Outcome Measures: Reform at the Core: Page 1. The Triple Aim Goals. Getting Down into the Weeds

Transcription

1 Outcome Measures: Getting Down into the Weeds LeadingAge Missouri Fall Conference 18 September 2013 Andy Edeburn, VP of Continuum Strategies 2 Reform at the Core: The Triple Aim Goals Better Care Improve/maintain quality and patient outcomes Eliminate avoidable re/admissions Eliminate potentially preventable conditions (e.g., never events) Better Health Primary Care Driven Focus on Prevention & Wellness Reduce Cost Reduce/eliminate duplication Improved coordination Page 1

2 Value Based Payment Value Based Payment: a reform initiative whereby health care providers will receive payment for service based on their performance or the potential outcomes of the service Tying payment to performance is perhaps the most significant aspect of health care reform. The de facto definition of value in health care reform is the intersection of lower cost and improved quality. Providers who can lower costs and deliver quality will be measured as value based providers Lower Cost Improved Quality Increasing Intensity Around Measures 4 As the emphasis on quality goes up and reimbursement goes down, the intensity around measures will be profound. Evolving preferred or select provider networks are creating complex evaluative criteria and clearly defined expectations about ongoing participation. Managed care organizations (for Medicare Advantage and inevitably duals) while not on the record yet, have conceded that outcome performance over time will dictate many of their contracting and referring decisions. In almost every network scenario, measurement plays a key role in determining if you are on the field or on the bench. Evolving Network Measures for SNFs 5 Measurement sets like this represent the ground floor in evolving hospital and ACO SNF network environments. Core Measures: SNF % of patients readmitted to acute within 30 days of discharge all cause, all diagnosis # of patients referred to ED or Observation and returned to SNF setting within 24 hours % of patients discharged to home, community or a lower level lof care in 60 days or less # of patients discharged from SNF with home health services % of home health patients discharged to hospital VNS % of patients that would likely or very likely recommend facility to another person Average length of stay for Medicare FFS patients in postacute venue % of patients seen by primary care physician within 10 days of PAC discharge Page 2

3 6 Selection Criteria for Post Acute Partners: Today Demonstrated Access and Quality Outcomes Data proving low 30 day hospital readmission rate, across your post acute episode (SNF HHA) Low readmission rates during and following post acute episode Immediate admissions; competencies for high acuity, medically complex patients; solutions for difficult to place patients Appropriate use of hospice Integration with ACO Primary Care Physicians Embedding PCPs into post acute and senior services Communication; reporting; solutions for patients with non medical needs Care Management Care transitions (between all settings); care navigation beyond episode 7 Selection Criteria for Post Acute Partners: Tomorrow Cost Management Low cost provider with best outcomes Data on your costs of post acute episode by condition Care monitoring and management for at risk elders Health Information Technology (HIT) EHR connectivity with hospital, physicians, and other providers May be via health information exchange (HIE) Ability to Share Risk Shared savings/risk, payment bundles 8 On the Horizon MAP The Measures Application Partnership may change everything. Public private partnership convened by the National Quality Forum provides input to DHHS on selection and development of performance measures for reporting and performance based payment py systems. Charged with developing the quality standards that every provider must achieve. Will determine which data sources are to be used and how measurements will ultimately be calculated MAP composition is noteworthy, and the work results (to date) are extremely rigorous. Learn more: Source: MAP Strategic Plan: Page 3

4 PAC/LTC Performance 9 MAP published its Coordination Strategy for PAC and LTC Performance measurement report in February 2012 sets forth priority areas and core measurement goals across PAC/LTC. Source: Coordination Strategy for PAC and LTC Performance, February Think More About Measurement 10 Ask Yourself: What is your ability or track record to manage and SUCCEED with clinically or medically complex patients? How many short termterm patients do you readmit to the hospital in 30 days? What about 60 or 90 days? How many LTC residents do you send to the hospital as unplanned hospitalizations? How would patients or family members recommend your facility? More importantly how do you compare to others? What are your outcomes? 11 Starting Point Understanding the Key Metrics and Building Towards Value Based Healthcare Page 4

5 Defining Performance Measures 12 Outcomes Measures that demonstrate quality via patient outcomes Functional status improvement % of residents with pressure sores Hospitalization or readmission rate % of patient discharge to home in 60 days or less Process Measures that ensure certain best practices are being met Patient assessed upon admission for risk of readmit Medication reconciliation Influenza Immunization Patient evaluated for home health services Cost Measures of actual dollars spent, derived from claims data Average patient treatment costs by diagnosis or episode of care Variation from established benchmark or target Alternative site of care comparatives Interrelationships Will Inform and Drive Quality Background: Measurement, Metrics, and What s In Play 13 What We Know: SNF case mix has consistently intensified since hospitals moved to Prospective Payment (PPS) in 1982; this trend continues New Admissions (Medicare) Pre PPS (1982) Post PPS (1986) Tube Feeding 20.9% 28.6% UTI 6.7% 13.1% Oxygen 6.1% 14.3% Nursing home utilization has DECLINED in the same timeframes Fewer Patients but Sicker Patients Background: Measurement, Metrics, and What s In Play 14 What We Know (continued) Statistical correlation exists between SNF quality and staffing Physician care can have a significant impact on quality of nursing home care and outcomes Quality of care breaks down during transitions from one setting to the next Health information systems are underutilized in SNF, particularly in QA/QI and monitoring Improving quality (i.e., better outcomes) will require valid metrics, good data and proactive systemic approaches Source: A. Kramer, MD. Evolving Role of Quality Assessment and Outcome Assessment in Post Acute Care, NIC, 2011 Page 5

