Winning at Care Coordination Using Data-Driven Partnerships

Size: px
Start display at page:

Download "Winning at Care Coordination Using Data-Driven Partnerships"

Transcription

1 Idriz Limaj, LNHA, RN Chief Operating Officer Winning at Care Coordination Using Data-Driven Partnerships Session #166, February 22, Steven Littlehale, MS, GCNS-BC EVP & Chief Clinical Officer

2 Speaker Introduction Idriz Limaj, LNHA, RN Chief Operating Officer LifeBridge Health Steven Littlehale, MS, GCNS-BC EVP & Chief Clinical Officer PointRight Inc. 2

3 Conflict of Interest Idriz Limaj, LNHA, RN Has no real or apparent conflicts of interest to report. Steven Littlehale, MS, GCNS-BC Has no real or apparent conflicts of interest to report. 3

4 Agenda What s going on in the post-acute world? What data is available from post-acute care? What are the steps for building and managing a high-performing post-acute provider network? How can predictive analytics play a role in managing the network? How can this advance population health management? 4

5 Learning Objectives Recognize the depth and breadth of available LTPAC data and what it can do for you public domain data, MDS data, OASIS Evaluate the critical components of a data-driven strategy for building and managing a smart network of LTPAC providers Discuss how predictive analytics can directly impact care coordination, reduce readmissions and optimize placements Develop the necessary steps for integrating LTPAC data into population health management programs 5

6 STEPS to Value An introduction to the benefits realized for the value of Health IT The value STEPS impacted were: Treatment/Clinical Patient Engagement & Population Management Savings Improved the Hospital discharge and admission process Improved the Nursing Home to Hospital transfer process Reduced overall risk-adjusted rehospitalization rate by 1.06 percentage points Improved LifeBridge Quality Score by 6.81% Improved overall Five-Star by 4.45% 6

7 What s Going On in the Post-Acute World? The journey to valuebased care New Measures HHVBP New Data New Measures Five-Star New Data New Data HVBP New Measures IMPACT Act New Measures Affordable Care 7 Act New Data SNFVBP New Measures New Data

8 There is an Alignment New Measures Five-Star New Data New Data IMPACT Act New Measures New Measures HHVBP New Data New Data HRRP New Data SNFVBP New Measures New Measures 8

9 HHS Payment Reform HHS announced targets to increase the number of payments that are linked to quality outcomes by We are setting clear goals and establishing a clear timeline for moving from volume to value in Medicare payments. Our first goal is for 30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide and to do it by Our goal would then be to get to 50% by Our second goal is for virtually all Medicare feefor-service payments to be tied to quality and value; at least 85% in 2016 and 90% in HHS Secretary Burwell Jan. 26,

10 Focus on Quality Payment is now aligning with quality. The Administration has set measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients. The final rule includes policies that advance that vision and support building a health care system that delivers better care, spends health care dollars more wisely and results in healthier people. CMS 8/3/

11 Understanding post-acute data And knowing what it can do for you 11

12 Available Data: Home Health Agencies (HHAs) The Outcome and Assessment Information Set (OASIS) Home health quality measures (both outcome and process measures) Medicare claims Medicare claims data is used to calculate certain utilization-based home health quality measures. The patient experience of care survey uses the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) instrument. Medicare.gov/HomeHealthCompare 12

13 Available Data: Skilled Nursing Facilities (SNFs) CMS s health inspection database Nursing home characteristics and health deficiencies issued and data about staffing and penalties The Minimum Data Set (MDS) Clinical data for quality measures come from the MDS Repository Medicare claims Medicare claims data is used to calculate certain utilization-based home health quality measures Medicare.gov/NursingHomeCompare Many states have unique data sets/report cards 13

14 Available Data: Metrics in the Future IMPACT Act QRP Measures and C-CDA files Long-Term Care Hospitals (LTCHs): LTCH Care Data Set (LCDS) Skilled Nursing Facilities (SNFs): Minimum Data Set (MDS) Home Health Agencies (HHAs): OASIS Inpatient Rehabilitation Facilities (IRFs): IRF-Patient Assessment Instrument (IRF-PAI) 14

