Discharged to the community 37.6% 29.4% 46.5% 1.6. Potentially avoidable readmissions during SNF stay 10.9% 7.8% 13.6% 1.7

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1 BEST PRACTICES FOR CREATING AN EFFECTIVE POST-ACUTE CARE NETWORK Introduction Historically, hospital leaders and clinicians performing complex procedures on Medicare patients have had little incentive to pay careful attention to the cost and quality of care provided in the post-acute setting. Most have had loose or informal referral relationships with post-acute providers, and there have been limited standards to help clinicians determine the best settings for this type of care. Determining how much or what type of post-acute care (PAC) is appropriate has traditionally been challenging, due in large part to a lack of data comparing outcomes to the cost-effectiveness of care 1 as well as the lack of incentives to improve care coordination. As a consequence, hospital leaders and clinicians have simply taken it on faith that post-acute providers in their communities are able to deliver high-quality and cost-effective care. Yet the evidence suggests facts to the contrary. MedPAC has consistently found that Medicare s payments for PAC fluctuate greatly, with cost variation among providers, even those that provide the same kind of care for similar patients. This cost variation can often be tied to use of unnecessary services and a reimbursement structure that historically incents volume over value. Over the Next Three Years 85% of C-suite leaders plan to expand their partnerships with local post-acute care providers. 95% of C-suite leaders report hospitals and health systems may experience challenges in creating successful, high-value post-acute partnerships. Source: Premier 2016 Fall Economic Outlook Survey By way of example, MedPAC found wide variation across five quality measures tracked for skilled nursing facilities (SNFs), including the percent of residents with new or worsened pressure sores, the percent of residents who self-report moderate to severe pain and the percent of residents who experienced falls with major injury. Similar variation was seen in the readmission rates. In analyzing these findings, MedPAC concluded that the amount of variation across and within the groups suggests considerable room for improvement, all else being equal. 2 Figure 1: Variability Across Skilled Nursing Facilities Quality Measure Mean 25th percentile 75th percentile Ratio of 75th to 25th percentile Discharged to the community 37.6% 29.4% 46.5% 1.6 Potentially avoidable readmissions during SNF stay 10.9% 7.8% 13.6% 1.7 Potentially avoidable readmissions within 30 days after discharge from SNF 5.6% 3.6% 7.3% 2.0 Average mobility improvement across the three mobility ADLs 43.5% 35.5% 52.1% 1.5 No decline in mobility during SNF stay 87.1% 82.7% 92.7% 1.1 Note: Source: SNF (skilled nursing facility), ADL (activity of daily living). Higher rates of discharge to community indicate better quality. Higher readmission rates indicate worse quality. Mobility Improvement is the average of the rates of improvement in bed mobility, transfer, and ambulation, weighted by the number of stays included in each measure. No decline in mobility is the share of stays with no decline in any of the three ADLs. Rates are the average of facility rates and calculated for all facilities with 25 or more stays, except the rates of potentially avoidable readmissions during the 30 days after discharge, which are reported for all facilities with 20 or more stays. MedPAC: Moreover, a New England Journal of Medicine study found that lower quality post-acute providers had risk-adjusted readmission rates of 23 percent or more for five potentially avoidable conditions, while high performers had rates below 15 percent 3. In addition, top performers had an average Medicare length-of-stay of less than 24 days, while lower tier performers reported more than 34 days a quality differential that adds up to about $4,000 per admission given prevailing Medicare rates 4. Low Performer 23% + < 15% High Performer $4,000 differential 34 days 24 days ibid Readmission rates Length-of-stay 1

2 What s driving these disparities? One main factor is the variation among providers due to characteristics unique to each community. For instance, placement decisions often reflect local practice patterns and the availability of different types providers, as well as patient and family preferences. As a result, there is widespread variation in PAC referral patterns, with some hospitals referring fewer than 3 percent of their patients to post-acute facilities, while others refer up to 40 percent 5. Similarly, some hospitals recommend home healthcare for just 3 percent of patients, while others refer as many as 58 percent of patients 6 to this setting. This variation is particularly concerning for health systems. With incentive structures shifting to measures that require hospitals to manage care across the continuum, these hospitals are now held accountable (at least in part) for the performance of their post-acute partners. Payment is now tied to readmission rates, patient satisfaction, 30-day outcomes and the cost of care for 30 days past discharge. Moreover, mandatory bundled payment programs for joint and cardiac procedures and hip and femur fractures create additional incentives to align more closely with post-acute. The transition period after a major hospital procedure represents a critical time that can mean the difference between a full recovery and an adverse event. In effect, PAC is now a critical extension of a hospital s care delivery model, with implications for the hospital s reputation and financial viability. Given this new reality, providers must better understand trends after patients are discharged from the health system and better manage how and where they engage PAC. As the healthcare industry pushes providers more toward managing population health, hospital leaders must optimize the use of PAC and establish partnerships to deliver highest-quality, most cost-effective patient care. With new tools, data and resources available, leaders can reshape how they engage these providers and work toward the shared goal of making care better, smarter and more efficient. This paper serves as a roadmap to help guide healthcare leaders through the necessary steps when creating effective PAC networks. Alternative Payment Models Incenting Change PAYING FOR QUALITY Hospital Value-Based Purchasing Program The Hospital Value-Based Purchasing (VBP) Program is an initiative that puts a certain percentage of payment at risk, with bonuses and penalties meted out based on performance against quality and efficiency metrics. Institutions are analyzed on the quality