Strategic Options for Hospice and Palliative Care in the Era of Accountable Care Organizations NHPCO 26 th Annual Management & Leadership Conference April 2011 1
Presenters Jade Gong, MBA, RN Vice President, Strategic Initiatives Health Dimensions Group 4012 Nelly Custis Drive, Arlington, VA 22207 703-243-7391; jadeg@hdgi1.com Kyle R. Allen, DO, AGSF Chief, Division of Geriatric Medicine Medical Director Post Acute & Senior Services Summa Health System 75 Arch Street, Ste G1, Akron, OH 44303 330-375-3747; allenk@summahealth.org Jane Gorwin, RN, BSN, LNC, MA Senior Home Health and Hospice Consultant Health Dimensions Group 4400 Baker Rd, Ste 100, Minneapolis, MN 55343 760-250-4558; janeg@hdgi1.com 2
Topics Health care reform and its impact on postacute and aging services providers Strategies for hospice and palliative care providers PEACE model of care PACE as an accountable care organization (ACO) model 3
Drivers of Partnerships for Future Success for Post-Acute Providers Accountable Care Organizations Bundled Payment Hospital Readmission Penalties 4
Home Health 30-Day Hospital Readmissions by State 5
Why Post-Acute Is Key to Managing Health Care Costs 6
Post-Acute Payments by Venue and Condition In ACO-land, expect greater use of subacute skilled nursing and home health Hospital Condition PAC Average OP Rehab Home Health SNF IRF LTCH Stroke $10,680 $569 $2,478 $8,527 $18,923 $22,070 Hip & Femur Procedures for Trauma $10,392 $1,217 $2,595 $8,761 $16,018 $22,738 Cardiac Bypass with Catheterization $5,230 $837 $1,778 $5,737 $14,631 $24,526 Heart Failure $4,144 $612 $1,611 $6,462 $14,698 $20,236 Note: Data are preliminary and subject to change. Numbers reflect standardized payment rates and therefore do not reflect provider-specific adjustments such as the area wage index or DSH payment adjustments. Spending captures payments for all PAC services that occur within 30 days of discharge from the hospital. Source: MedPAC analysis of 5% Medicare claims files 2004 to 2006. 7
ACOs One of the Ways Health Care Reform will Bend the Cost Curve Payment Changes Reimbursement cuts Value-based reimbursement Bundled payments Care Delivery System Changes Accountable care organizations Medical homes Health information exchange 8
How ACOs Provide Accountable Care in a New Delivery System Capacity to deliver continuum of care, grounded in strong primary care and minimal use of high-cost institutional settings Payment rewards slower cost growth so long as combined with improvements in quality Reliable measures of a person s health assure that savings are achieved through improvements in care 9
Accountable Care Organizations Medicare/Other Payers 5,000+ Medicare fee-for-service beneficiaries Accountable for all Medicare Part A and Part B service Physician Network Accountable Care Organization Continuum of Care Ancillaries Requires integrated provider network; successful chronic care management; comprehensive home-based services EHR across settings Medical Group(s) Community MDs Medical Home Outpatient services Skilled nursing Home health Hospice Geriatric care management Non-institutional home-based services Prevention and wellness programs 10
Medicare ACOs in 2012, But Many ACO Demonstrations Now 3 Medicare Pilot Sites Many Private Payer Pilots Roanoke, VA Medica and Insurers Louisville, KY Tucson, AZ Torrance, CA 11
Medicare ACO Eligibility Who Can Be An ACO? Group practices Networks of individual practices Partnerships or JV arrangements between hospitals and ACO professionals Hospitals employing ACO professionals Such other groups of providers of services and suppliers as the Secretary determines appropriate ACO Professionals Doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State Physician assistant, nurse practitioner, or clinical nurse specialist Certified registered nurse anesthetist Certified nurse-midwife Clinical social worker Clinical psychologist Registered dietitian or nutrition professional 12
How Do You Qualify as a Medicare ACO? Become accountable for quality, cost, and overall care Formal legal structure to receive and distribute payments for shared savings Have enough primary care physicians Have a minimum of 5,000 beneficiaries Leadership and management structure that includes clinical and administrative systems Processes to promote evidence-based medicine and patient engagement, report on quality/cost measures, and coordinate care Meet patient-centeredness criteria Minimum three-year contract with Medicare 13
New Payment Model for Medicare ACOs: Shared Savings Current per-capita spending for assigned patients determined from claims for past three years Spending target is determined (Medicare) 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 14 Institute 14