15 The critical components of a data-driven strategy Building and managing Smart LTPAC provider networks 15

16 Building a Narrow vs. Smart Network NARROW NETWORKS Efficient Geared toward the stakeholder SMART NETWORKS Customized to fit patients needs High Performance/Data-driven 16

17 Three Keys to Success Transparent Standardized Operational 17

18 LifeBridge Health Overview Leading provider of hospital services in northwestern Baltimore and all of Carroll County, Maryland $1.8B health system 4 hospitals 249 nursing home beds (1 free-standing, 1 TCU) ~550 employed physicians ~2,000 employed nurses 100+ locations 22 urgent care sites 18

19 SNF Collaborative A Preferred Network The SNF Collaborative was developed to: Create a network that is focused on quality and patient experience Enhance patient outcomes while reducing the cost of care Standardize and share best practices across systems Enhance problem-solving and collective navigation within today s healthcare landscape 19

20 Continuum of Care PRIMARY CARE, PREVENTION, WELLNESS AMBULATORY CARE ACUTE CARE, TERTIARY CARE POST-ACUTE CARE 20

21 Ongoing Performance Monitoring Metrics Quality Rehospitalization Patient and family satisfaction Goals Improve scores by 10% annually if below state average Improve scores by 20% annually if above state average 21

22 The Collaborative Dashboard Transparency. Standardization. Operational. 22

23 23

24 Pro30 Rehospitalization for Collaborative 20% 19% 18% 17% 16% 18.6% 18.1% 19.0% 19.1% 18.5% 18.5% 18.6% 18.7% 18.1% 18.2% 18.3% 18.2% 18.2% 17.8% 17.8% 17.8% 17.5% 17.0% 17.1% 16.8% 17.3% 17.0% 17.1% 16.8% 15% Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Observed Adjusted 24

25 SNF Outcomes to Date Transparency and data exchange drive change: Improved the Hospital discharge and admission process Improved the Nursing Home to Hospital transfer process Reduced overall adjusted rehospitalization rate by 1.06 percentage points Improved quality metrics by 6.81% Improved overall Five-Star by 4.45% 25

26 Next Steps for the SNF Collaborative Leverage a Smart network for discharge planning Discharge patients to the right setting based on outcomes Standardized clinical pathways based on best practices CHF, UTI, COPD, Pneumonia, Diabetes Reduce costs Monitor length of stay and quality outcomes Investigate acute care end of life admissions 26

27 The power of predictive analytics Knowing what to look for so you can better prepare for what lies ahead 27

28 Choose the Right Benchmarks When it comes to using your data, it s not just about choosing the right outcomes it s about choosing the right benchmarks AND proper risk adjustment. 28

29 Risk Adjusted Rehospitalization Rates Nation 15% and below 15% to 18% 18% and above Source: Original PointRight Research

30 Observed vs. Risk Adjusted Rehospitalization Rates California Observed Risk-Adjusted 12% and below 12% to 20% 20% and above Source: Original PointRight Research

31 Predictive Analytics = Better Partnerships PointRight Post-Acute Grades vs. the CMS Five-Star Ratings Chronic Obstructive Pulmonary Disease (COPD) 2% Points Difference 9% Points Difference CMS 5 Star Ranking PointRight Grade % 19.3% 19.5% 20.0% 21.1% A B C D E 16.0% 17.3% 19.0% 21.3% 24.9% 2% Points Difference 10% Points Difference CMS 5 Star Ranking PointRight Grade Post-Operative Care (All Procedures) % 19.1% 20.0% 19.1% 20.0% A B C D E 14.1% 17.0% 18.4% 20.8% 24.4% 33

32 1 and 2 Star SNFs Might be Best Choice in Some Markets

33 Care Processes at One SNF CARE PROCESSES AND OUTCOMES Measure Group State National Pain Management: % of Patients 50% 33% 38% 51% Advanced Directives: % of Patients 2% 20% 20% 59% Behavior Management Ratio 5% 40% 42% 80% Diagnosed with Depression: % of Patients 17% 35% 38% 41% Facility Acquired Contractors: % of Patients 6% 5% 6% 2% Hospice Care Utilization 8% 5% 5% 4% Respiratory Therapy: % of Patients 13% 7% 9% 13% Observed Drug Administration Errors No 36 Source: Original PointRight Research 2016