of care provided, how closely best clinical practices are followed, how hospitals are able to improve care efficiency and how well hospitals enhance patients satisfaction during their episode of care. CMS assesses each hospital s total performance by comparing its Achievement and Improvement scores for each applicable Hospital VBP measure ACCOUNTABLE CARE ORGANIZATIONS (ACOS) Medicare Shared Savings Programs (MSSP) Track 1: This is a shared savings only arrangement if it meets overall quality and spending benchmarks for its patient population and doesn t include any penalties if savings are not obtained meaning limited risk. 95 percent of MSSP participants are in this track. Track 2: This track includes some downside financial risk. Participating ACOs face between around 5 to 15 percent of total losses over the three performance years along with a higher 60 percent rate for the ACO share in savings. Track 3: The third track allows ACOs to earn up to 75 percent of generated savings and qualify for specific legal waivers in exchange for accepting higher downside risk of up to 15 percent of all Medicare Part A and Part B payments. Next Generation ACOs Starting in 2017, Next Generation ACO participants can choose capitated payment, meaning CMS would pay ACOs a lump sum for the duration of care for each patient, making providers responsible for any and all care that patients need, even if it exceeds the capitated amount. This high-risk, high-reward payment model builds upon the Pioneer ACO Model and MSSP. Unlike other models, Next Generation includes prospectively set benchmarks and pilots certain patient incentives, including increased access to telehealth and care coordination services ibid 2

3 Alternative Payment Models Incenting Change - continued BUNDLED PAYMENTS Bundled Payments for Care Improvement The Center for Medicare and Medicaid Innovation s BPCI initiative, which began on October 1, 2013, tests four bundled payment models: retrospective acute hospital stay only, retrospective acute care hospital stay plus PAC, retrospective PAC only and prospective acute care hospital. More than 2,100 acute care organizations participate in this initiative. Participants are given flexibility in selecting clinical conditions to include in the episode, based on a list of diagnosis-related group options. Comprehensive Joint Replacement Model A mandatory bundled payment program which focuses on cardiac and joint procedures holds providers accountable for the costs and quality of joint replacement surgeries, starting with the index hospitalization through 90 days of recovery. Roadmap to Creating a Successful Post-Acute Care Network In 2012, Premier launched an initiative to foster shared learnings and strategies for success in alternative payment models. Premier s Population Health Management Collaborative (PHMC) convenes physicians and clinicians in hospitals and other healthcare facilities to network, share data and communicate best practices. It is one of the largest collaboratives in the U.S. to promote and facilitate the use of alternative payment arrangements to improve healthcare and reduce health costs, in both the private and public sectors. This growing collaborative represents approximately 65 health systems and 450 individual facilities. Hundreds of hospitals and thousands of clinicians in Premier s PHMC are working together to develop value-based care and alternative payment model capabilities. Additionally, Premier s Bundled Payment Collaborative helps providers develop, implement and succeed in using bundled payment arrangements in both public and private markets. Approximately 50 health systems, which represent more than 125 facilities across 26 states, are committed to sharing best practices and data with each other with a focus on improving care and reducing costs across multiple episodes of care, including hip/knee joint replacement, lumbar spine fusion, coronary artery bypass grafts, heart valve replacement, congestive heart failure, percutaneous coronary intervention and colon resection. Since forming these collaboratives, Premier has collected a range of best practices from participating members, enabling us to develop a framework for evaluating PAC providers and ensuring success in alternative payment programs. This framework, coupled with other best practices, is a key enabler of success, evidenced by Premier collaborative participants outperforming other CMS MSSP and Pioneer ACO participants in shared savings payments over the past three years. This paper will describe key steps in the PAC network development process, and provide case studies from Premier members that have successfully implemented them, in order to help others replicate and scale successful PAC strategies. Determining Roles and Accountability Begin to Understand Consumption, Costs and Outcomes through Data Start Dialogue with Post-Acute Care Providers Establish Narrow Network with Preferred Institutions Improve Care Together for Patients Determining Roles and Accountability Prior to talking with potential post-acute partners, there s an important need to determine roles and responsibilities internally to ensure all potential partners and stakeholders are fully aware of both the health system intent and expectations around post-acute engagement. There is a need to define who oversees leadership and management of the network, and who has ownership and accountability for implementing, monitoring and improving network operations. This includes clarifying the roles, responsibilities, staffing, frontline communication and workflows that will be used in the collaboration between health systems and preferred PAC providers, as well as accountabilities for ongoing communication, decision-making processes and conflict resolution methods. In the early stages of post-acute partnering and selection, it s often best that the hospital or system develop some form of workgroup or committee to manage and inform the process. This group would ideally engage individuals across the organization who are impacted by PAC and may play a role in the development process. At the very least, a workgroup should include both an administrative and a clinical lead. Additional individuals should represent care management, 3

