Navigating Through the Continuum of Care Are we effective stewards as professionals in care resource management in the care continuum?

Transcription

1 Navigating Through the Continuum of Care Are we effective stewards as professionals in care resource management in the care continuum? DR. Susan P. Smith, DHA, RN, MSN

2 Objectives The learner will understand the Healthcare Continuum and how payment mechanisms differ The learner will understand that as reimbursement moves to value-based models, coordination healthcare providers is essential The learner will be able to understand and describe what is impacting healthcare resources The learner will have an understanding and describe different levels of healthcare delivery systems and impact on discharge options The learner will have a basic understanding of Provider payment systems and impact on patient care and the patient Understand Effective Stewardship as physicians and professionals are engaged in care resource management in the healthcare delivery system

3 How can we wrap our hands around this thing called the Healthcare System?

4 SUSTAINABILITY. A systems thinking approach Sustainability: is often described as an Iron Triangle. Some theorists say a triangle demonstrates that there are three dimensions on any project or process. The Iron Triangle" means that, in equilibrium, increasing the burden on the health care system in any one of these dimensions can compromise one or both of the other dimensions, regardless of the amount that is spent on health care.

5 We are experiencing now: Technology Advances Economics and Healthcare Disparities Advances in Health Care Growing Populations of Chronic Ill Environmental Changes and Exposures Regulations and Rules Lifestyles / Social and Genetic Makeup

6 Life Expectancy by State 80.0 to 81.3 years 79.5 to 79.9 years 78.4 to years 77.2 to years 75.0 to years

7 Projected Age 65 Years and Older, Are our systems ready? Are You? Source: U.S. Bureau of the Census.

8 Assets Deficits Conceptual Framework - Dynamic Model of Frailty The guide to patient centered care

9 DYNAMIC MODEL OF FRAILTY Assets (that maintain people s independence) Health Functional Capacity Positive Attitude toward health and other resources (social, spiritual, financial, and environmental). Questionable Attitude toward health by self or others, limited resources Deficits (that threaten independence) Disease Chronic Disease Disability Dependence on Others - amount of burden on the caregiver 4 Levels of Dynamic Model of Frailty 1 ST - Well elderly have assets that outweigh the deficits 2 ND - Elderly who have deficits that outweigh the assets and can no longer maintain their independence in the community and live in institutions 3 RD - Whose assets and deficits are in a precarious balance and are frail and still live in the community *4 TH - Whose deficits have taken over their assets, they are critically chronically ill, in the hospital, and it is questionable at what level of frailty will they be discharged Source. Dynamic Model of Frailty in Elderly People. Rockwood, K., Fox, R., Stolee, P., Robertson, D., & Beattie, B. (1994) Frailty in elderly people: an evolving concept. Canadian Medical Association Journal (150)4,

10 Determinants Of Health Socioeconomic, cultural and environmental conditions Living and working conditions Social and community influences Individual lifestyle factors Age, sex and hereditary factors ASSETS DEFICITS Balance (wellness) occurs when deficits are contained and the person s assets function at their optimal state. (Dynamic Model of Frailty). World Health Organization Source: Adapted from Whitehead M, Dahlgren G. What can we do about inequalities in health? Lancet, 1991, 338:

11 Hospitalization During hospitalization, patients are commonly deprived of sleep, experience disruption of normal circadian rhythms, are nourished poorly, have pain and discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognitions and physical function, and become deconditioned by bed rest or inactivity. ASSETS DEFICITS New England Journal of Medicine. 368:2. January 10, 2013, Harlan M. Krumholz, M.D

12 The time is right for transforming care and payment systems the status quo is not sustainable. The new sustainable Patient Centered Iron Triangle Quality & Stewardship Coordinated Provider Care Delivery Maximized Well Being