34 Average Length of Stay (ALOS) Year State Median 2012 Nation Nation Nation Nation 22 Year State Median 2015 Nation AL FL MD MA MS TX Source: Original PointRight Research 2016

35 What Impacts Average Length of Stay? State Cognitive Impairment Nation No 22 Nation Yes 25 Median State Incontinence Median Nation No 21 Nation Yes 28 State Pain Median Nation No 22 Nation Yes 24 State Depression Median Nation No 22 Nation Yes 27 Source: Original PointRight Research

36 What s next for LTPAC data? Accelerating population health management 39

37 Performance by Clinical Cohort 40

38 COPD at One SNF Source: 41

39 Source:

40 Summary Data is abundant; turning it into action requires an extra layer of intelligence ACTION Partnerships are best achieved through metrics that are: TRANSPARENT STANDARDIZED OPERATIONAL Alignment and communication improve outcomes INTELLIGENCE DATA 44

41 STEPS to Value A summary of the benefits realized for the value of Health IT The value STEPS impacted were: Treatment/Clinical Patient Engagement & Population Management Savings Improved the Hospital discharge and admission process Improved the Nursing Home to Hospital transfer process Reduced overall risk-adjusted rehospitalization rate by 1.06 percentage points Improved LifeBridge Quality Score by 6.81% Improved overall Five-Star by 4.45% 45

42 Questions Idriz Limaj, LNHA, RN Chief Operating Officer Steven Littlehale, MS, GCNS-BC EVP & Chief Clinical 46

Physician Performance Analytics: A Key to Cost Savings

Physician Performance Analytics: A Key to Cost Savings Physician Performance Analytics: A Key to Cost Savings Session #90, February 21, 2017 Jim Gera, SVP of Business Development, Signature Medical Group, Inc. 1 Speaker Introduction Jim Gera, MBA SVP of Business

More information

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016 Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver HEALTH FORUM AND AHA LEADERSHIP SUMMIT JULY 18, 2016 SAN DIEGO, CALIFORNIA Please note that the views expressed are those of the conference

More information

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016

Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver JULY 18, 2016 Post-Acute Care Networks: How to Succeed and Why Many Fail to Deliver HEALTH FORUM AND AHA LEADERSHIP SUMMIT JULY 18, 2016 SAN DIEGO, CALIFORNIA Please note that the views expressed are those of the conference

More information

Post-Acute Care. December 6, 2017 Webinar Louise Bryde and Doug Johnson

Post-Acute Care. December 6, 2017 Webinar Louise Bryde and Doug Johnson Post-Acute Care December 6, 2017 Webinar Louise Bryde and Doug Johnson Topics for Discussion Background What Is Post Acute Care? Lexicon Levels of Care Why Focus on Post Acute Care? Emerging PAC Trends

More information

Emerging Issues in Post Acute Care Trends

Emerging Issues in Post Acute Care Trends Emerging Issues in Post Acute Care Trends Lavonne Elston, PT Senior Director of Operations & Strategic Initiatives Skilled Nursing & Rehabilitation Kingston HealthCare Company April 28, 2016 Disclosures

More information

Maximizing the Power of Your Data. Peggy Connorton, MS, LNFA AHCA Director, Quality and LTC Trend Tracker

Maximizing the Power of Your Data. Peggy Connorton, MS, LNFA AHCA Director, Quality and LTC Trend Tracker Maximizing the Power of Your Data Peggy Connorton, MS, LNFA AHCA Director, Quality and LTC Trend Tracker Objectives Explore selected LTC Trend Tracker reports & features including: re-hospitalization,

More information

Changes to CMS Five-Star: What Investors and Operators Need to Know

Changes to CMS Five-Star: What Investors and Operators Need to Know Changes to CMS Five-Star: What Investors and Operators Need to Know Thursday, March 8, 2018 4:00 PM 5:15 PM Dallas Ballroom F #NICForum18 Please Complete the Session Evaluation Mobile App Home Page Session

More information

Overview of Home Health Star Ratings

Overview of Home Health Star Ratings Overview of Home Health Star Ratings September 23, 2015 Presented by: Liz Silva Deyta Analytics, a division of HEALTHCAREfirst Agenda Home Health Star Ratings Quality of Patient Care Star Rating Patient