Sample ACO Calculation Year 1 Year 2 Year 3 Quality Standards Met? Cost Savings Achieved? Medicare FFS Payment ACO bonus payment that year? Yes No Yes No Yes* Yes* Medicare Fee Schedule No Medicare Fee Schedule No Medicare Fee Schedule Yes X% of Savings** An organization must meet quality standards AND achieve cost savings to earn bonus payments * Actual costs for assigned population are less than pre-set expected costs based on riskadjusted trends ** PGP demonstration gave groups 80% of savings; actual split for ACOs to be determined 15
Three Strategic Partnership Imperatives for Post-Acute and Aging Services Providers Partner with hospitals and ACOs to address biggest concerns: Length of stay Pending re-admission penalties Partner with other providers to enhance your post-acute and home care continuum Partner with like providers to create one-stop chronic care management Strategy includes care transitions management and electronic health record 16
The New Reality for Aging Service Providers: Partnerships with Other Providers Provide an array of aging services, not just skilled nursing and long-term care; be the navigator or partner for services or venues you do not offer = care management Become preferred partner for integrated health systems or ACOs from whence Medicare dollars will flow 17
Strategies for ACO and Hospice- Palliative Care Relationships Jane Gorwin, RN, BS, MA Health Dimensions Group 18
How Do Palliative and Hospice Care Fit into an ACO Model? Laying the foundation for a palliative care framework first 19
How Do Palliative and Hospice Care Fit into an ACO Model? (continued) Wellness Specific Disease Intervention Chronic Disease Management Focus still on interventions only Interventional Palliation Combination medical treatment, comfort care Hospice Focus on comfort, quality of life, symptom control 20
What Needs to Change? The basic way we work with patients, especially in one of these three categories: Chronic Disease Management Need to better identify where a patient is within this trajectory Enhance acute to community-based transitional care coordination Interventional Palliation Educate/enlighten patient and family earlier Provide options for patient/family choice Hospice Care Marketing strategy and partnerships with hospitals and PCP 21
What Do ACOs Want from Post-Acute and Aging Services Providers? Not likely to be a partner, with skin in the game, but rather a contractor ACOs will want few PAC provider-contractors who: Can demonstrate value (quality and cost reductions) with credible data Few 30-day hospital readmissions High volume of discharges to home Have evidence-based clinical programs for most common SNF-HHA discharges and a care transitions program between venues Have facilities/services that are geographically convenient to primary care physicians and hospitals Already have positive relationship with hospitals and PCPs Willing and able to be part of health information exchange 22
Hospice: Well Positioned for the Future Aging demographics baby boomers Chronic disease explosion Key offenders: Congestive Heart Failure Diabetes Chronic Obstructive Pulmonary Disorder Pneumonia Parkinson s ALS Dementias Depression 23
Not-for-Profit Accountable Care Readiness Strategy: Aging Services Provider Partnerships Create a not-for-profit consortium within a market that has more value than any organization individually Benefits: One-stop shopping for hospitals and ACOs Benchmarks for hospital readmissions and ongoing comparison Post-acute provider partnerships in geographic areas creating care continuum with standardized protocols Care management projects Bundling experiments with Medicare Advantage Plans as we learn to take risks Apply for grants for demonstration projects 24
To Be a Player in the ACO Arena You have to be ahead of the curve in developing relationships with hospitals, primary care physician groups, and even insurers/managed care Partnerships must be value-based: what do you bring? Hospital readmission reduction Cost reductions for post-acute episode of care Care coordination across the continuum Chronic care management to reduce ED visits and hospitalizations Electronic information exchange Ability to share payment risk based on outcomes 25
Define Your Services: What are You Providing Within the Continuum? Palliative Care: interventional and comfort care focus Palliative care in patient hospital versus home health Hospice Care: comfort care and quality of life focus Routine hospice care Respite Continuous care General in patient 26
Overarching Strategy of Why You Will Benefit an ACO Ability to reduce 30-day (+) hospital readmissions Ability to reduce emergency/urgent care visits Reduce hospital length of stay Potentially decrease in-patient hospital mortality rates KNOW YOUR DATA AND SHARE IT! 27
Critical Elements for a Successful Strategy Implementation Evidence-based practice (interventional PC and hospice) Use of aligned, care protocols Patient/family centered self-care management driven Coaching: motivational interviewing skills Patient/Family self goal-setting Medication awareness (PHR) Self symptom management and interventions 28