4 finance, quality, emergency department, information technology, education and communications. As the network evolves, these functional areas will be essential in both providing input to its development and supporting collaboration with post-acute providers. Some organizations further segment these areas into smaller workgroups or subcommittees, depending on the scope of work to be done. As with any infrastructure or governance effort, clear charters and expectations are important to the management process. With respect to senior leadership, a C-suite or comparable champion is critical as part of the network development process. The network development process is likely to encounter challenges to historical thinking and practices that are heavily vested in fee-for-service thinking. A C-suite champion who embraces both value-based thinking and recognizes the importance of PAC will be person to help overcome these challenges. Some health systems have looked to create new roles, such as Vice President of Care Management, Vice President of Post-Acute or Vice President of Continuum Services, who would oversee the logistics and relationships with the broader posthospital continuum and work to migrate both hospital and post-acute provider thinking toward the new model. Put another way, this role is responsible for the planning, development, implementation and operations of care management and the patient transition process to post-acute care. Begin to Understand Consumption, Costs and Outcomes Through Data Health systems must think strategically about which postacute providers to include in their networks for collaboration and performance improvement. When looking at potential partners, there is a distinct need to understand the gaps between the current landscape and desired state in order to create the infrastructure necessary to sustain a high-performing PAC network. The data on local post-acute providers as well as internal discharge processes offers a foundation to design an effective cross-continuum care management system that can manage the linkages between the care settings and help inform who, where, what and how these processes will be carried out for each patient. Understanding Trends of Local Post-Acute Providers While macro trends have been documented on PAC variation for utilization, costs and patient outcomes, providers will have to dig deeper to truly understand what s happening at a local level. Starting with the basics, leaders should take the opportunity to learn about the capacity and capabilities of all the PAC providers in the communities they serve, stratifying for details like type of PAC setting (i.e. SNF or IRF), ownership (non-profit vs. privately owned), and capacity (i.e. beds available or under-utilization). Having a sense of clinical leadership or existing relationships is also important. Decision makers should evaluate available quality and clinical measures such as: Centers for Medicare & Medicaid Services Five-Star Quality Ratings 30-day readmission rates Average length of stay or utilization Falls recorded per 1000 patient days Patient and family satisfaction rates This data can typically be accessed via public domains but often considers the total patient population of a provider. For nursing homes, this means both short-stay rehabilitative patient and long-term care custodial patients (see Appendix). This preliminary review should shed light on the performance trajectory of local facilities and identify high-level challenges, but more detailed data will be required when working through a selection process with potential partners to glean a more accurate view of the top performers. If detailed claims data is available (either via participation in one of the alternative payment opportunities or another source), the hospital or health system should conduct a thorough analysis of these data points. The interaction of various measures can be particularly telling. Post-Acute Care Options Skilled Nursing Facility (SNF) SNFs treat a broad variety of patients; respiratory, kidney and other infections, and joint replacements are common conditions among SNF patients. Because of the diversity profile of SNF patients, these facilities offer a broad variety of services. Typically, care is less intensive compared to services provided in inpatient rehab facilities (IRFs). SNFs are paid a prospective per diem payment for all costs (routine, ancillary and capital-related costs). A rule from CMS established a two percent withhold to SNF Part A payments that can be partially earned back based on a SNF s re-hospitalization rate and level of improvement, which starts in Inpatient Rehab Facility (IRF) IRF patients generally need significant rehabilitation following life-changing health events, including brain and spinal cord injuries, stroke and traumatic injuries. Medicare beneficiaries treated in IRFs need the assistance of an interdisciplinary team of medical providers and must require and benefit from at least three hours of rehabilitative care per day. A tailored plan of care for each patient is required, which is overseen by a rehabilitation physician. Specifically, to be classified for payment under Medicare s IRF prospective payment system, at least 60 percent of a facility s total inpatient population must require IRF treatment for one or more of 13 conditions. Home Health Agency (HHA) Patients who require some assistance and ongoing care following a hospitalization can benefit from home health visits. Patients who receive assistance from HHAs do so in the form of medication administration, changing dressings and physical or occupational therapy. 4

5 For instance, a post-acute provider with a shorter post-acute length-of-stay may be desirable, but if its readmission rate outweighs the cost associated with a slightly longer length-of-stay, it quickly becomes less appealing. As they delve deeper into the variation that occurs post-acute, hospitals and health systems should pay close attention to related clinical quality measures that inform a provider s track record and identify red flags that might challenge an effective partnership without significant process improvements. Understanding Internal Trends and Practice Beyond the performance of post-acute providers, the hospital or health system must also consider its historical use of PAC and its practices around discharge planning and referral to PAC. The organization should profile its discharge data to identify those post-acute providers receiving the bulk of historical referrals. This helps to identify both the scope and depth of post-acute distribution. In situations where patients are sent to multiple providers, the desire should be to consolidate post-acute use and improve span of control. In some instances, where scope of use is already narrow, the high-volume providers should potentially represent the key partners for consideration. In most instances, case managers and discharge planners are often a driving force for post-acute referral. As such, many will have established referral patterns and sometimes those patterns are not aligned with highest quality providers. Seeking out their opinions and experiences with providers will further define the nature of