13 What impacts Wellness?

14 Definitions: Chronic Illness: Condition that lasts a year or longer, limits activity, and may require ongoing care Prevalence of chronic illness is increasing in middle aged people and earlier in older aged persons Terminal illness: Results in the death of a person regardless of treatment intervention and when the estimated life expectancy is six months or less Many people with chronic illnesses, usually more than one, face problems including: High medical costs Financial issues Loss of time at work / Loss of income Added burdens for family, community, and the health care delivery system

15 Comorbidities and the Chronically Ill Patient Comorbidities (disease or conditions) that coexist with a primary disease interact with one another or become a separate disease or condition Medications or other treatment modalities for the comorbidity may interfere in the treatment of other comorbidities HRR/CC_HRR_Dashboard.html

16 The Chronically Ill Medicare Patient The average Medicare patient with 1 chronic condition will see 4 different physicians a year The average Medicare patient with 5 or more chronic conditions will see more than 10 different physicians a year Bodenheimer, Chen, & Bennett, Medicare beneficiaries with 5 or more chronic conditions account for the largest percentage of expenditures.

17 Risk Prediction for Hospital Readmission Research suggest that risk prediction models generally fail to properly consider all the variables that combine with clinical factors to determine readmission risk: 1. Medical History and Current Medical Diagnoses 2. Functional Level variables 3. Social Variables 4. Behavioral Variables (Kansagara D, Englander H, Salanitro A, Kagen, D., Theobald, C., Freeman, M., & Kripalani, S. 2011).

18 Medicare Payment A, B, C, D

19 Medicare A, B, C, D s Medicare Part A covers: Hospitals Inpatient care Short Term Acute (STACH) Critical Access Hospitals (CAH) Long Term Acute (LTCH) Inpatient Rehabilitation Hospital (IRF) Skilled Nursing Facility care (SNF) Hospice Care Home Health Care When hospitalized, a participant pays a deductible /co-pay for each benefit period A benefit period starts the day of admission as an inpatient and ends when a patient has not received any inpatient care for 60 days in a row

20 Medicare Part A - Benefit Period 150 HOSPITAL BENEFIT DAYS Year 2016 o Deductible $1,288 for each benefit period (up $28 from 2015) o Full-Days: Co-pay $0 o Co-Days Co-pay $322 per day (increase $7 from 2015) o o o Days 1-90 will rejuvenate after a patient has been out of the hospital for 60 consecutive days Lifetime Reserve Days" 60 Days" Co-Pay $644 for days These days never rejuvenate. Must "Hospital Issued Notice of Non-coverage" (HINN) (increase of $14 per day from 2015) Beyond lifetime reserve days: all costs Medicare exhaust HOME HEALTH - Medicare A - Pays 100% per 60 day episode HOSPICE - Medicare A - Pays 100% some medications excluded

21 Medicare & SNF Medicare Part A total SNF days Patient will pay (2016) $0 for the first 20 days each benefit period $161 per day (increase $3.50 per day from 2015) for days each benefit period All (100%) costs for each day after >100 days in a benefit period These days will rejuvenate if the patient stays out of the hospital and SNF for 60 consecutive days Medicare DOES NOT pay for Nursing Home, Assisted Living or Custodial Care

22 Medicare B, C, & D Medicare Part B covers Services from doctors and other health care providers Outpatient therapy & diagnostic services Durable medical equipment Some preventive services 20% Co-pay Medicare Part C - Medicare Advantage Plans Administered by Medicare-approved third party payors Includes all benefits under Part A and Part B Usually includes RX coverage (Part D) Extra benefits and services at extra cost Hospice converts to Medicare Part A payment Medicare Part D - RX coverage (Part D)

