A Brave New World: Lessons Learned From Healthcare Reform. Brandy Shumaker, MBA, LPTA, LNHA Regional Vice President HealthPRO/Heritage

Transcription

1 A Brave New World: Lessons Learned From Healthcare Reform Brandy Shumaker, MBA, LPTA, LNHA Regional Vice President HealthPRO/Heritage 1

2 Learning Objectives Participants will understand: The impact health care reform is having on the post-acute care industry; Key changes in market position & healthcare policy; changes in hospital networks and how they affect the post-acute care continuum; Requirements for being part of a narrowing network; uncovering new opportunities; Expectations for a successful and mutually beneficial partnership; The importance of tracking performance & clinical outcomes measures that drive inclusion to bundles payments programs (beyond simple re-hospitalization rates, LOS); How key performance metrics are critical to unlocking strategic partnerships and ultimately fortifying your future as a member of the network; and Future considerations based on proposed changes and updates to CMS innovations. 2

3 A Brave New World Hospitals and networks seek strategic partnerships to remain financially viable; All providers to focus on Triple Aim model of health care reform; Providers can no longer focus on just the operational metrics; Hospitals & networks will demand objective results & outcomes beyond simply discharge disposition & re-hospitalization statistics; Providers expected to deliver clinical efficacy, efficiency & positive outcomes to justify & fortify long-term relationships. 3

4 THE STATISTICS: Tell the Story of Post-Acute Reform HISTORICALLY: TODAY: By 2018: Post-acute services accounts for ~73% of regional variations in cost /beneficiary 4

5 Hospital Pay For Performance Understanding the Hospital s pain points to begin the conversation: 5

6 SO, WHAT S NEW? Critical Health Care Reform Updates BPCI and newly proposed EPMs Mandatory bundle expansions - EPMs Hip and Femur fractures(shfft) added to current CJR - delayed Mandatory CV Bundles July 2017 delayed until October 2017 Final rule 2017 and 2018 New and expanding Quality Measures Medicare Post Acute Care Value-based Purchasing Act (VBP) MACRA and MIPS- Medicare Access and Chip Reauthorization Act and Merit Based Incentive Payment Advancements in the Impact Act Expanding risk arrangements Narrowing networks continue 6

7 New Mandatory Cardiac Bundles Include patients treated for AMI (MS-DRGs ; MS-DRGs ) and undergoing CABG (MS-DRGs ). Launch in July 2017 in 98 MSAs randomly selected; comments accepted thru September 23. Delayed until October 2017 Emphasis on Cardiac Rehab Services and test impact of incentive payments ($25 for first 11 services; subsequent services reimbursed at $175) Hospitals incentivized to choose preferred HH providers based on: Hospital readmissions reduction initiatives; Sophisticated discharge planning; Strategies to improve patient adherence to cardiac rehab; Star Ratings; Qualitative measures (e.g.: willingness to collaborate, ease of communicating, transparency in sharing performance data, etc.) 7

8 Pennsylvania MSAs 8

9 Five Star 2017 State to National Comparison 2017 State to National Comparison The Triple Aim 2017 PA Avg U.S. Avg. Population Health Patient Experience Reducing Costs OVERALL SURVEY QUALITY S TAFF RN STAFF

10 Medicare Star Ratings Five Star Rating What You Need To Know PA CMS History: Overall Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Overall Axis Title Overall Linear (Overall)

11 Medicare Star Ratings Five Star Rating Where Quality is King PA CMS History: Quality Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Oct-15 Jan-16 Apr-16 Jul-16 Oct-16 Jan-17 Quality Axis Title Quality Linear (Quality)

12 NARROWING NETWORKS: Critical Areas Defined 12

13 Understanding the Impact Across the Care Continuum Hospital SNF Senior Living Increasing hospital readmission penalties Expansion of quality metrics/hac penalties Timely collection and better understanding of PAC metrics Additional payer and convener expectations Usually share performance metrics with partner providers In collection period for SNF readmission penalties Looking to develop own preferred providers Focused on rehospitalization mitigation strategies, including ER diversion programs Have limited access to timely data for evaluation of partners Looking to increase their clinical capabilities to support aging in place models Increasing on campus health service offerings At the center of resident care coordination Looking to collect and improve quality metrics 13

14 Preferred Provider Agreements Preferred Provider Agreements are often specific Do you have the clinical capability to meet this How do you track and report it What is your QAPI plan Nursing and rehab Competencies 14

15 Common Provider Inquiries Advanced clinical capabilities profile Medical and APRN coverage Use of telemedicine Vendor status for ancillary services / timeliness Internal and external care transitions process including liaison expectations Rehab Services: SOC/coverage/service delivery patterns Current partners in provision of care across the continuum (e.g., hospice) Integration of EMR /data collection procedures 15