existing provider relationships but also serves as a good barometer for how much work will be required to change case manager and discharge planner behavior in utilizing an eventual post-acute network. Finally, the evaluation of internal use should consider the biggest areas of challenge for the organization. What is driving the need for improved post-acute relationships? Is it in response to specific clinical conditions like joint replacement or cardiac procedures? Or does the focus relate to a desire to reduce acute length-of-stay or impact readmission performance? Understanding these issues is central to rationale for development of a post-acute network and should inform eventual clinical integration and quality improvement efforts. Start Dialogue with Post-Acute Care Providers After the deep dive on preliminary data and a sense of how a post-acute network will be managed and developed, the next step is to begin the discussion with post-acute care providers within your community to determine their level of interest in working with you. Selecting strategic partners requires a rigorous approach that should include not only comprehensive reviews of cost, quality and market data, but also should evaluate post-acute provider capacity to meet your expectations. A key goal early on is to garner enough information that will ultimately streamline the process to identify the right post-acute partners in your community. A best practice is for health systems is to conduct a Request for Information (RFI) process to gather a wide range of data about the post-acute providers and start to winnow down the pool of potentially qualified applicants. RFIs should include extensive questions around size and capacity, ownership, facility or program leadership, staffing, clinical skills, quality measures and other factors. On-site visits of prospective post-acute participants are also beneficial when it comes to broadening the hospital or system s understanding of post-acute capacity and offerings. Via the on-site process, the network builder can better equate outcomes and quality via interviews of senior leaders and key clinical staff and touring a facility. Home Health Agency (HHA) - CONTINUED Under prospective payment, Medicare pays home health agencies a predetermined base payment. The payment is adjusted for the health condition and care needs of the beneficiary and geographic wage differences. The home health PPS will provide HHAs with payments for each 60-day episode of care for each beneficiary. If a beneficiary is still eligible for care after the end of the first episode, a second episode can begin; there are no limits to the number of episodes a beneficiary who remains eligible for the home health benefit can receive. Long-Term Acute Care Hospital (LTACH) Patients who require intensive, longterm care for complex medical issues may receive care in LTACHs following hospital discharge. LTACH patients are some of the most vulnerable patient populations, including complex respiratory problems, severe postsurgical wounds, renal failure and other infections and complications. LTACHs deliver rigorous care over a significant period of time. Payment is based on admitting diagnosis and supporting documentation. Medicare payment rules require that the average length of stay at LTACHs be more than 25 days. Long-term acute care facilities will be paid at the full Medicare prospective rate only for patients who spend at least three days in an intensive care unit or four days on a ventilator. LTACH care for other patients will be reimbursed on a per diem, site neutral rate that amounts to less than the PPS rates on average. Starting in 2017, long-term acute care hospitals that receive more than 25 percent of their patients from a single referring hospital will receive payment reductions. 5

6 During onsite visits, an organization should consider: What is the physical environment, taking into account amenities and services, availability of private rooms, age of equipment and general condition of the physical plant? What are the availability and response time of key ancillary services, like pharmacy, specialized rehab, respiratory services and lab and radiology? How do staff interact with patients and one another? Are there evident practices around customer services and patient experience of care? What is the post-acute facility s ability to accommodate the hospital s referral patterns (e.g., patient volume, time of day, patient type, average response time for referral requests, clinical complexity, discharging service lines, etc.)? With RFI and site-visit results in hand, the network builder is in a better position to reconsider consumption and quality metrics and ultimately segment the potential candidates into low and high-performing post-acute providers (see Appendix). While selection criteria can vary among markets across the country, decision makers should look for potential PAC providers that demonstrate or show willingness to work toward: Low readmission rates Average lengths of stay Top quartile performance for decreased fall risks and decreased infection rates Better than average patient-to-staff ratios High patient and family satisfaction scores Demonstrated willingness to engage in integration and care redesign Establish Narrow Network with Preferred Institutions After culling through this baseline assessment work and data, health system leaders should be equipped with the right information to identify potential partners that share or are willing to embrace value-based/accountable care measures, as well as a culture that aligns with health system values around safety, quality and patient centeredness. Preferred post-acute partners set themselves apart as a top performer that can deliver the best quality and cost outcomes, successfully manage medically-complex patients and commit to ongoing performance improvements. Leading candidates must: Possess an adequate number of beds that can meet service volume requirements Set suitable utilization targets, possess high-quality clinical services capabilities (or ability to develop them) Fulfill unique service needs in relation to geographic distribution and patient population Overall, partners must be willing to agree upon overarching strategy and goals, adopt practice tools and implement processes that standardize patient experience, and promote quality outcomes. Once partners have been identified and selected, new value-based collaboration or preferred provider agreements will need to be developed. Post-acute and acute care providers will have to work together to create specific goals that improve quality and ultimately impact total cost of care. Most forward-looking post-acute organizations recognize that they can no longer operate