23 Levels of Care SHORT STAY ACUTE CARE HOSPITAL (STACH) LONG TERM ACUTE CARE HOSPITAL (LTCH) INPATIENT REHABILITATION FACILITY (IRF) SKILLED NURSING FACILITY (SNF) HOME HEALTH (HHA) Diagnosis, surgery and short term acute interventions; patient problems determined & stabilized. Care for multiple comorbidities, exacerbation of chronic illness, or catastrophically injured. High medical acuity. MS-LTC-DRG payment qualifiers = direct admission from STACH & 3 day ICU or CCU stay or greater than 96 hours on a ventilator. Restoration of functional independence in an inpatient hospital setting. Skilled care for medical/rehab care is needed on limited basis --See note on SWING BEDS* Medicare payment requires prior 3 day inpatient hospital stay. If a break in skilled care lasting longer than 30 days, and new 3-day hospital stay required for additional SNF care In home skilled services to maintain or restore health and independence level. Patient is normally unable to leave home unassisted or without considerable effort. Medicare Part A - DRG Commercial Ins. Medicare Part A DRG Commercial Ins. Medicare Part A CMG Commercial Ins. Medicare A - RUGS Commercial Ins. Medicare A - HHRG Commercial Ins.

24 Levels of Care PALLIATIVE SERVICES HOSPICE CARE NURSING HOME (NH) ASSISTED LIVING (ALF) Patient has serious chronic illness (es) that may be permanent. Services may be home based or patient may be readmitted to General Inpatient Unit (GIU). Routine care in the home scheduled; intermittent visits; call services. Disease directed therapies are no longer working or the burdens of the therapies begin to outweigh the benefits. 4 Levels of Care: *Routine Car: *Care: home setting crisis intervention *Respite Care *General Inpatient Care Long Term Supportive Care (Custodial, supervised residential). Stable Patients able to ambulate/self-care. Becomes the patients home patient is a Resident Housing facility. Have as much independence as with the knowledge that personal care and support services are available if they need them. Don t offer complex medical services. Varies for Medicare & Commercial Ins. Medicare A Commercial Ins. Medicaid, Private pay Private Long Term Ins. Private pay, some Private Long Term Ins., some state funded - HUD

25 DRG Payment STACH and LTCH Settings Diagnosis Related Groups (DRGs) o o DRG based on distinct diagnostic groups and clinical characteristics and expected resource needs Assignment based on physician documentation LTCH Setting - MS-LTC-DRGs o o o weighted to reflect the resources required to treat medically complex patients treated and medical severity predetermined, per discharge amount to cover operating and capital costs Updated yearly effective OCT 1 Sept 30 each year Payment/LongTermCareHospitalPPS/ltcdrg.html 25

26 SKILLED NURSING FACILITY (SNF)

27 What is Skilled Nursing Care? Health care that requires the involvement of skilled nursing or rehabilitative staff in order to be given safely and effectively (CMS Publication No ) 27

28 A nursing home bed is not always a skilled care bed About 95% of nursing home beds in the US are in facilities that are dual-certified for Skilled (Medicare Part A) as well as for intermediate sustained care (Medicaid). Skilled is not considered legal residence but episodic. Assisted living facilities are not eligible for Medicare funds and generally do not receive Medicaid payments, except under special state Home and Community-Based Services waiver programs, so all payments for these services are private pay.

29 SNF ADMISSION RULES Basic Requirements, 42 C.F.R day qualifying hospital stay for medically necessary inpatient hospital care; admission to SNF within 30 days of hospital discharge Physician certification of resident s need for SNF care Physician daily care/oversight not required Resident requires daily skilled nursing (RN/LPN) or rehab services provided by PT/PTA, OT/COTA, SP Medicare-certified facility; Medicare-certified bed Admission decisions by Administrator and DON

30 SKILLED CARE: Daily - Not as Needed / Interim 1. Nursing, 7 days a week/therapy, 5 days a week for a condition for which the beneficiary received inpatient hospital services or a condition which arose while the beneficiary was receiving care in a SNF 2. Combination of nursing and therapy, 7 days a week 3. Break of 1-2 days will not preclude coverage if, for example, resident cannot participate in therapy because of extreme fatigue.

