Fred Benjamin AHCA/NCAL Regional MultifacilityCo- Chair COO Medicalodges, Inc.

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2 Fred Benjamin AHCA/NCAL Regional MultifacilityCo- Chair COO Medicalodges, Inc.

3 Getting Ready for 2016 and Beyond Mark Parkinson, President and CEO

4 Areas to Focus on in 2016 Rehospitalization Your rehospitalization rate starting January 1, 2017 will impact your future Medicaid rate Five-Star Major changes and how to maintain (and even increase) your star level Comprehensive Care for Joint Replacement Started April 1 in only 67 MSAs but could have nationwide implications Mandatory Electronic Staffing Data Collection July 1 will be here soon

5 Panel Discussion: Strategies used by top performing organizations to achieve low rehospitalization rates & 5 stars David Gifford MD MPH May 5 th, 2016

6 Panelist Five Star Patrick Fairbanks- Vetter Health Services Phil Fogg Marquis Rehospitalization Tom Boerboom Welcov Jay Moskowitz Vivage

7 Payment & Referrals Linked to Quality SNF PAC networks & referrals will be tied to SNF quality (e.g. rehospitalization rates) Five Star ratings Hospital payment programs SNF Part A payments linked to quality in Oct 2018 SNF VBP Statute requires CMS to implement a 2% withhold of SNF Part A payments that can be returned based on your rehospitalization rates

8 Five Star determines referrals MA plans creating networks based on Five Star Hospitals & ACO use Five Star to establish networks CMS waives hospital 3 day stay to qualify for Part A SNF stay for SNFs with 3, 4 or 5 Star for hospital discharges from Pioneer ACO hospitals CJR hospitals

9 Protecting Access to Medicare Act (PAMA) of 2014 contains SNF VBP section

10 SNF s Rehospitalizations linked to payment Passed in 2014, PAMA links SNF rehospitalization to SNF Medicare Part A payments Uses a with-hold approach o 2% withhold of SNF Part A payments o SNFs can earn back 2% withhold based on their rehospitalization score; ü Rehospitalization score is a combination of level of achievement and improvement, which ever is better Last year CMS finalized the rehospitalization measure (SNF RM) This year CMS will finalize details about the program

11 11 Timeline for SNF VBP Implementation SNF comment Post s withhol Analyze d Data Collect Data Withhold Starts Baseline Period Jan 2015 Oct 2015 Dec 2015 Oct 2016 Measurement Period Jan 2017 Oct 2017 Dec 2017 Oct 2018 Oct 2019

12 Rehospitalization Score Better of your achievement or improvement score Achievement Score (0 to 100 points) based CY 2017 Bottom 25% = 0 points Top 5% = 100 points All others based on your how much greater your rate is above the rate for the bottom 25%. Improvement Score (0 to 90 points) based CY 2015 vs CY 2017 No improvement = 0 points All others based on how much you close the gap between your baseline rate and the rate for top 5%

13 Rehospitalization Score 100 points 0 points

14 CMS SNF RM Measure Includes only Medicare FFS Part A beneficiaries Used data from Part A Medicare Claims All cause readmission Counts rehospitalizations during 30 day window from admission to the SNF During & after SNF stay (if discharged home prior to 30 days) Excludes elective admits observations stays Risk adjusted o (Actual Predicted) x National average

15 SNF VBP Timeline FY2016 FY2017 FY2018 FY2019 FY 2020 etc CMS Specified Measure (SNF RM) CMS publish how 2% withhold will be determined CMS will specify withhold for FY 2019 CMS provide preview of SNFs Rehospitalization rates 1 st withhold to take effect CMS will specify withhold for next year FY20 2 nd withhold to take effect CMS will specify withhold for next year FY21 NOTE: performance period will be 12 month window that likely will start in July 2016

17 Your Rehospitalization Data See handout Organizations blinded via random ID generator Data presented Organizations rate % Centers above top 25% % Centers below bottom 25%

18 Your Five Star Data See handout Organizations blinded (same rehosp report) Data presented % Centers with at least 3 star rating 2016 % Centers with at least 4 star rating 2016 % Centers with at least 5 star rating 2016 Change in Star ratings from XX to 2016 % Centers with at least 4 stars on Staffing % of Centers with 5 star on quality measures

20 Features of Successful Health Care Organizations Use data to track performance Set goals and make them visible Conduct Root cause analysis Need right philosophy or view point Teams to pilot test new ideas and approaches Pilot tests short time periods with few residents at a time Leadership Empower staff to solve problems Provider resources to staff to achieve goals and solve problems Problem solving and learning Adverse events viewed as opportunities to learn Learn from others