More information

Using EHRs and Case Management to Improve Patient Care and Population Health

Using EHRs and Case Management to Improve Patient Care and Population Health Using EHRs and Case Management to Improve Patient Care and Population Health Session #211, February 22, 2017 Thomas Schiller, MD and Jennifer Kuroda, SwedishAmerican Health System A Division of UW 1 Speaker

More information

Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings

Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings May 11, 2009 Avalere Health LLC Avalere Health LLC The intersection

More information

5D QAPI from an Operational Approach. Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Pathway Health 2013

5D QAPI from an Operational Approach. Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Pathway Health 2013 5D QAPI from an Operational Approach Christine M. Osterberg RN BSN Senior Nursing Consultant Pathway Health Objectives Review the post-acute care data agenda. Explain QAPI principles Describe leadership

More information

Data-Driven Strategy for New Payment Models. Objectives. Common Acronyms

Data-Driven Strategy for New Payment Models. Objectives. Common Acronyms Data-Driven Strategy for New Payment Models Mark Sharp, CPA Partner msharp@bkd.com Objectives Understand new payment model reforms and bundling arrangements Learn how these new payment models can impact

More information

4/9/2016. The changing health care market THE CHANGING HEALTH CARE MARKET. CPAs & ADVISORS

4/9/2016. The changing health care market THE CHANGING HEALTH CARE MARKET. CPAs & ADVISORS CPAs & ADVISORS experience support // ADVANCED PAYMENT MODELS: CJR Eric. M. Rogers MEd. RT(R) Managing Consultant The changing health care market THE CHANGING HEALTH CARE MARKET HHS goal of 30% of traditional

More information

Quality Management Report 2017 Q2

Quality Management Report 2017 Q2 Quality Management Report 2017 Q2 Quality Management Program CMS STAR Ratings Member Satisfaction (CAHPS & HOS) HEDIS Risk Adjustment DHS Member Incident Reporting Member Satisfaction Surveys Pay for Performance

More information

Using Structured Post Acute Assessment Data as the Raw Material for Predictive Modeling. Speaker: Thomas Martin November 2014

Using Structured Post Acute Assessment Data as the Raw Material for Predictive Modeling. Speaker: Thomas Martin November 2014 Using Structured Post Acute Assessment Data as the Raw Material for Predictive Modeling Speaker: Thomas Martin November 2014 1 Learning Objectives SNF s place in continuum of care Large variance across

More information

Activity Based Cost Accounting and Payment Bundling

Activity Based Cost Accounting and Payment Bundling Activity Based Cost Accounting and Payment Bundling 1 Agenda Introduction of Speakers Fast Facts about Jewish Senior Life/Jewish Home of Rochester Determining the need and uses for an Activity Based Cost

More information

Taming Length of Stay Challenges Through Analytics

Taming Length of Stay Challenges Through Analytics Taming Length of Stay Challenges Through Analytics March 3, 2016 Dr. Michelle Pezzani, Medical Director Utilization Management at El Camino Hospital & Palo Alto Medical Foundation (PAMF) Petrina Griesbach

More information

Executive Summary MEDICARE FEE-FOR-SERVICE (FFS) HOSPITAL READMISSIONS: QUARTER 4 (Q4) 2012 Q STATE OF CALIFORNIA

Executive Summary MEDICARE FEE-FOR-SERVICE (FFS) HOSPITAL READMISSIONS: QUARTER 4 (Q4) 2012 Q STATE OF CALIFORNIA MEDICARE FEE-FOR-SERVICE (FFS) HOSPITAL READMISSIONS: QUARTER 4 (Q4) 2012 Q3 2013 Executive Summary STATE OF CALIFORNIA The Centers for Medicare & Medicaid Services (CMS) has tasked Health Services Advisory

More information

Medicare / Accountable Care Organization CHS Finance Division CPE Day November 2, 2015

Medicare / Accountable Care Organization CHS Finance Division CPE Day November 2, 2015 Medicare / Accountable Care Organization CHS Finance Division CPE Day November 2, 2015 Steve Neorr Chief Administrative Officer, Triad HealthCare Network Jeff Jones Chief Financial Officer, Cone Health