16 The 90-Day Landscape 30 day 60 day 90 day Hospital Stay 30-day re-hospitalization penalty risk SNF inpatient stay (if applicable) Initiation of Home Health services Hospital satisfaction process PAC follow-up calls hours post discharge Follow up MD visit Completion of the Home Health episode ****Care transition**** Possible follow up outpatient therapy services Follow up MD appointments? SNF satisfaction process ****Care transition**** Initiation of community services- if applicable Risk for readmission continues Risk for readmission continues Follow up MD appointments? Community services? Case management follow-up? Who is accountable for patient follow-ups during this time? Provider coordination is key! 16

17 Conveying Senior Living Value Acknowledge Senior Living Clinical Capabilities Understand Senior Living Potential to Support Hospital Goals View Senior Living as partner Identification and communication Of clinical capabilities to health system Demonstrate potential to partner with hospital system to achieve clinical and financial goals Collaborate to address common challenges and potential share opportunities 17

18 Imperative Clinical Assets of Senior Living Communities Home Health Primary Care Clinical Staffing Rehabilitation 18

19 INTERNAL CARE REDESIGN: The Key to PAC Success Let go of the status quo Accept need for change Plan for future Be nimble and grow Cross continuum communication is the cornerstone for effective internal care redesign Regular meetings, care pathways with primary partners including primary care MDs Reevaluate opportunities with existing liaisons Risk based care plans and service delivery Joint QA plans and meetings (Share metrics, scorecards and plans for improvement) Patient and caregiver health literacy programs (Use evidenced based programs, align with hospital/snf when available) Early and ongoing palliative and hospice services 19

20 WHAT DO YOU NEED? Outcomes! Outcome measures Re-hospitalization rates by diagnosis (30 and 60 day) ER visits without hospitalization Episode length and discharges with outpatient referrals Organizational capability measures Clinical Capabilities profile Care coordination measures Patient engagement measures Home Health CAHPS scores Efficiency measures Average response time to referrals Average LOS by payer/diagnosis Performance Measures Therapy intensity/visits per episode Functional Status Changes (Section GG/CARE Tool- 2017) 30 day cost/episode by diagnostic group Internal Scorecards Quality Measures- sepsis/uti, falls, cognition, pain, meds, etc. Casper Reports 5-Star Ratings- listed by criteria Control group/peer benchmarking/ hospital & national standards 20

21 Clinical Capabilities 21

22 Risk Assessment 22

23 Sample Scorecards Home Health Design of Scorecards & Clinical Capabilities can be effective ways to demonstrate scope of care 23

24 Re-Hospitalization Mitigation Focus Nursing availability 24/7 ER diversion program Frequent communication Videoconferencing Post discharge follow up calls Risk stratified programs 30 day all cause re-hospitalizations from both hospital and SNF Additional support services House calls Telehealth programs Transitional therapy programs 24

25 Strategies to Consider Review and standardize clinical delivery pathways to main diagnostic groups you are currently serving Coordination with service delivery patterns Develop specialized pathways when indicated Develop expanded relationships with hospitals, preferred SNFs and Home Health Agencies Consider all opportunities for care coordination to avoid duplications in service Work to create additional referral patterns Review and Reinvent re-hospitalization mitigation strategies and pathways Collaborate with upstream partners Design internal and external scorecard to measure success and assess areas for improvement Know your market and market expectations 25

26 CASE STUDY: Community Transitional Care Model Van Dyk Healthcare identified a unique niche opportunity to better serve post acute patients by partnering with Valley Home Care (a non-affiliated home health agency) Strategic Plan: Best meet patients needs as they transition thru post acute continuum To create focused care transitions, clinical pathways and joint outcome measures Therapists follow patient from SNF to community based HH resulting in: Improved transitional communication Reduced redundancy of services Improved efficiency of start of service delivery in all settings Improved patient / caregiver satisfaction Created continuity of patient care / preserved functional gains Completed pre-discharge assessment in hospital or SNF before return to home 26

27 ON THE HEALTH CARE REFORM HORIZON: Future Considerations The impact of the new Quality Measures will be significant; Network narrowing will continue; The benchmarks become more competitive, and only organizations with experience / systems in place will make the cut; other PAC communities will be challenged and may not endure the evolution; Implementation of IMPACT tools across PAC settings; Programs will be expanding, you must be ready for them; Programs will include multiple payers; Outcomes, processes and data sharing are keys to success; The fun will continue 27

28 References /medicare-and-medicaid-programs-reform-ofrequirements-for-long-term-care-facilities#h Advisory Board Company

29 IN SUMMARY: Pursue Meaningful Collaborations and Choose Strategic Partners Contact HealthPRO /Heritage with questions/feedback or to learn more about consultative services or strategic planning: Kristy L. Yoskey, MOT, OTR/L, RAC CT Vice President of Clinical Strategies