8/28/2018. Presentation agenda CURRENT STATE OF THE POST ACUTE PROVIDER SECTOR. Impact of The Medical Director in Preserving Your Future

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1 Impact of The Medical Director in Preserving Your Future Rajeev Kumar MD FACP Chief Medical Officer Symbria Aaron Hagopian MBA Director of Data Analytics Symbria Copyright 2018 Symbria, Inc. Presentation agenda I. Current state of the post-acute provider sector II. Provider perspective outcomes and strategies that matter III. Market perspective how does your organization compare to the market IV. Best Practices in PALTC; A pilot! V. The role of the Medical Director their big time influence on outcomes CURRENT STATE OF THE POST ACUTE PROVIDER SECTOR 1

2 What do we see Decreasing census due to lower length of stay and bypassing of SNF Fierce competition for med A/post acute patients Rapidly escalating managed care penetration Influence of ACOs and bundles Narrowing of networks Reimbursement shift Managed care Value based purchasing (VBP) PDPM Alternative payment models ACOs Advanced BPCI isnps Risk sharing/gain sharing What matters Outcomes Marketing Maintaining a margin 2

3 Outcomes Star rating Readmission rates Length of stay Return to home Section GG Validate with referral sources Marketing Know what matters to who Differentiate Tell your story Evaluate skill set of marketing personnel Primer on Value Value = Quality/Cost Physician payments will be tied to Value. Hospitals and SNFs already are affected by VBP Improve Value (Improve Quality & Reduce Cost) by reducing readmissions, LOS and improving DC to home with better care coordination and case management Readmissions: Affect VBP for hospitals and SNFs in many ways. They cost a lot and often result in complications. Higher readmissions will also diminish referrals to SNFs and therefore reduce census 3

4 Paradigm shift in PALTC due to Accountable Care and Value Based Purchasing (VBP) Higher acuity of care provided to sicker and more frail patients Increased need for Collaboration and continuity Need to reduce clinical variation Shorter LOS Risk sharing: ACOs and Bundles Value Based Purchasing Switch from Episodic care to Outcomes based care Pay for performance: MIPS & MACRA Census is now driven by these PROVIDER PERSPECTIVE OUTCOMES AND STRATEGIES THAT MATTER Bottom line of post-acute care No current option for PAC to initiate episodes - that may change so be prepared PAC can be a convener in right circumstances All PAC providers should understand who is thinking about bundling in their market and get a seat at the design table Existing Model 3 BPCI participants and forward-thinking PAC providers should approach local hospitals and PGPs to discuss how they can take a portion or all of the post-acute risk through an NPRA Sharing Agreement Accurate risk adjustment is critical 4

5 Gain/risk is permitted: Definition of NPRA Sharing Partner A Participating Practitioner, clinician employed by an ACH participant or Episode Initiator, ACH, PGP, ACO, or postacute provider, that: is participating in BPCI Advanced activities; is identified as an NPRA Sharing Partner on the financial arrangement screening list; and has entered into a written NPRA Sharing Agreement that satisfies all of the applicable requirements of the BPCI Advanced Model Participation Agreement NPRA = Net Payment Reconciliation Amount ACO/PAN common metrics Length of stay Star rating Hospital/ER readmission rate within 7 days Hospital/ER readmission rate within 30 days Home care capture rate Ownership of patient experience and outcomes Outcomes Best Practices Clinician Engagement Network: Hospital, SNF, Home Health, PC and Hospice How do we keep up??? Know where you stand. DATA. 5

6 MARKET PERSPECTIVE HOW DOES YOUR ORGANIZATION COMPARE TO THE MARKET Objective measures for comparison 7 day hospital readmission rate 30 day hospital readmission rate Length of stay Star rating Home care capture rate Data sources Nursing Home Compare Freely available Risk adjusted Fairly current except for the measures we want to review CMS Claims Data Requires a data use agreement/ study Costs money Raw Not risk adjusted (although it can be) 6

7 LeadingAge Ohio districts Central / Southwest Mideast / East Northeast Northwest South / Southwest 7-day readmission rate District Readmission rate Central / Southwest 6.6% Mideast / East 7.0% Northeast 7.6% Northwest 6.4% South / Southwest 7.4% 7.8% 7.6% 7.4% 7.2% 7.0% 6.8% 6.6% 6.4% 6.2% 6.0% 5.8% 30-day readmission rate District Readmission rate Central / Southwest 20.7% Mideast / East 21.8% Northeast 22.8% Northwest 20.1% South / Southwest 21.2% 23.0% 22.5% 22.0% 21.5% 21.0% 20.5% 20.0% 19.5% 19.0% 18.5% 7

8 Length of stay District Average length of stay Central / Southwest 22.7 Mideast / East 23.5 Northeast 22.6 Northwest 23.1 South / Southwest Star rating District Star Rating Central / Southwest 2.6 Mideast / East 3.2 Northeast 3.5 Northwest 3.4 South / Southwest Home care capture rate District Capture rate Central / Southwest 26.4% Mideast / East 28.7% Northeast 30.1% Northwest 26.1% South / Southwest 29.0% 31.0% 30.0% 29.0% 28.0% 27.0% 26.0% 25.0% 24.0% 8