Critical Elements for Successful Strategy An integrated care management and health system navigator approach Effective electronic information exchange From provider to provider Patient/family to provider (tele-health, bio-sensory technology, video-audio interface) Real-time data management decision-making 29
What are Some of the Current Challenges? Current fiscal realities (shrinking margins) Hospitals Home Health Hospice Regulations and future Medicare payment models are always behind Hospice: limited to 6-month end-of-life prognosis Palliative care: not officially recognized No specific reimbursement for care management models..yet 30
More Challenges Need for highly sophisticated data management information systems that will: Enhance traditional quality care indicators (pain management, satisfaction surveys post-death) Provide predictive statistical modeling as relates to primary diagnoses and co-morbid conditions Help to identify patients clinical and social needs within their trajectory (chronic disease management, interventional palliation, hospice) 31
Next Steps to Move Your Strategy Forward Evaluate your current services Do you provide what your hospital(s) and PCP(s) need? Do you collect the right data? Research your most likely ACO partners What are their specific needs? Get their data: mortality rates, lengths of stay, top chronic diseases causing the readmissions 32
Moving Your Strategy Forward Develop your presentation to meet with potential ACO partners: hospitals and PCPs Be specific with your data to show how YOU will be essential to their accountable care organization Explore current funding opportunities: Shared risk ventures with Medicare Advantage plans Grants Demonstration projects Be proactive to get a seat at the table and start now! 33
If everything seems under control, you're just not going fast enough Mario Andretti. 34
PEACE TRIAL Promoting Effective Advanced Care for Elders Kyle R. Allen, DO* Steven Radwany, MD* Susan Hazelett, MS, RN* Denise Ertle, MSN, RN, CNS* * Susan Fosnight, RPh, CGP, BCPS* Pamela Moore, PharmD, BCPS* Patricia Purcell, MSN, RN, CNS* * * Barbara Palmisano, MA * * * * Ruth Ludwick, PhD, RN.C, CNS* * * * * * Summa Health System, Health Services Research and Education Institute * * Area Agency on Aging 10B, Inc. * * * The University of Akron * * * * Northeastern Ohio Universities Colleges of Medicine and Pharmacy * * * * * Summa Affiliate, Robinson Memorial Hospital The PEACE Trial is supported by The National Palliative Care Research Center & the Summa Foundation Area Agency on Aging, 10B, Inc. Summa Health System NEOUCOM Kent State University The University of Akron
Key Points A National Palliative Care Research Center-funded trial ($154,000 over 2 years) Collaboration between The University of Akron, Kent State University, Northeastern Ohio Universities Colleges of Medicine and Pharmacy, the Area Agency on Aging 10B Inc., and Summa Health System A randomized controlled pilot study A palliative care case management intervention for PASSPORT consumers Intervention involves collaborative care between a hospital-based interdisciplinary team, the Area Agency on Aging, and the consumer s PCP 36
The S.A.G.E. Project (Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project: A Successful Health Collaborative (Est. 1995) Improving Care through Collaboration: Integration of the Aging Network and Acute and Post Acute Medical Care Services 37
SAGE Goal Goal: To integrate a comprehensive geriatric hospital-based clinical program with the community aging network to improve the health, functional status, and prevent institutionalization of older adults at risk for nursing home placement. S.A.G.E. Project is an example of how to partner with a community agency: Acute hospital and medical care services; and, A community-based Area Agency on Aging 38
The SAGE Project A 15-year collaboration partnership Multiple initiatives, a cast of thousands, well maybe 100s, but you get the point Common goal to improve the health, well being and functional status of Akron region frail older adult population Identified major gaps in the continuum and care processes from each partner Searched and defined mutual benefits Shared mutual threats and concerns Built trust Grew and multiplied to other regional systems Communication, communication, communication Vision, Vision, Vision, Vision 39
Area Agency on Aging Programs Mission: To provide older adults andtheir caregivers long-term care choices, consumer protection and education so they can achieve the highest possible quality of life. Aging Resource Center PASSPORT Home Care Medicaid Waiver Assisted Living Medicaid Waiver Community Services Division Care Coordination Alzheimer s Respite Program Family Caregiver Support Elder Rights Division 40
