will demand PAC to manage patients post discharge. Peace of Mind for both patient and family Post Discharge Patient Engagement Process Improvement & Real Time Data Avoiding Re hospitalization penalties 6

7 Aging Enriched Services Aging Enriched Services (AES) is a full service communication center providing a wide variety of in bound and out bound phone calls for not for profit senior care providers The WeCare Connect Service We connect with your customers and staff primarily through phone calls, but also and mobile app All data is stored in our proprietary software platform Real time access to actionable data through a wide range of dynamic reports LeadingAge Recognized Program exclusive to LeadingAge members 7

8 Rehab Follow Up Calls Keep you connected with your post discharge rehab patients Allow you to extend your care while improving outcomes and reducing rehospitalizations Preset call schedule from time of discharge (~15 questions) 24 hours, 48 hours, 7 days, 21 days Includes questions specific to primary diagnosis Important reminders Patient feedback on care and services Response triggers that generate instant notifications to staff Example Trigger Questions Do you understand/are you following discharge instructions? NO: Triggers Do you have all of your medications from your discharge form? NO: Triggers Is your pain medication controlling your pain? NO: Triggers Do you have a fever or chills? YES: Triggers Have you fallen? YES: Triggers Have you had to seek non emergent medical care? YES: Triggers Have you gone to the emergency room/ stayed overnight at the hospital for any reason? YES: Triggers Primary Diagnosis Example Trigger Questions Orthopedic: Are you having any problems with your incision site? CHF: Are your hands or feet swollen? Are you having any difficulty breathing when at rest? Cardiac: Are you having any difficulty breathing? COPD: Are you having any difficulty breathing when at rest? Pneumonia: Are you coughing up any mucous? Are you having any difficulty breathing? Any YES triggers notification 8

9 Reporting Actionable Data Access dynamic reports to change processes or take action Compare with aggregate peer data Do you have all of your medications from your discharge form? Who is primarily taking care of you at this time? 9

10 Did someone from home care make their first visit yesterday? Issue Tracking & Resolution All triggers and patient feedback are listed in the system Staff can directly enter action plans and resolutions into the AES web based software for each issue Management gets real time status reports Increase staff accountability Improve quality and customer satisfaction Of Course HIPAA compliant SSL Encrypted Cloud based Secure hosting and data backup Role based access AES proprietary software 10

11 Getting Started We know your time is valuable and critical No locked in or minimum cost contracts 10 minute training on how to enter your discharged patients Call agents start making your calls within 1 week Report training scheduled as your data accumulates Summary Helps us meet the TRIPLE AIM GOALS expectation of the ACA Ability to intervene to improve recovery and reduce re hospitalizations Consolidates our issue tracking and resolution process Great differentiator in an increasingly competitive marketplace We love how all positive feedback is collected and automatically sent to marketing Accountability and transparency with our referral sources Eliminated the high cost and untimeliness of our old satisfaction surveys Strengthens relationships with our patients so they return to our facility Peace of mind for our patients and their families Aging Enriched Services (AES) provides an exceptional support in advancing the Triple Aim of the Affordable Care Act. By strengthening communications and relationships in a personcentered manner, WeCare Connect helps us improve quality and decrease costs. Through staying connected to short stay residents post discharge, we are proactively identifying issues that might result in re hospitalization, which we can then act on with our hospital, physician and other post acute care partners. The WeCare Connect Rehab Follow Up call has also provided us with a competitive advantage as hospitals are more comfortable discharging to us because they know that we will continue to monitor their patients after they return home. Paul Winkler President & CEO Presbyterian SeniorCare 11

12 Customer Connections Home Health Start of Care call Discharge call Recertification call Telemonitoring call Private Duty Client Welcome call Service Quality call Skilled Nursing & Rehab Rehab Follow Up call Re Hospitalization Check call Service Quality call Hospice Start of Care call Bereavement call Service Quality call CCRC Service & Amenities Quality call New Resident Move In call Staff Connections Hiring Pre Hire Screening call Pre Hire Process Reminder call New Employee New Hire Post Onboarding call New Hire 60/90 day Touch Point call Existing Employee Employee Satisfaction call Employee Feedback call Resigned/Termination Resigned Employee Feedback call Terminated Employee Feedback call 12