9 30-day readmissions versus Length of Stay Five-Star Home Capture Rate 30 day readmissions vs. length of stay 23.0% % % % 21.0% 20.5% % % % % Central / Southwest Mideast / East Northeast Northwest South / Southwest day readmissions vs. star rating 23.0% % % 21.5% 21.0% 20.5% 20.0% 19.5% % % Central / Southwest Mideast / East Northeast Northwest South / Southwest 0 9

10 30 day readmissions vs. home capture rates 23.0% 31.0% 22.5% 22.0% 21.5% 30.0% 29.0% 21.0% 28.0% 20.5% 27.0% 20.0% 19.5% 19.0% 26.0% 25.0% 18.5% Central / Southwest Mideast / East Northeast Northwest South / Southwest 24.0% Patient Driven Payment Model (PDPM) Effect National FY17: RUG-IV Total Payment: $26,661,528,455 PDPM Total Payment: $26,661,528,456 $1 dollar difference 11 states calculated to have a total of $311 Million less in reimbursement while the other 39 are calculated to increase. PDPM Effect FY17 District $ Diff % Change Central / Southwest $2,116, % Mideast / East $1,384, % Northeast $6,011, % Northwest $4,027, % South / Southwest $1,935, % 2.5% 2.0% 1.5% 1.0% 0.5% 0.0% 10

11 BEST PRACTICES IN POST ACUTE CARE A PILOT! Purpose To study the impact of best practices in post acute care in preventing avoidable rehospitalizations. Study design 6 skilled nursing facilities in the Chicagoland area compared against all of Chicagoland Medicare Part A patients only 1 physician group with regular visits to 4 of the 6 SNFs Symbria Rx for medication reconciliation Standards of practice introduced and monitored for 6 months 11

12 Study protocol Limit any additional work for the communities as much as possible Use multiple sources of verification where possible Use objective measures to study results Study protocol Capture data at 4 phases of the post-acute stay 1. Pre-admission 2. Admission 3. SNF stay 4. Discharge Study protocol required data 1) Pre-admission Warm handoff 2) Admission Admission date/time Initial visit within 24 hours of admission 12

13 Study protocol required data 3) SNF Stay Physician and APN visits Log reasons (scheduled, change of condition etc.) Acute change of condition 4) Discharge Warm handoff Discharge visit within 48 hours of discharge Discharge date/time Study protocol physician group Extract all physician visits from the group s EHR Physicians noted in their EHR: H&P Acute change of condition notifications and marked when a visit was due to change in condition Warm handoffs Discharge visit Study protocol SNF Admissions, discharge and transfers to be tracked for all eligible patients Timeliness of Provider visits Acute change of condition 13

14 Study protocol Symbria Rx Pharmacist reviews all 3 medication lists upon admission (within 60 minutes). Discrepancies are sent back to facility for review. Outcome of discrepancies is reviewed and graded for impact (high, medium, low or none). Results Physician compliance versus their personal readmission rates Medication Reconciliation Community readmission rates Results: Physician Compliance Results are still being analyzed Physician group studied on average had significant drop in personal readmission rates at pilot sites only. Those willing to document change in condition observation and visit date tended to have lower readmission rates than those who did not document as well. 14

15 Results: Medication Reconciliation 134 reviews were conducted by a pharmacist 75 had one or more discrepancies that were sent to the community 57 of those discrepancies were returned with an outcome Analysis of 33 random discrepancies was conducted by a pharmacist and physician to rank them by clinical significance in preventing a hospitalization or adverse event; ranked as low, medium, or high probability High 3 of 33 (9%) Medium 7 of 33 (21%) Low 9 of 33 (27%) Results: Community Readmission Rates (30 Day) 24.7% 23.8% 24.3% 23.1% 19.9% 19.6% 21.9% 22.8% 24.0% 25.7% 21.4% 15.4% 15.3% 14.2% 2016-Q Q Q Q4 1 st full quarter of physician compliance we see a significant drop in readmission rates, then resumes previous trend Note: Rates are NOT risk adjusted Chicagoland 2017-Q3 Pilot Sites THE ROLE OF THE MEDICAL DIRECTOR BIG TIME INFLUENCE ON OUTCOMES 15

16 Key roles of Medical Directors in PALTC Physician leadership Patient care clinical leadership Quality of care Education, information and communication Physician leadership Credentialing Recruitment Establishing policies and procedures and ensuring compliance and peer review Liaison with hospitals, PCPs, hospitalists, home health, palliative care and hospice Patient care clinical leadership Chair QAPI committee Data analytics Root cause analysis 5 star rating Survey process, annual and complaint Physician practice patterns/score cards Readmissions/value based purchasing 16

17 Quality of care Institute best practices Transitions of care and med reconciliations Timely visits by practitioners Warm hand-offs Coordination of care QMs and data analytics reports Education, information and communication In services Education for staff and administration Liaise with ACOs, IDNs, PHOs and insurance companies Advance care planning Accurate data gathering Accurate data reporting (MDS) QUESTIONS? 17