31 When Medicare Does Not Cover Skilled Nursing Care (SNF) If someone only needs custodial care, and does not require skilled care, Medicare will not pay for a stay in a skilled nursing facility (SNF). Custodial care refers to non-medical care that provides assistance with activities of daily living, such as bathing, dressing, eating, etc. 31

32 SNF Payment - HIPPS & RUGS SNF is paid HIPPS (health insurance prospective payment) vs. DRGs Patient admitted from hospital is presumed to meet level of care requirements for first five days of SNF stay and correctly assigned to a Resource Utilization Group (RUG) designated as meeting the level of care required/provided Components of RUGS Nursing per diem (direct care and ancillary services) based on time spend caring for patients in a particular group; wage index Therapy per diem based on resource minutes spent caring for patients in a particular group; wage index RUGs IV major shift of $ with higher indices for nursing; lower for therapy than in past SNF requires data system to capture information for RUGs

33 Steps to Choosing SNF partners Find what is right for your facility and service region - (transitional care unit vs. partnering with free standing) Involve SNF partners in care planning The Agency for Healthcare Research and Quality, an entity of the US Dept. HHS provides guidance on how to find high-quality services in both home care and nursing home care settings. Your Guide to Choosing Quality Health Care: Long-term Care Medicare.gov - Steps to Choosing Long-Term Care

34 1.5 million patients are admitted to 16,000 SNFs yearly

35 HOME HEALTH (HH) Do you really understand?

36 Home Health Medicare defines part-time or intermittent as skilled nursing care that s needed or given on fewer than 7 days each week or less than 8 hours each day over a period of 21 days (or less) with some exceptions in special circumstances. Medicare doesn t cover home health aide services unless the patient is also getting skilled care such as nursing care or other physical therapy, occupational therapy, or speech-language pathology services from the home health agency. Home health aide services may be covered when given on a part-time or intermittent basis if needed as support services for skilled nursing care. Home health aide services must be part of the care for the patient illness or injury. The amount, frequency, and duration of the services must be reasonable. What is NOT covered by Medicare: 24-hour-a-day care at home. Meals delivered to the patient home. Homemaker services like shopping, cleaning, and laundry when this is the only care the patient may need, and when these services aren t related to the patient plan of care. Personal care given by home health aides like bathing, dressing, and using the bathroom when this is the only care a patient may need.

37 Home Health - Therapies Medicare uses the following criteria: The therapy services must be a specific, safe, and effective treatment for the patient condition. The therapy services must be complex or the patient condition must require services that can safely and effectively be performed only by qualified therapists One of the 3 following conditions must exist: 1. It s expected that the patient condition will improve in a reasonable and generally-predictable period of time. 2. The patient condition requires a skilled therapist to safely and effectively establish a maintenance program. 3. The patient condition requires a skilled therapist to safely and effectively perform maintenance therapy. The amount, frequency, and duration of the services must be reasonable.

38 Medicare & Home Health Use by age 50.0% 45.0% 43.4% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 16.4% 13.0% 27.5% 27.7% 35.3% 12.4% 24.2% % All Medicare Beneficiaries % Home Health Users 5.0% 0.0% Age <65 Age Age Age 85+ Source: Avalere analysis of the Medicare Current Beneficiary Survey, Access to Care file, 2011.

39 HOSPICE

40 4 LEVELS OF HOSPICE CARE Routine Home Care Receive hospice care is at home and is not receiving continuous care Continuous Home Care Not in an inpatient facility Receives hospice care consisting predominantly of nursing care on a continuous basis at home Home health aide (also known as a hospice aide) or homemaker services or both may also be provided on a continuous basis Furnished during brief periods - only as necessary to maintain the terminally ill patient at home.