6 15 Readmissions Establishing a Standardized Readmissions Tracking Tool 16 Readmissions are the initial focal point since they represent the largest driver of costs following an initial hospitalization Therefore, implementing practices to track readmissions and avoidable admissions to acute hospitals will be critical into the future Providers must track readmission rates in a standardized fashion that is understandable to hospitals and payors and serve as the basis for readmissions reduction effort Being addressed in the clinical track via readmissions tracking and root cause analysis tools and assessments Readmission Tracking Tool Implementation 17 A tool must be used daily! 1. Integrate as key component of patient care management protocol 2. Should be used in evaluating any patient considered for hospital admission 3. Ideally employed real time to capture most reliable and meaningful data 4. May additionally require implementation of evidence based tools for patient assessment and management like INTERACT! Page 6

7 Strategies for Addressing Readmissions 18 Within Post Acute Facilities: improving clinical staff skill, developing care pathways, employing evidence based practice, securing additional physician support Within Patient Homes: increasing patient education, utilization care transition techniques, improving caregiver awareness, deploying technologies Among Providers: increased emphasis on communication and coordination of care, integrating EHR/HIT, developing joint or shared protocols Strategies for Addressing Readmissions 19 Additional Strategies for Addressing Readmissions Avoid generics with narrow therapeutic index medications Develop strategic plans of care for each patient diagnosis Use algorithm for nurses to ensure assessments and interventions are complete Require weekly family meetings and pre admission family meeting with hospital case manager Employ liaison to served as transition point of care between acute and post acute venues Require medical director on site 4 days/week Source: Case Management Monthly, January Patient Perception of Care Page 7

8 Patient Experience Opinion of Care 21 Perceptions equate to reality for patients and residents; their input is a critical measure moving forward If we listen to (i.e., document) resident concerns, we can learn a great deal; staff interaction, impressions of service, perceived outcomes Satisfaction is not the same as quality of life HOW you ask the questions matters Patient Perception of Care 22 Measuring Patient Perception Annual satisfaction survey processes, while important, are typically too late to identify emergent concerns and cannot provide real time CQI Short stay discharge surveys can be more effective in capturing immediate data Patient Perception of Care 23 Considering short stay discharge surveys: Tool should be brief; 15 to 20 questions with simple rating scale Simplicity is key for two reasons 1. Ease of patient completion 2. Ease of data entry and management for staff Tool should be employed on the day of discharge (as part of standard discharge practice) Page 8

9 Patient Perception of Care 24 Deploying patient perception data Survey data should be collated weekly for analysis and review Should be employed as component of weekly leadership meeting for immediate QI Should be reported as a running score; to staff, customers and potential partners Key dashboard component Survey tool should be modified and coordinated with future industry wide Consumer Assessment of Healthcare Providers and Systems (CAHPS) initiatives 25 Patient Outcomes/Functional Status Functional Status Improvement 26 Measuring patient ability at admission and again at discharge represents the true measure of what you can accomplish; real patient improvement Variety of different scales: FIM (Functional Independence Measurement) scale widely accepted functional assessment measure for rehabilitative care 18 item ordinal scale too, used primarily within inpatient rehab settings but has been adapted for use by some rehab intensive SNF organizations PRO: widely accepted, large benchmark dataset CON: can be expensive to adopt, primarily suited to IRF Proprietary scales; evolved by individual organizations to identify comparable measures Page 9

10 Functional Status Improvement 27 Possible to evolve your own metric Measuring improvements in functional status rest in the difference between BEFORE and AFTER It is possible for providers to develop their own measurement and benchmarks Patient s need for assistance by number of ADLs Patient s capacity for mobility or self ambulation; get out of bed, toileting, etc. Patient s ability to ambulate a certain distance; time Patient s ability to manage own care Functional Status Improvement 28 Many proprietary organizations are already marketing to outcomes, preparing for Accountable Care Source: HCR ManorCare, Quality Report Community Discharge Page 10