21 Themes of High Performing Health Care Organizations 1. positive organizational culture 2. senior management support 3. effective performance monitoring 4. building and maintaining a proficient workforce 5. effective leaders across the organization 6. expertise-driven practice 7. interdisciplinary teamwork

22 BMC Health ServRes Jun 24;15:244

23 Panel Discussion

24 Tips to avoid 2% PAMA withhold

25 Tips to Success SNF VBP Review all of your rehospitalizations assume 100% were preventable Use AE free excel tracking tool Implement INTERACT program Focus on the purpose of each component Make sure Stop & Watch and SBAR are used consistently Treat rehospitalizations as trigger to have end-of-life discussion

26 INTERACT Goals Prevent conditions from becoming severe enough to require hospitalization (early identification, assessment & management) Manage conditions in the nursing facility without transfer when feasible and safe Improve advance care planning and use of palliative care plans when appropriate 26

27 Member s Change in Rehospitalizations Reduced by 30% Increased by 30% Getting Better No change Getting Worse % Change in Rehospitalization Rates

28 Does End-of-Life Counseling help? Study 1 to evaluate if for patients with three or more hospitalizations in the past 6 months, a palliative care consultation could help Identify realistic goals of care and address barriers to discharge home; Determine whether rehospitalization was consistent with the patient s goals of care or if worsening symptoms would best be managed in the SNF, longterm care, or at home. Results Rehospitalization declining by 19.4% (from 16.5% to 13.3%) Discharges to home increased by 6.4% (from 68.6% to 73.0%) Patients were more 2.45 times more likely to die in the SNF vs hospital 1 JAGS 59: , 2011

29 Pursue AHCA/NCAL Quality Award Program

30 Quality Award Program Based on Baldrige Performance Excellence for Health Care Three levels of distinction 1. Bronze Commitment to Quality (5 pages) 2. Silver Achievement in Quality (20 pages) 3. Gold Excellence in Quality (55 pages) Similar framework to CMS QAPI program Organizations must achieve the award at each level to continue to the next level

31 Value of Quality Award Silver & Gold recipients have better Survey Scores and fewer deficiencies 5 Star Ratings Quality Measures Rehospitalization rates Staff Retention & less turnover Occupancy

32 Quality Award vs Non-Participants Five Star Overall Ratings, April % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% NON- Participants Non-participant 16% 20% 19% 24% 22% >3 Star 64% Bronze BRONZE awardee 14% 17% 25% 24% 20% 69% SILVER/GOLD Silver/gold awardee 4% 4% 11% 32% 49% 82% ê êê êêê êêêê êêêêê

33 Rehospitalizations Lower Silver & Gold

34 Occupancy Higher in Silver & Gold

35 Gross Margin Gross Margin GROSS MARGIN Quality Award Recipients Nation AHCA Members

37 Contact Information David Gifford MD MPH SR VP for Quality & Regulatory Affairs American Health Care Association 120 L St. NW Washington DC Dgifford@ahca.org

38 Break 9:30am 9:45am

39 Nanci Wilson, RPT, DPT, CCI, HHA VP Research and Development Plum Healthcare Group, LLC May 4, 2016

} Hip and knee replacements are the most common inpatient surgeries for the Medicare beneficiaries 2014 Data: 400,000 procedures; $7 billion cost; cost variances from $16,500 to $33,000 Chose 67

40 } Hip and knee replacements are the most common inpatient surgeries for the Medicare beneficiaries 2014 Data: 400,000 procedures; $7 billion cost; cost variances from $16,500 to $33,000 Chose 67 Metropolitan Service Areas in urban regions with a population of at least 50,000 Cost variation was found to be highly correlated to post surgical recovery, specifically Skilled Nursing Facilities

} Mandatory Bundled Program } Introduced 7/9/16; finalized rule November 2015 } MS-DRGs: 469 (Major joint replacement or reattachment of lower extremity with Major Complications or Comorbitities

44 } Mandatory Bundled Program } Introduced 7/9/16; finalized rule November 2015 } MS-DRGs: 469 (Major joint replacement or reattachment of lower extremity with Major Complications or Comorbitities (MCC)) and 470 (Major joint replacement or reattachment of lower extremity without MCC) } 67 Metropolitan Service Areas (Model 1,2,4 BPCI Hospitals who have elected to test the LEJR bundle are excluded ) } Hospitals bear the risk (Not physicians nor PAC providers)

45 } Includes approximately 800 hospitals throughout the nation } 5 year program: initiating April 1, 2016 through December 31, 2020 } 90 day episodic durations } Upside savings only in the first year } BPCI participants with LEJR episode selection will take precedence over CJR