More information

Managing Healthcare Payment Opportunity Fundamentals CENTER FOR INDUSTRY TRANSFORMATION

Managing Healthcare Payment Opportunity Fundamentals CENTER FOR INDUSTRY TRANSFORMATION Managing Healthcare Payment Opportunity Fundamentals dhgllp.com/healthcare 4510 Cox Road, Suite 200 Glen Allen, VA 23060 Melinda Hancock PARTNER Melinda.Hancock@dhgllp.com 804.474.1249 Michael Strilesky

More information

FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge. July 24, 2018

FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge. July 24, 2018 FHA HIIN Readmissions Peer Sharing Webinar: Improving Care Transitions through a Discharge Lounge July 24, 2018 Welcome & Overview How are we doing on Reducing Readmissions? Peer Sharing Presentation:

More information

POST-ACUTE CARE Savings for Medicare Advantage Plans

POST-ACUTE CARE Savings for Medicare Advantage Plans POST-ACUTE CARE Savings for Medicare Advantage Plans TABLE OF CONTENTS Homing In: The Roles of Care Management and Network Management...3 Care Management Opportunities...3 Identify the Most Efficient Care

More information

Succeeding in a New Era of Health Care Delivery

Succeeding in a New Era of Health Care Delivery March 14, 2012 Succeeding in a New Era of Health Care Delivery Building Value-Based Partnerships LeadingAge Pennsylvania Kathleen Griffin, PhD, National Director Post-Acute and Senior Services 1 Your Presenter

More information

Managing Risk Through Population Health Initiatives

Managing Risk Through Population Health Initiatives Managing Risk Through Health Initiatives Vicki DeBaca, DNS, RN Vice President, Health & Provider Services Sharp Rees-Stealy Medical Centers 1 Sharp Rees-Stealy Medical Centers San Diego s Multi-Specialty

More information

CAMDEN CLARK MEDICAL CENTER:

CAMDEN CLARK MEDICAL CENTER: INSIGHT DRIVEN HEALTH CAMDEN CLARK MEDICAL CENTER: CARE MANAGEMENT TRANSFORMATION GENERATES SAVINGS AND ENHANCES CARE OVERVIEW Accenture helped Camden Clark Medical Center, (CCMC), a West Virginia-based

More information

Quality Measure Indicators +Throughput Metrics + Automated Dashboard = Innovation to Improve Quality Goals

Quality Measure Indicators +Throughput Metrics + Automated Dashboard = Innovation to Improve Quality Goals Quality Measure Indicators +Throughput Metrics + Automated Dashboard = Innovation to Improve Quality Goals DMC Harper- Hutzel Hospital The DMC is an 8 facility academic medical center Harper-Hutzel is

More information

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario

Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario 4/1/2014 This document is intended to provide health care organizations in Ontario with guidance as to how they can develop

More information

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

A Brave New World: Lessons Learned From Healthcare Reform. Brandy Shumaker, MBA, LPTA, LNHA Regional Vice President HealthPRO/Heritage A Brave New World: Lessons Learned From Healthcare Reform Brandy Shumaker, MBA, LPTA, LNHA Regional Vice President HealthPRO/Heritage 1 Learning Objectives Participants will understand: The impact health

More information

Skills, Technologies & Attributes Case Managers Need to Succeed In Value- Based Care

Skills, Technologies & Attributes Case Managers Need to Succeed In Value- Based Care Skills, Technologies & Attributes Case Managers Need to Succeed In Value- Based Care January 19, 2017 Kimberly S. Hodge, MSN, RN, ACNS-BC, CCRN-K Learning Objectives After attending this presentation,

More information

California s Health Homes Program

California s Health Homes Program California s Health Homes Program HPSM Network Webinar 9/05/18 Goals for Today: Health Homes Program overview CB-CME requirements Program readiness and implementation timeline Gather take-away questions

More information

MEASURING POST ACUTE CARE OUTCOMES IN SNFS. David Gifford MD MPH American Health Care Association Atlantic City, NJ Mar 17 th, 2015