as if they re in a silo. Many are eager to see themselves as an extension of the hospital or health system. To that end, provider agreements must define expectations around collaboration, consistent communication and data sharing. As relationships evolve and integration occurs, these value-based agreements will evolve to address risk-based payment and potential gain-sharing methodologies. Figure 2: Study Finds Post-Acute Care Top Opportunity to Reduce Costs for Hip Replacements, Colectomies Difference between top and bottom quintile incost per episode Lowest cost $17,784 Hip replacement Highest cost $24,693 $25,392 $27,992 Colectomy Source: Health Affairs - Percent of difference between highest and lowest cost case by service type Index Admission Physician 84% 9% 7% Hip replacement Readmission PAC 44% 9% 36% 11% Colectomy Hospitals in Action: Banner Health (PHOENIX, AZ) Banner Health examined the operations, culture and quality of care at nearly 100 skilled nursing facilities in Phoenix. After putting out an invitation to all Medicare-certified institutions to apply, Banner received more than 70 applications. Of the 70 applicants, 34 of which were chosen to be part of their narrow network. The preferred post-acute care providers agreed to work with Banner to improve recovery times for patients and prevent hospital readmissions. Preferred providers also benefitted as an affiliated provider due to the partnership. Banner reports patients sent to preferred facilities have stays that are 5-7 days shorter than those sent to non-preferred facilities, and all but one facility in the network hit their targets for readmissions. Banner s affiliated network s SNF readmission rate is less than half of the national average compared to non-affiliated SNFs. 6

7 Improve Care Together for the Patient Identifying potential post-acute partners and establishing a network is relatively straightforward for many organizations. The hard work lies in setting up the network for success. Health systems and post-acute providers must recognize that significant changes need to take place within both entities in order to improve internal processes and establish best practices. This means working closely toward a shared vision that makes care better and safer for patients, while also reducing clinical inefficiencies and creating new practices that foster collaboration and prevent siloes in care. While the unique or specific needs of systems can vary greatly when it comes to improving care for patients along the acute/post-acute continuum, there are three key areas of focus for most organizations to consider. #1: Effectively Planning and Improving Acute to Post-Acute Transitions While identifying local trends and patterns among PAC providers is a crucial element for success, hospital leaders should also work to learn more about their own processes and potential inefficiencies internally regarding the discharge-to-post-acute process. Standardizing documentation, assessments and placement tools are essential for streamlining the acute/postacute transfer. More than one in five Medicarebeneficiaries discharged to a PAC facility experienced an adverse event. 60 percent of the adverse events were considered preventable if better care processes had been established. Source: MedPAC: contractor-reports/apr13_communitydischarge_contractor.pdf What is the Acute Discharge and Referral Management Process? Institutional knowledge about internal processes and patterns on where patients are being directed for post-acute care will help identify best practices and areas for improvement. Leaders should begin by connecting with the care management department and get an idea of how the process works currently. The care management program is essential to ensure that care is coordinated across the continuum to allow smooth transitions for the appropriate level of care and services, as well as to guarantee a quality patient experience. One of the key questions to ask is who on the staff is involved in the transition process? Leaders should assess skill and competency of those involved and those who can affect both successful outcomes for patients and success of the PAC network. Discharge Planning Team: A social worker or nurse care manager should be involved in every interaction with a patient to guide the team forward on where patients should receive care after discharge. Therapists might also be involved (depending on the patient s condition), and this interdisciplinary team should meet with the patient and family on what to expect when a patient is discharged from the hospital to PAC. Every discharge plan should be tailored to the patient and aligned uniquely to patient-specific factors, including type of condition and procedure, medication and device use, comorbidities and demographics. Physician Involvement: While physicians are an essential part of the care delivery team, they are often detached from choosing or recommending a PAC setting for their patients. In complex situations; however, the patient s status and capacity may directly inform physician recommendations about specific PAC options that can foster proper healing and recovery. Finally, it s important to outline and know key steps in the discharge planning process. Identifying specifics like what actions around discharge occur immediately upon admission to the hospital and what tasks are performed within 72, 48 and 24 hours of discharge can assist with performance improvement measures. For instance: How and when is the patient assessed for likelihood of readmission? Is the patient flagged in some manner to advise the post-acute provider of this higher risk? Who performs the medication reconciliation process, and is this process standardized to ensure consistency? Are advance directives or advanced planning included as part of the process or as a condition of discharge? Who is accountable for clear handoff and communication with the post-acute based clinicians? What are the different roles and responsibilities of the discharge planning team members? Evaluating issues around these questions, as well as many others, often reveal wide variation among hospital staff. Such inconsistencies can be leading causes for readmission issues, less then optimal patient outcomes and decreased patient satisfaction. A list of additional considerations around inpatient discharge and referral management is presented in the breakout on the next page. 7