46 } January 26, 2015: Press release from US Department of Health and Human Services - Secretary Sylvia Burwell announced measurable goals and a timeline to move the Medicare program. By 2016: 85% of Medicare claims will be tied to quality or value; 30% of those claims through APMs By 2018: 90% of Medicare claims will be tied to quality or value; 50% of those claims through APMs

47 } Hospital Services (MS-DRGs 469, 470) } Physician Services } Outpatient services, Part B, DME, clinical labs, hospice } Post Hospital discharge for the remainder of the 90 days LTAC, IRF, SNF, Home Health, Hospital re-admissions

48 } Target prices are set prospectively from a 3 year baseline period with a 2-3% discount (established by using actual Medicare FFS claims; rebased every other year to capture changing utilization) First 2 years: blend 2/3 hospital specific and 1/3 regional average spending 3rd year: 1/3 hospital specific and 2/3 regional average spending 4 th & 5 th year: based entirely on the regional average spending

49 } Risk: 1 st year: upside savings only Following years there is upside and downside Benefit of this program: there is no shared savings as with other models such as ACO-MSSP programs } Reconciliation: Retrospective; beginning 2 months after the end of the calendar year

50 } High outlier limits have been established above the regional average episode amount and will be applied to the baseline target price calculations as well as reconciliations } Individual episodes where Medicare payments exceed the outlier limit, the payments will be truncated to that limit

51 } Payback position: Years 2-3 The discount percentage for payback calculations will range from 2% to 0.5% (influenced by the discount % based on the program year and the hospital s quality performance) Years 4-5 Hospitals that are poor quality performers will have a full 3% discounted target for any repayments Top performing hospitals will be held to discount percentage of 1.5%

52 } Year 1: gains only; limited to 5% of the aggregated target amount } Year 2: limited to 5% of the aggregated target amount } Year 3: 10% } Year 4 & 5: 20% } Limits are lower for the Sole Community, Medicare Dependent, and Rural Referral Centers

53 } The rule permits gainsharing with other providers 2 funding streams Reduction in Medicare spending below the target price Internal cost savings } Limits on the gainsharing or repayments with collaborating providers Only 25% of repayment losses can be passed to a single collaborating provider Gainsharing to PGPs are capped at 50% of the total Medicare amounts approved under the fee schedule for services provided during the performance year.

54 } Beneficiary allowances: equipment post discharge } Risk adjustment added for hip fractures } Waivers: Home Visit PPS, telehealth, 3-day hospital stay (Not applicable during 1 st performance year, then to SNFs with 3 star or above for at least 7 of the 12 preceding months) } Federal anti-kickback statue and physician self referral: protect payments made under gainsharing and share risk agreements

55 } Infrastructure Administrative Operational P&Ps, protocol, etc. Support personnel to educate, monitor and ensure proper follow through Health Information Technology Tracking throughout the episode QM and performance reporting Resource availability predictive analysis of necessary changes and capital required } Clinical operations Care re-design Interoperability or collaborative communication systems } Patient engagement in care } Continuum development } Business opportunities

56 } Composite quality performance measure Includes the following and weighted as indicated: Surgical complication within 90 days (NQF#1550) 50% Patient satisfaction (NQF#0166) 40% New outcome measures for LEJR (NQF#1551) - 10% 4 categories are possible: below acceptable, acceptable, good, excellent Must be met in order to receive reconciliation payments

57 } Baseline data has been provided to hospitals } Performance period data will be provided on a minimum of a quarterly basis } CMS will also provide summary data reports on hospital and regional performance (to hospitals only)

58 Hospital General Strategies } Integration with CJR Collaborators: Physicians and Mid Level Providers Physician Group Practices (PGP) Inpatient Rehab Facilities (IRF) Long Term Acute Care (LTAC) Skilled Nursing Facilities (SNF) Home Health Agencies (HHA) Outpatient Services/Supplies } Narrowed Networks Hospital SNF-Specific Strategies } Downward management of SNF Services Aggressive LOS expectations Therapy utilization } Avoidance of SNF Services Send patients home to greatest extent possible Utilize HH and outpatient therapy wherever possible

59 } Facilities in 5 MSAs San Francisco/Oakland/Hayward, CA Modesto, CA Los Angeles/Anaheim/Long Beach,CA Clearfield/Ogden, Utah Provo/Orem, Utah

60 } Understand the implications of the policy from a hospital s perspective } Understand the interactions between all of the new value based programs } Identify the hospitals located within the 5 MSAs that have historically referred to facilities within the Plum family } Strategized a plan in order to become a preferred provider with a possible gainsharing opportunity (Re-admission rates, decreased LOS, complication rates, functional gains, patient satisfaction noted on the providers performance report card)