11 Community Discharge Rates 30 Encompasses the percentage of shortstay (Medicare) patients discharged to the community (i.e., home or community based care setting) Rate has shown little improvement over the last decade: 27.8% in 2011 Rate of Community Discharge 31 Community discharge is equated to quality but not necessarily a direct relationship Important to monitor potential acute hospital readmissions if SNF discharge is <30 days from acute hospital discharge Due to Readmissions Penalties and proposed hospital VBP rules for FY2015 Service After the Sale continued management of patients after discharge will play an important role Downstream continuum management: home health / AL Care transitions intervention or health coaching 32 Post Discharge Tracking Is Key to the Community Discharge Process Expand or evolve patient and family education to include discharge directions or suggestions specific to their condition Follow up with discharged patients (or family members) via telephone to assess their status and determine if they ve seen their primary care physician Partner with a home health agency to provide post SNF discharge care Page 11

12 33 Evolving Dashboards What is a Dashboard? 34 Dashboards represent an ideal method for collating and presenting different data streams in a singular document or format Can provide a snapshot view of business dynamics and identify key areas for improvement or correction Entirely dependent on quality data input Focus can be either singular or trend oriented Reference to benchmarks, if available, may be essential Highly effective tool when courting potential partners If the only tool you have is a hammer, you tend to see every problem as a nail. Abraham Maslow Get Started 35 Can You Evolve A Dashboard? You ll Need One 1. Pick your data points and start capturing your own data. 2. At the outset, benchmark against available references; absent establish numbers, benchmark against yourself, month to month. 3. Recognize that t a dashboard dis also a tool for improvement, so embrace Deming: Plan Do Check Act Cease dependence on inspection to achieve quality. Eliminate the need for massive inspection by building quality into the product in the first place. Page 12

13 36 Putting Data to Work: An Example Data About Hospitals Can Drive Business 37 For post acute organizations, hospitals are key but every hospital is different! For post acute providers, a one size fits all approach will not work forget the generic or singular strategy Discharges to a post acute venue vary greatly among hospitals some will use a SNF aggressively while others will refer to HHA more. Clinical strengths and weaknesses in the hospital lead to wide variations in LOS what one hospital does well, another does not. Understanding your own data and the differences among hospitals is the springboard for developing specific value based relationships with each organization Acute Hospital IPPS & DRGs 38 Hospitals paid for acute care inpatient stays on prospectively set rates IPPS. Each patient case (i.e., discharge) categorized into a diagnosisrelated group (MS DRG). Amount paid for each MS DRG based on weight, which assumes an average volume of resources used to treat the patient, and accounts for co morbidities and other frailty factors. 746 MS DRGs in Nine Major Diagnostic Categories Average (National) DRG Payment = $10,179 Payment also impacted by a series of other adjustments wage adjustment, medical education, DSH. Page 13

14 Examples: Stroke, COPD & Total Joint 39 PA MS DRG Pymt Type Description Wt GMLOS 061 No MED No MED Acute ischemic stroke w use of thrombolytic agent w CC No MED Acute ischemic stroke w use of thrombolytic agent w/o CC/MCC Yes MED Chronic obstructive pulmonary disease w MCC Yes MED Chronic obstructive pulmonary disease w CC Yes MED Chronic obstructive pulmonary disease w/o CC/MCC Yes SURG Major joint replacement or reattachment of lower extremity w MCC Yes SURG Major joint replacement or reattachment of lower extremity w/o MCC Subject to payment discount, if PA too early Average expected hospital stay Acute Hospital Discharge Behavior 410 Bed Tertiary Acute Care Hospital Michigan 40 MS-DRG Version 25 MS-DRG Name SNF Acute Medicare Hospital Part A Days Discharges CMS GMLOS Days ALOS at Hospital CMS GMLOS LOS Over (Under) GMLOS 871 Septicemia w/o MV 96+ hours w MCC 113 1, Respiratory infections & inflammations w MCC Major joint replacement or reattachment of lower extre Renal failure w MCC Rehabilitation w CC/MCC Hip & femur procedures except major joint w CC Pulmonary edema & respiratory failure Major joint replacement or reattachment of lower extre Acute myocardial infarction discharged alive w MCC Infectious & parasitic diseases w O.R. procedure w M Heart failure & shock w MCC Renal failure w CC Intracranial hemorrhage or cerebral infarction w MCC Syncope & collapse Intracranial hemorrhage or cerebral infarction w CC Respiratory infections & inflammations w CC Nonspecific cerebrovascular disorders w CC Kidney & urinary tract infections w MCC Septicemia w/o MV 96+ hours w/o MCC Nonspecific cerebrovascular disorders w MCC Total 643 5,539 3, Understanding the Intersection 41 The Partnership Development Matrix What You Know About the Hospital and Their CHALLENGES What You Know About Your Facility: Your OUTCOMES Your VALUE Page 14

15 If you think you can run your company the next ten years the way you ran it the last ten years, you are out of your mind CEO, Coca Cola 42 Questions 43 Thank You! 44 Andy Edeburn, MA VP of Continuum Strategies p: Page 15

16 Page 16