Who were the partners? Summa Health System Geriatric Medicine Department 6 Hospital System 2,027 licensed beds 61,800 admissions Level 1 Trauma 113,059 ED visits Community Locations 4 outpatient health centers Wellness Institute medically-based fitness Health Plan 110,000 Covered Lives 16,000 Medicare Risk HMO Major Teaching Residency and Fellowship Program Post Acute/Senior Service Line 10 Certified Geriatricians 12 Geriatric Certified APNs Continuum of Care Acute Care/Acute Rehab/ LTAC/ SNF Beds Home Care/ Hospice/ Home Infusion/ HME Summa Akron City Hospital Summa Western Reserve Hospital Summa St. Thomas Hospital SummaCare, Inc. 41
Summa s Institute for Seniors and Post-Acute Care 42
Transitions of Care: AD-LIFE, PEACE, and Bridge to Home The Primary Care Physician Medical model Limited time with patient AD-LIFE, PEACE, & SummaCare s Bridge to Home The Area Agency on Aging Social service model but now becoming more integrated Care management and services for long-term care Limited interaction with PCP Addresses functional abilities/geriatric syndromes but challenged with high risk enrollees with multiple chronic illnesses The Center for Senior Health and Senior Services Consult and support across the continuum including outpatient, inpatient, house calls and skilled/long- term care Addresses medical and psychosocial Post-discharge care management of low income frail elderly Advance care planning and palliative care/geriatric syndrome management for low income seniors Nurse care manager activation of client Collaboration between a hospital-based interdisciplinary team, Area Agency on Aging, and PCP Integration of acute and longterm care Transitional care to reduce readmissions AD-LIFE trial is supported by the Agency for Healthcare Research and Quality Grant # R01 HS014539. PEACE is funded by the National Palliative Care Research Center. Both are supported by the Summa Foundation. Bridge to Home is funded by SummaCare. 43
Purpose of the PEACE Pilot Study This randomized pilot study will determine the feasibility of a fully powered study to test the effectiveness of an in-home interdisciplinary palliative care management intervention to improve the quality of palliative care for consumers of Ohio s communitybased long-term care Medicaid waiver program, PASSPORT 44
Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System Hospitalization prompting advance care decisions (often by the family) Community-dwelling chronically ill patient with poor symptom control and coordination of care whose advance care wishes are rarely documented E xacerbation of chronic illness 45
Palliative Care and Advance Care Planning Independent Management Advance Care Planning Hospice Symptom Management Disease Management Diagnosis Death 46
Patient Centered Care Well Older Adults Cancer Gait Disorders Stroke Preventive care Advanced Organ Failure Stable chronic dx Chronic Critical Illness Geriatric syndromes Frailty Peri-operative care Dementia Osteoporosis AIDS TBI Cancer (<65) Genetic/ Developmental Disorders Pediatric Oncology Cystic Fibrosis Morrison, S. National Palliative Care Research Center 47
Target Population for the PEACE Pilot Study New PASSPORT enrollees >60 years old with one of the following diseases and the corresponding level of severity will be eligible for inclusion: CHF and being actively treated (AHA class C) COPD and on home O 2 or nebulizer treatments Diabetes with renal disease, neuropathy, visual problems, or CAD End-stage liver disease, cirrhosis Cancer (active, not history of) except skin cancer Renal disease on dialysis ALS with history of aspiration Pulmonary hypertension Parkinson s disease (stages 3 and 4) 48
Enrollment RN assessors from the AAoA will screen consumers at the time of their initial PASSPORT assessment RN assessor will obtain HIPAA release Research nurse will obtain consent and obtain baseline measures Consumers will be randomized to usual care or the intervention group 49
PEACE Intervention Intervention E ach Care Manager will have approximately 10 consumers Care Manager will make 2 home visits centered on symptom assessment & advance care planning Care Manager will take her assessment findings to an interdisciplinary team Team produces recommendations for consumer & PCP Care Manager accompanies consumer to 1 PCP visit to assist consumer in discussing advance care goals with PCP Care Manager & Palliative Care N urse supervisor make another home visit to begin implementation of plan of care Care Manager follows-up with consumer monthly for 1 yr to assure team recommendations are implemented 50
Outcomes Measured at 3, 6, 9 and 12 months 5 Domains Measurements made to determine domain score 1) Symptom management Memorial Symptom Assessment Scale 2) Quality of life/death QUAL-E 3) Relationships Meaning in Life Scale 4) Decision making; care planning; continuity; communication; patient activation Palliative Outcome Scale, Patient Activation Measure 5) Depression and anxiety Hospital Anxiety and Depression Scale 51