61 } Plum s BPCI Model 3 Program Development that effectively translates to use within CJR LEJR episode clinical and care pathways, specific EHR observations, risk stratification tool (LACE Tool) Tracking Tool Care Navigators Modified Medical Management Model OversightMD and Interactive Voice Reporting Report Card

62 } Administrator to connect with each hospital within the MSA } Share the care redesign that has been implemented with BPCI } Share a report care with LOS, hospital re-admission percentages and average cost of stay } Propose implementation of surgeon s protocols or use of orthopedic

64 } CJR Overview: } Federal Register - Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services: } AHCA s Final Rule Summary: 20of%20CJR%20Final%20Rule.pdf } Participating Hospitals: } Exclusion List:

65 Payroll Based Journaling (PBJ) in Practice

66 Overview What is PBJ? What are the benefits of PBJ? High Level Requirements Potential Challenges / Risks How Golden Living is Addressing this Requirement 1

67 What is PBJ? A requirement provisioned in the Affordable Care Act that must be met in order to qualify in Medicare and Medicaid programs. All Long Term Health Care Facilities are required to electronically submit staffing and census information each quarter. The data, when combined with census information, will be used to report on the level of staff in each nursing home, and also to report on employee turnover and tenure. CMS has defined the format and criteria related to direct care staffing. First reporting period will start July 1, 2016 with first submission due to CMS by November 15, Submission will be time records from 7/1/16 thru 9/30/16. 2

68 What are the benefits of PBJ? Same basic process across all long term care facilities. More inclusive tracking of direct care staff and associated providers. Consistent reporting processes across the same time frames. Provides an auditable record of staffing. Over time, a better process to achieving a better star rating. Eventual elimination of the 671 form and the accompanying manual processes. 3

69 Golden Living s High Level Requirements Golden Living largest pilot partner with CMS. Introduce a limited amount of process change to our facilities. Build as much automation as possible. Leverage existing systems and processes as much as possible. Limit the investment in new technology. Account for non-employee care / contract hours being provided at each building. Make sure we focus on compliance / accuracy. Use the CMS edits as our guide. 4

70 Golden Living s High Level Process Flow Care Hours Entry Hourly Actuals Salaried hours, less training Contractor actuals from sign-in log Ongoing Review Submission Weekly Review Time clock corrections Pre-submission review of hours Creation of CMS file per facility Submission to CMS portal Post submission review of file Corrections / resubmission of file 5

71 Golden Living s Challenges / Potential Risks A lack of vendor solutions, early on. Additional work load per building for capture / review of non-employee / contractor hours. Time Constraints / Requirements for Creation and transmission of files to / from CMS. Review of CMS responses and resubmission of corrected file. Training / Compliance Implications on 5 star ratings Recurring changes to the process by CMS Potential for legal exposure 6

72 Golden Living s Progress to Date Late 2013, in cooperation with CMS, initial pilot program conducted with different business rules (Salary Swipe) Initial pilot included both Operations and IT efforts. Pilot submission to CMS was successful for two quarters. New CMS rules were issued, late 2014 Working group of GLC Ops, finance and IT was assembled. Three separate technology solutions were evaluated. Web based internally developed solution Kronos / Cognos solution (recommended solution) Realized that this process is best overseen / managed as a centralized back office function for our 300 facilities. 7

73 Golden Living s Progress to Date, cont Business Process Development Decision to manually collect contractor hours was made. Daily entry of these hours into Kronos. Build on existing process of payroll registry review. Develop expanded training and awareness. Registry / contractor vendors notified of new process. Organizing / Creating / Staffing a Centralized Back Office Function. Pilot underway Registry / Contract hours entered into Kronos 5 selected Living Centers Pilot started 3/3/16 8

74 Golden Living s Progress to Date, cont Pilot Update / Observations Data is being collected as planned. Contractor challenges Additional communication Process reinforcement Staff getting acclimated to new process. Waiting for CMS to allow file submission Will test the remaining part of the new process. (the big unknown!) Estimated to begin late June

75 Processes and Supporting Technology 10

76 PBJ Timeline 11

77 Summary Benefitted from working as a pilot partner with CMS. Golden Living chose to use existing systems. Centralization of audit, review and submission will be important due to the size and scope of our operation. Communication with employees and vendors is vital. This process will take a lot of time but we look forward to the benefits. 12

78 Payroll Based Journaling (PBJ) in Practice

79 Fred Benjamin AHCA/NCAL Regional MultifacilityCo- Chair COO Medicalodges, Inc.

The Pain or the Gain?

The Pain or the Gain? Comprehensive Care Joint Replacement (CJR) Model DRG 469 (Major joint replacement with major complications) DRG 470 (Major joint without major complications or comorbidities) Actual