8 Improving Inpatient Discharge and Referral Management As health system leaders seek to evaluate and improve their discharge and referral management practices, there are a wide range of underlying behaviors, habits and patterns that can hinder successful coordination along the continuum and create potential pitfalls for patients entering PAC. Here are some key areas of consideration: COMPLETING ASSESSMENTS AND TIMING It s important to evaluate risk for patients headed to a post-acute setting. Depending on the severity of the case, some discharge discussions should start well in advance, taking into account social and physical risk factors. Waiting until the day of discharge may lead to hasty decisions, which are not optimal for patient outcomes, or drive overuse of post-acute care. Depending on the patient s particular diagnosis, having discussions prior to the initial hospitalization can be especially helpful to optimize a patient s condition. Early functional assessments may determine if a person could use physical therapy during their stay to recover faster, or when they can leave the hospital and begin recovery. KEEPING EVERYONE INFORMED All handoffs should include a safety net and feedback loop. Inpatient care managers need to keep in touch with PAC managers and patient navigators consistently. Additionally, primary care providers should be aware of a patient s case and recovery plan. Frequently, primary care physicians aren t informed about a patient s hospital stay and subsequent care, creating siloes in the continuum. TARGETING HANDOFFS AND READMISSIONS It s important to take a deeper data dive when evaluating readmissions considering how they compare for certain conditions and determining if certain handoff processes or underlying causes could be the source of higher readmissions rates. Improving handoffs for high-risk patients is especially important, as they remain most vulnerable to readmissions post-discharge. When looking at readmissions, leaders should particularly focus on those that occur within five to seven days of acute discharge. Looking within this window considers immediate missteps tied to discharge, including confusion about medication, absent handoffs or decreased post-acute staffing (in or around the weekend). Simple telephone follow-ups can go a long way to address patient understanding of medications or discharge orders. Engaging with network post-acute providers to adjust and coordinate staffing on weekends and evenings can improve care transitions and crossover communication occur as expected. BREAKING PHYSICIAN HABITS The adage that more care is better isn t necessarily true. Historically, physicians have had neither risk nor incentive to be involved in the decision-making process about where patients receive care after leaving hospital. As hospitals increasingly take on more risk for patients and their outcomes (especially in accountable care organizations), acute care institutions are creating more incentivebased payment arrangements with physicians tying a portion of salary to patient outcomes (i.e., readmissions, utilization, and so on). While some may be receptive to changing their behaviors around post-acute use, many physicians may need assistance on how to discuss options with patients and inform the selection process. This can take the form of simple scripts for physicians to use with patients and their families, discussing time spent in post-acute, options available and the patient s recovery path. INCLUDING MEDICATION RECONCILIATION Before any patient leaves for PAC or home, they may be prescribed a number of new or different prescriptions that need to be reviewed. One best practice is to establish medication reconciliation as a key component of discharge planning and to include a clinical pharmacist in the process. Working as team, a nurse and pharmacist can educate the patient, answer questions, and review prescriptions to evaluate what a patient was given prior to hospitalization, during the hospital stay, and afterwards to reconcile any errors or potentially dangerous drug-to-drug interactions. NAVIGATING PATIENT CHOICE While hospitals and health systems cannot require the use of preferred network providers for Medicare beneficiaries, case managers and discharge planners can help patients make more informed choices by highlighting how quality, service, and continuity of care can be achieved when they select a preferred post-acute provider. To that end, working with frontline care management and discharge planning staff to script how they share the post-acute and preferred provider choice lists may enhance referrals to the preferred network. 8

9 What Is the Right Post-Acute Setting? There is no simple formula or process to determine the right PAC setting for a patient. This ambiguity is one of the reasons that PAC has come under considerable scrutiny by CMS and policymakers. Appropriate selection hinges on a number of factors, including the type and severity of the patient s condition, mobility, living arrangements, the availability of caregivers and other various risk criteria. While there have been various pilot studies to develop uniform post-acute placement tools, they have proven challenging and time-consuming for hospital staff. As a result, many organizations have adopted simpler screening or evaluation tools, primarily targeted at the choice between a SNF or a home health provider. Beyond these basic practices, a range of software tools have also evolved that can guide the care management team in these determinations via questions about the patient s functional status, co-morbidities and physical risk factors. In some circumstances, PAC may not be needed at all. For example, hospitals that have capacity may choose to extend patient s acute stay and discharge home with outpatient services, rather than discharge them to a SNF or order home health services. The cost of an extra day or two in the hospital can often be less than what it cost to send a patient to post-acute. Figure 3: Breakdown of Post-Acute Care Usage 17% 20% 58% Snapshot: Where Medicare Patients are Getting Care After Discharge Skilled Nursing Facility Home Healthcare Agency Long-Term Acute Care Hospital No Post-Acute Care Hospitals in Action: Centra Health Inc. (LYNCHBURG, VA) 4% Inpatient Rehab Facility 1% In January, 2014, six months after conducting extensive research and development, Centra Source: MedPAC: s-post-acute-care-trends-and-ways-torationalize-payments-(march-2015-report).pdf?sfvrsn=0) #2: Improving Post-Acute Care Clinical Capacity and Practice For many post-acute providers, meeting acute hospital expectations around improved patient outcomes, quality and reduced costs will require investments of time and resources to develop and enhance their clinical skill sets and capacity. As network developers, hospitals and health systems can (and should) play a leading role in supporting this development process. Hospital-sponsored clinical training and on-site clinician deployment serve as key elements in an acute/post-acute clinical