Challenges Getting buy-in from case managers Education and knowledge gaps Changing culture of the AAA Needing to get more top-down support for the project so AAA CM supported for the project Not over medicalizing the care plans 52
Successes Strong working relationship and commitment by the AAoA A team that has gone from forming to storming, not yet norming Culture sensitivity and knowledge between aging network and acute care sector becoming bilingual Outgrowths of other educational projects, additional funding for PC research, and bridging the community network and acute sector 53
Additional PEACE Related Projects A survey of knowledge and attitudes about ACP and PC sent to all area PCPs. Funded by the Summa Foundation. A statewide survey of all care managers at all AAoA that will examine knowledge and attitudes regarding ACP and PC. Funded by Northeastern Ohio Universities Colleges of Medicine and Pharmacy. An educational program to teach AAoA care managers how to bring PC upstream in the disease process. Funded by the First Merit Foundation. 54
Contact Information Principal and Co-Investigator: Kyle R. Allen, DO, AGSF Chief, Division of Geriatric Medicine Medical Director Post Acute & Senior Services Summa Health System 75 Arch Street, Suite G1 Akron, Ohio 44303 330-375-3747 Email: allenk@summahealth.org Co-Investigator: Steven Radwany, MD Medical Director Hospice and Palliative Care 75 Arch Street Suite G-1 Akron, Ohio 44304 330-375-3747 Email: radwanys@summahealth.org Co- Investigator and Project Manager: Sue Hazelett, MS, RN Manager HSREI Summa Health System 75 Arch Street, Suite G1 Akron, Ohio 44304 330-375-3051 Email: hazelets@summahealth.org 55
PACE as an ACO Model of Care Jade Gong, MBA, RN Health Dimensions Group 56
Comprehensive Services Integrates preventive, acute, and long-term care services All Medicare and Medicaid services, plus community long-term care services No benefit limitations, co-payments, or deductibles PACE is the only fully capitated and integrated Medicare and Medicaid program to serve frail nursing home eligibles 57
PACE Eligibility Criteria 55 years of age or older Live in a PACE service area Be certified as eligible to receive a nursing home level of care Be able to live safely in the community at point of enrollment 58
PACE Enrollees Snapshot Mean Age 80 Gender Average Number of Basic ADL Deficits 75% women 3.5 Cognitive Impairment 63% Average Life Expectancy 4.5 years 59
PACE Nationally 79 PACE organizations and growing 31 states 20,000 PACE participants 100 to 2,000 participants per program 60
Well-functioning IDT Key to PACE Success Home Care Social Services Pharmacy Nutrition Activities Personal Care Primary Care OT/PT Transportation 61
PACE Network Specialty Care Hospital Care Medication Supplies Subacute Care DME Personal Care Transport ation Meals 62
PACE Payment Sources Payment features are unique Capitated payment system per member per month (PMPM) Combines funding from multiple payor sources to meet all participant needs 63
Integrated Financing Medicare Medicaid Medicare Part D Pooled Capitation (PMPM) Private Pay 64
Place of Death in PACE 34% 21% 45% 53% Older Americans 20% Hospital Home Nursing Home 65
Survival in PACE South Carolina Two counties PACE group same baseline risk as NH group PACE group higher baseline risk than Waiver group 5 4 3 2 1 0 4.2 3.5 2.3 Median Survival (years) NH Waiver PACE 66
PACE Core Competencies Provider-based model Tightly controlled care management and utilization systems Serves a nursing home-eligible population in the community when enrolled Good health care outcomes, high enrollee satisfaction, and low disenrollment rates Established existing program with a proven track record 67
Opportunities for Hospice and PACE Collaboration in the Delivery of Person-Centered Care 68
Exploring Common Ground: PACE and Hospice Patient centered Holistic approach to care Utilizes interdisciplinary teams Supports caregivers Utilizes managed care efficiency Receives capitated payment (per diem or per month) 69
Why Should Hospice Develop PACE Programs? Meet community needs with broader care options for frail seniors at the end of life Build upon community awareness of hospice Draw upon greater stability of multiple revenue streams Greater efficiency through shared allocation of administrative expenses 70
PACE with Hospice Opportunities for Collaboration Each provider can focus on providing patient-centered care Some hospice referrals may be more appropriate for PACE Some PACE referrals may be more appropriate for hospice PACE can utilize hospice expertise through contracting: Pain and symptom consultation/pain management Use of hospice interdisciplinary team (IDT) Training in end-of-life care Inpatient hospice facility if needed by participant 71