41 4 LEVELS OF HOSPICE CARE Inpatient Respite Care General Inpatient Unit Receives care in an approved facility on a short-term basis for respite Receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings

42 Hospice 2013 ALOS at Death or Discharge 35.0% 30.0% 34% Are over 1/3 with d/c <7 days referred too late to reduce inpatient expense? 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% < 7 days 14.3% 12.7% 18.0% 8 to 14 Days 15 to 29 Days 30 to 89 Days 90 to 179 Days 9.2% 11.3% > 180 Days Source: NHPCO S Facts and Figures Hospice Care in America 2014 Edition

43 Duration of Hospice Care - Medicare Initial 90 day period Subsequent 90 day period Unlimited number 60 day periods Periods of care are available in order listed and may be elected separately at different times A hospice may discharge a patient if patient moves out of the hospice's service area, transfers to another hospice, or hospice determines that the patient is no longer terminally ill. The patient/representative may revoke the election of hospice care at any time during an election (admission) period.

44 HOSPICE OVERVIEW What Medicare Covers For care for a condition other than the patient terminal illness - The Medicare hospice benefit covers the patient care, and the patient shouldn t have to go outside of hospice to get care (except in very rare situations). Once the patient chooses hospice care, the patient s hospice benefit should cover everything the patient needs. All Medicare-covered services the patient receives while in hospice care are covered under Original Medicare, even if the patient was previously in a Medicare Advantage Plan (like an HMO or PPO) or other Medicare health plan. Patient must pay the deductible and coinsurance amounts for all Medicare-covered services to treat health problems that aren t part of the patient terminal illness and related conditions.

45 Hospice Coverage What Medicare Won t Cover Medicare won t cover any of these once the patient chooses hospice care: Treatment intended to cure the patient terminal illness and/or related conditions. Talk with the patient doctor if the patient is thinking about getting treatment to cure the patient illness. The patient always has the right to stop hospice care at any time. Prescription drugs (except for symptom control or pain relief). Care from any provider that wasn t set up by the hospice medical team. **The patient must get hospice care from the hospice provider the patient chose. All care that the patient gets for the patient terminal illness and related conditions must be given by or arranged by the hospice team. The patient can t get the same type of hospice care from a different provider, unless the patient changes the patient hospice provider. However, the patient can still see the patient s regular doctor if the patient has chosen him or her to be the attending medical professional who helps supervise the patient hospice care. Medicare doesn t cover: room and board. However, if the hospice team determines that the patient needs short-term inpatient or respite care services that they arrange, Medicare will cover the patient stay in the facility. The patient may have to pay a small copayment for the respite stay. Care the patient get as a hospital outpatient (like in an emergency room), care the patient get as a hospital inpatient, or ambulance transportation, unless it s either arranged by the patient hospice team or is unrelated to the patient terminal illness and related conditions. **Note: Contact the patient hospice team before the patient gets any of these services, or the patient might have to pay the entire cost

46 Other Organizations that Impact Case Management Accountable Care Organizations (ACOs) Bundled Payments Medical Home Models

47 The ACO An ACO is a legal entity of eligible providers working together by means of joint governance to coordinate care for Medicare beneficiaries. ACO member providers are still reimbursed by Medicare under existing law; however, the ACO is eligible to receive a portion of the money it saves through its improved use of resources and health of its Medicare members.

48 Accountable Care Organizations Since 2011, the number of CMS-sponsored ACOs has expanded from 23 to more than ACOs incentivize health care providers to treat an individual patient across care settings: physician offices, hospitals, post acute, and long term and outpatient settings. Shared savings from lower health care costs while meeting performance standards for quality care result from stewardship. 1 Mcfarlane, M. (2014) Sustainable Competitive Advantage for ACO, Journal of HealthCare Management, 59:4, July/August 2014.