integration effort. Health Inc. (Lynchburg, VA), another Premier bundled payment collaborative participant, began a heart failure bundle and opened a CHF clinic. Among its research findings from the January 2014 inception through October 17, 2014, 15.5 percent of Centra s CHF readmissions during the time frame occurred within the first three days from discharge, and nearly 61 percent of CHF readmissions took place within the first 15 days after discharge. How Are the Post-Acute Providers Staffed? Appropriate staffing and skillsets are crucial to deliver quality PAC, as this typically makes the difference between a quick recovery and a relapse or complications. The post-acute clinical team must be ready to admit patients in the post-acute facility on a 24/7 basis. Around the clock staffing of registered nurses (RNs) has emerged as a minimum expectation in SNFs to ensure patient safety, improve management of patient conditions and prevent re-hospitalizations. Post-acute RNs should employ evidence-based practice, such as Interventions to Reduce Acute Care Transfers (INTERACT), to assess changes in status, communicate with other clinicians, and make appropriate determinations around care. Beyond RN staffing, there are a range of other areas for consideration: Increasing post-acute clinical capacity through embedded frontline medical personnel: To boost skills and increase resources for preferred post-acute providers, health systems may create tailored programs to address readmissions and assign health system nurse practitioners, physicians and other healthcare staff onsite at post-acute care facilities. By way of example, it may be difficult for a nursing assistant to catch the early symptoms of a urinary tract infection or sepsis. If a nurse practitioner or another medically-trained professional is involved in the post-acute facility rounding process, these complications may be identified faster to prevent readmissions. Centra used these findings to refine its CHF post-acute programs and procedures. Their initial step was to ensure that all patients were scheduled for the heart failure clinic and/ or their primary care physician within seven days of their discharge from the hospital. The data also cast a light on the correlation between readmissions and comorbidities. Most readmitted post-acute patients had at least two of the following comorbidities: atrial fibrillation, anxiety, dementia, depression and diabetes. This new revelation prompted leaders to implement proper follow-up procedures for individuals with these comorbidities. Deploying patient navigators: Patient navigators can play a key role in improving PAC transitions and work closely with patients and families so they know what to expect during the recovery process in PAC. As a guide, they can connect the dots between care managers at the hospital and post-acute providers to discuss discharge planning, step-down plans, home care plans and other community-based needs like transportation or meals. They are also able to assist on arranging follow-up appointments and medication reconciliation (see Appendix for sample job description). 9

10 Offering post-acute staff training and development: Hospitals and health systems should develop and raise the clinical skills among preferred PAC providers through training and professional development. Most post-acute providers will readily welcome increased focus on training, particularly on avoiding readmissions, and learn how to better assess and stabilize a patient to avoid knee-jerk reactions that send patients back to the hospital. While an affiliated or embedded physician working in post-acute may be on hand to handle complex patients, postacute staff must have the skills to address everything else. How Does Post-Acute Manage Transitions in Care? As patients recover and improve in PAC, patient needs will change. It s fairly common for patients to spend time in more than one post-acute setting during a given episode. For those patients discharged directly home, there may still be challenges during recovery. Left unmanaged, either scenario creates an opportunity for patient decline or acute readmission. While fee-for-service thinking has made it financially beneficial to keep patients in post-acute settings for as long as possible, alternative payment models have shifted incentives on how and where care should be delivered, addressing overuse or misuse of care that doesn t improve outcomes and leads to increased costs. Opportunities to transition level of care: Given an emphasis on appropriate setting and cost, PAC providers should be looking consistently for opportunities to transition patients to the next level of care, either in an alternative post-acute setting or at home. Transitions at this level should be managed with as much rigor as those from acute to the first post-acute setting. The post-acute provider should employ appropriate patient activation efforts, offer caregiver or family education, arrange for follow-up with primary care and establish clear protocols about what the patient should do in the event of a change in status or decline. It s often wise for the health system and post-acute providers to work collaboratively in developing a uniform process. Deploying technology when appropriate: For some patients, appropriate technologies might make care more accessible while reducing need for high-touch, expensive care. Various telehealth services can support in-home monitoring of vital health data or identify behaviors that are indicative of a patient s physical or mental status. Video conferencing tools can support live patient/clinical consultations and in-home medication dispensing systems can reinforce medication adherence. The versatility of smart-phone enabled apps can support patient reminders and communication with family members and caregivers. Hospitals in Action: Kaleida Health (BUFFALO, NY) Kaleida Health put in place a predictive modeling program for patients in total joint replacement bundles known as the Ticket to Discharge. Previously, the health system had been discharging orthopedic patients to SNFs at a high percentage rate. In contrast, in other parts of the country, the majority of total hip or total knee replacement patients were being discharged to home with home care services. The Ticket to Discharge program features a predictive post-discharge assessment completed by a surgeon recommending that a patient undergo joint replacement surgery, and is used at the same time the patient is scheduled for surgery and for a pre-operative class. Typically, these patient post-discharge assessments had a roughly 80 percent degree of accuracy. Armed with these assessments, pre-op class educators could better prepare individual patients for one of three options: going home and receiving outpatient services, going home and receiving home health services or going to a SNF for post-acute rehab. Many patients recieve care in multiple PAC settings during a given episode. Figure 4: Analysis of Selected Discharge Patterns among Medicare PAC Users, 2006 PAC Setting 1 PAC Setting 2 PAC Setting 3 AH 4.6% SNF 2.7% Skilled Nursing Facility (SNF) 31.3% HH 7.8% OT 1.8% Acute Hospital (AH) Home Health (HH) 31.8% AH 6.0% OT 2.7% HH 1.5% Inpatient Rehabilitation Facility (IRF) 5.4% Outpatient Therapy (OT) 6.0% HH 2.8% OT 1.3% Note: Percentages indicate share of beneficiaries who completed transition through that point. Includes only patterns representing more than 1.3% of all transitions. Source: American Hospital Association 10