MEASURING POST ACUTE CARE OUTCOMES IN SNFS. David Gifford MD MPH American Health Care Association Atlantic City, NJ Mar 17 th, 2015 MEASURING POST ACUTE CARE OUTCOMES IN SNFS David Gifford MD MPH American Health Care Association Atlantic City, NJ Mar 17 th, 2015 Principles Guiding Measure Selection PAC quality measures need to Reflect

More information

Introduction 4/7/2015

Introduction 4/7/2015 The Perfect Storm: A Distinguished Post-Acute Rehabilitation Program (Session # W25) Wednesday April 29 th, 2:30-4:30 Presented by: Hilary Forman PT, RAC-CT Senior Vice President of Clinical Strategies

More information

Health Care Systems - A National Perspective Erica Preston-Roedder, MSPH PhD

Health Care Systems - A National Perspective Erica Preston-Roedder, MSPH PhD Health Care Systems - A National Perspective Erica Preston-Roedder, MSPH PhD Outline Quality Overview Overview and discussion of CMS programs Increasing transparency Move from P4R to P4P Expanding beyond

More information

The President s and Other Bipartisan Proposals to Reform Medicare: Post-Acute Care (PAC) Reform. Summary

The President s and Other Bipartisan Proposals to Reform Medicare: Post-Acute Care (PAC) Reform. Summary Current Law The President s and Other Bipartisan Proposals to Reform Medicare: Post-Acute Care (PAC) Reform Summary Home Health Agencies Under current law, beneficiaries who are generally restricted to

More information

Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery

Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery Breaking Down Silos of Care: Integration of Social Support Services with Health Care Delivery Betty Shephard Lead VP, Care Management HealthCare Partners National Health Policy Forum October 19, 2012 HCP

More information

CY 2018 Home Health PPS Proposed Rule

CY 2018 Home Health PPS Proposed Rule CY 2018 Home Health PPS Proposed Rule Rochelle Archuleta & Caitlin Gillooley AHA Policy August 24, 2017 CY 2018 Proposed Rule Published in July 28 Federal Register Net Reduction: 0.4%, -$80m Same for facility-based

More information

West Valley and Central Valley Care Coordination Coalitions

West Valley and Central Valley Care Coordination Coalitions West Valley and Central Valley Ettie Lande, MS, BSN, ACM-RN February 08, 2018 Thank You! For sponsoring today s breakfast AstraZeneca and Cyndi Black If you can sponsor breakfast at an upcoming community

More information

Introducing the Discharge to Community Quality Measure

Introducing the Discharge to Community Quality Measure Introducing the Discharge to Community Quality Measure Rachel Delavan, Director of Research Dawn Murr-Davidson, RN BSN, Director of Quality Initiatives October 20, 2015 1 Objectives Define the discharge

More information

CPAs & ADVISORS. experience support // ADVANCED PAYMENT MODELS: CJR

CPAs & ADVISORS. experience support // ADVANCED PAYMENT MODELS: CJR CPAs & ADVISORS experience support // ADVANCED PAYMENT MODELS: CJR Andy M. Williams Partner BKD Eric M. Rogers Managing Consultant BKD Will McLeod VP of Patient Services McLeod Health Emily Adams Associate

More information

Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings

Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings Medicare Spending and Rehospitalization for Chronically Ill Medicare Beneficiaries: Home Health Use Compared to Other Post-Acute Care Settings Executive Summary The Alliance for Home Health Quality and

More information

PHCA Webinar January 30, Latsha Davis & McKenna, P.C. Kimber L. Latsha, Esq.

PHCA Webinar January 30, Latsha Davis & McKenna, P.C. Kimber L. Latsha, Esq. PHCA Webinar January 30, 2014 Latsha Davis & McKenna, P.C. Kimber L. Latsha, Esq. 1 2 Intended to: Encourage the development of ACOs in Medicare Promotes accountability for a patient population and coordinates

More information

L19: Improving Transitions from the Hospital to Post Acute Care Settings

L19: Improving Transitions from the Hospital to Post Acute Care Settings This presenter has nothing to disclose L19: Improving Transitions from the Hospital to Post Acute Care Settings Gail A. Nielsen December 8, 2013 25th Annual National Forum on Quality Improvement in Health