49 Options: Bundled Payments Model(s) One payment for full range of services associated with a specific event, e.g. knee replacement, general surgery, obstetrics, and higher volume Medicare DRGs Places providers at some financial risk with incentives to coordinate care and reduce duplicate services CMS data shows ACA reforms leading to lower hospital readmission rates for Medicare Beneficiaries* *CMS Blog; retrieved 2014 from:

50 Advanced Medical Home Model 50% of Americans report poor coordination of care 93% believe it is important to have one place or doctor responsible for primary care and coordinating care 86% support providers working in teams to improve patient care In a medical home model, patients are linked to a team of providers that are responsible for their primary care, coordination, prevention and self-management The Advanced Home Medical Home Model is grounded in: Evidence based medicine, clinical decision support tools, Chronic Critical Illness management, Coordinated care plans, Access to continuing care systems, Quantitative indicators of quality, and Health information technology. Payment reform was recognized as important to implement the model. Barr M, Ginsburg J (2005). The advanced medical home. A policy monograph. American College of Physicians.

51 Medical Home Away from Home for Continuing Care: Network rewarded, cost contained for their patients while improving quality over continuum (payment mechanism; bundled payment) Person-centric network; option to get care outside the network if desired (consumer engagement) Coordinated transition to recovery/wellness (home care, patient centered medical home) Network is one corporate entity or contracted partners (patient care ecosystem) Quality benchmarks must be met to get share of savings (care mgmt.; analytics) Graphic from: McKesson Strategy for an ACO model. Retrieved from

52 Value Based Purchasing

53 Consumers Support Quality Based Purchasing 96% of Americans feel it is important to have information about the quality of care provided by different doctors and hospitals 89% feel it is important that they have information about the costs of care to them before they actually get care 85% want public and private payers to reward high quality doctors and hospitals E. Andrews, Value Over Volume, March, Connecticut Health Policy Project

54 Quality Based Product Modeling: Rewards better outcomes Pays for value -- quality balanced with cost Data driven Removes incentives for more services Provides the right services to the right patient at the right time in the most effective setting Has flexibility for providers to customize care Rewards patient satisfaction Removes fragmentation and conflicting incentives Aligns provider, payer and consumer incentives to quality, effectiveness and efficiency

55 Long Term Acute Care Hospital Inpatient Rehab Facility Hospice Intermediate Care Facility Assisted Living Visiting Homemaker Services Outpatient Services Home Health Agency Skilled Nursing Facility

56 HEALTHCARE PARTNERSHIPS Characterized by several challenges requiring changes that must be intertwined: Health systems are challenged to meet the demand for services universally with no untoward events and high quality outcomes; People expect that the best and new technological advances must be made available to them; Seamless delivery will be the standard of care. Must be accomplished in a cost-effective manner without draining the economic system; Pay for Performance continues to be broadened Coordination of care is imperative to monitor the interactions of CARE PARTNERS (not vendors ) 56

57 Other Supportive Actions that Must Occur: Patient-Centered Care Management shared vision Not driven by Financial reimbursement Improve/redesign delivery systems in place (effective hand off; CM follow up post discharge)* EMRs, health information exchange, access or ability to continue EMR from level to level Care Partners are NOT vendors involved early in planning Comparative effectiveness through shared quality data Effective community/patient/family education program. *Involve stakeholders in redesign; use available academic resources (data analysis, IE, etc.) or technical assistance

58 Case Manager s Skill It is essential for case managers to have reasonable observation and assessment skills Must be able to address the patient s and caregiver s needs to evaluate the level of frailty. WHY? Evaluating level of frailty will allow case managers to: Apply the frailty model to chronic care management Offers a greater opportunity for recovery at a sustainable level Allows for further opportunity to improve outcomes and Assist in avoiding future hospitalizations for chronic critically ill populations

59 Coordination of Care - Must-Haves Healthcare needs of chronically ill patients are complicated and often require costly LOS Focused efforts must be towards the time to heal or early intervention for appropriate level of care Opportunities for re-thinking about effective healthcare provider service management can improve cost of care for the chronically ill The providers are partners with efficient specialized components that must be managed Wellness post discharge is needed to maintain health, not re-admit and fix again continuously 59

60 Thank you for your time Welcome to the RIDE