11 How Do PAC Providers Ensure Patient and Family Satisfaction? Engaging patients may be a new concept to some post-acute providers, but is a significant piece to ensuring success in the era of value-based care. Engaging caregivers and family members: Most patients go home after some degree of PAC, and remaining recovery time is usually overseen by caregivers, often a spouse, neighbor, or family member. Taking their cue from acute organizations, post-acute providers should use proactive efforts to engage these important members of the recovery team. It s likely that a patient will arrive at home with several different medications that look alike and have complex instructions. Postacute staff should offer appropriate teach backs on what medications to take, when and how they should be taken, and side effects to watch for. If wound care is required, education should review proper dressings and potential adverse events. Engaging with this audience is key not only to improving the patient s outcome but also impacting their entire experience of care. #3: Deploying a Framework for Partnering and Process Improvement Given the investment of time and resources dedicated to simply building a post-acute network, any sponsoring hospital or health system must be as equally interested in ensuring its long-term success. A high-performing post-acute network should emerge as an essential component of any organization s valued-based delivery system. To that end, it s essential to develop a framework that seeks quality outcomes and ongoing dialog among members around process and quality improvement. How Should Progress Be Measured? The role of outcome and quality metrics is central to a post-acute network, as the health system should desire to partner with providers that can address both quality and costs. Metrics additionally serve to distinguish the selected providers from others and to provide the basis by which participants will either remain in or be removed from the network. Developing Measures: Creating the quality measures or metrics should involve both the acute and post-acute organizations, and it should emphasize a core set of desired measures that address the challenges identified early in the network development process readmissions, rates of community discharge, post-acute utilization, patient satisfaction and so on. Some may parallel the system s broader quality measures; others might be specific to a particular post-acute setting. Both parties need to agree on defined metrics to monitor outcomes, improvement and quality. For example, utilization targets should be discussed by condition and also assessed based on needs of each patient. This is an evolutionary process and will require incremental development to set up preferred partners for success. Hospitals in Action: Regional Medical Center (ORANGEBURG, SC) The Regional Medical Center (RMC) put in place a program to reduce Heart Failure readmissions. Under the program, bundled Heart Failure patients are eligible for a one-time, free in-home visit by a home healthcare nurse within five to ten days post-discharge and a referral to the Heart Failure Clinic, which is part of the RMC Cardiopulmonary Rehabilitation program. The patient is asked during admission and arrangements are made prior to discharge. During the home care visit, the home healthcare nurse assesses the need for cardiac care, provides disease specific education, evaluates home medications and compares to hospital discharge medications, obtains vital signs, and assesses for signs and symptoms of worsening Heart Failure. If an issue is identified, the nurse will intervene. Cardiac rehab is available to patients with a diagnosis of Heart Failure. The program is free to all patients regardless of payer source. Patients go two times a week for 30 days. The nurses check their vital signs including weight, assess medications, and assess signs and symptoms of worsening heart failure. Patients also meet with a dietician. Leaders report these interventions have been the most successful tools at reducing readmissions. Reporting Data: While most forward-looking post-acute organizations deploy EHRs, many do not yet have the infrastructure in place to share data electronically within health IT systems. As such, partners must agree and establish quality reporting time frames and data submission practices to ensure consistency among network members and establish the bases for comparisons. Outcome data should be shared openly among participants and with patients to establish the network s credibility as a preferred destination for post-hospital care. What Are Strategies to Foster Continuous Improvement? Sharing data and quality information, however, is not enough. For the network to flourish, both the health system and the post-acute providers must see one another as real partners, meeting regularly to review quality data and trends, discussing clinical or operational challenges, and maintaining an open and frank dialog about continuous quality improvement. Expectations around these issues should be clearly defined as part of the preferred provider agreement discussed earlier. Supporting this interaction requires an established schedule of regular communication between the partners, be it weekly, monthly or quarterly. (The network management infrastructure explained earlier in this paper plays a key role in managing and maintaining this dialog.) Working in collaboration, the partners may ultimately evolve and improve a broad range of standardized network processes and practices, including: Uniform placement tools, care plans, documentation, assessments, transfer and admission processes Shared checklists and process maps Utilization guidelines and expectations Tools and training for episode/symptom assessment and early intervention to reduce emergency department visits or acute readmissions Defined practices for linking preferred post-acute partners with hospital case management 11