More information

Integrating Quality Into Your CDI Program: The Case for All-Payer Review

Integrating Quality Into Your CDI Program: The Case for All-Payer Review 7th Annual Association for Clinical Documentation Improvement Specialists Conference Integrating Quality Into Your CDI Program: The Case for All-Payer Review Katy Good, RN, BSN, CCDS, CCS CDI Program Coordinator

More information

MCOs Revealed: Strategies for Building Strong Hospital & Referral Relationships

MCOs Revealed: Strategies for Building Strong Hospital & Referral Relationships MCOs Revealed: Strategies for Building Strong Hospital & Referral Relationships June 2014 avalerehealth.net Today s Panelists John Hackett - JHackett@extendicare.com o Vice President of Strategy & Development,

More information

Readmission Program. Objectives. Todays Inspiration 9/17/2018. Kristi Sidel MHA, BSN, RN Director of Quality Initiatives

Readmission Program. Objectives. Todays Inspiration 9/17/2018. Kristi Sidel MHA, BSN, RN Director of Quality Initiatives The In s and Out s of the CMS Readmission Program Kristi Sidel MHA, BSN, RN Director of Quality Initiatives Objectives General overview of the Hospital Readmission Reductions Program Description of measures

More information

PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management

PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management PRISM Collaborative: Transforming the Future of Pharmacy PeRformance Improvement for Safe Medication Management Mission: To improve the health of the people of Connecticut through safe and effective medication

More information

Readmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ. A Catholic healthcare ministry serving Ohio and Kentucky

Readmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ. A Catholic healthcare ministry serving Ohio and Kentucky Readmission Project 2017 Janice M. Maupin, RN, MSN, CPHQ A Catholic healthcare ministry serving Ohio and Kentucky 1 Mission, Values and Promise Our Mission We extend the healing ministry of Jesus by improving

More information

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred 1

POPULATION HEALTH PLAYBOOK. Mark Wendling, MD Executive Director LVPHO/Valley Preferred   1 POPULATION HEALTH PLAYBOOK Mark Wendling, MD Executive Director LVPHO/Valley Preferred www.populytics.com 1 Today s Agenda Outline LVHN, LVPHO and Populytics Overview Population Health Approach Population

More information

Outcomes Measurement in Long-Term Care (LTC)

Outcomes Measurement in Long-Term Care (LTC) ASHA Short Course Outcomes Measurement in Long-Term Care (LTC) Bill Goulding, MS/CCC-SLP November 19, 2012 How Do We Show Value? Easy to measure! Not so easy! V $$$ A L Impact? Cost U Benefit E What do

More information

Home Health Value-Based Purchasing Series: HHVBP Model 101. Wednesday, February 3, 2016

Home Health Value-Based Purchasing Series: HHVBP Model 101. Wednesday, February 3, 2016 Home Health Value-Based Purchasing Series: HHVBP Model 101 Wednesday, February 3, 2016 About the Alliance 501(c)(3) non-profit research foundation Mission: To support research and education on the value

More information

Reducing Medicaid Readmissions

Reducing Medicaid Readmissions Reducing Medicaid Readmissions Webinar 1: Medicaid Readmissions 101 Amy E. Boutwell, MD MPP Co-Principal Investigator AHRQ Reducing Medicaid Readmissions Project February 25 2015 Agenda Introduction to

More information

Value Based Care in LTC: The Quality Connection- Phase 2

Value Based Care in LTC: The Quality Connection- Phase 2 Value Based Care in LTC: The Quality Connection- Phase 2 Joseph J. Tomaino, M.S., R.N., Principal Healthcare Transformation Consulting ChemRx/PharmMerica Geriatric Skilled Nursing Seminar December 7, 2017

More information

Maximize the Value of Your Data with LTC Trend Tracker. Peggy Connorton, MS LNFA Director, Quality and LTC Trend Tracker

Maximize the Value of Your Data with LTC Trend Tracker. Peggy Connorton, MS LNFA Director, Quality and LTC Trend Tracker Maximize the Value of Your Data with LTC Trend Tracker Peggy Connorton, MS LNFA Director, Quality and LTC Trend Tracker http://www.mushroomnetworks.com/infographi cs/the-landscape-of-big-data-infographic

More information

Creating a Virtual Continuing Care Hospital (CCH) to Improve Functional Outcomes and Reduce Readmissions and Burden of Care. Opportunity Statement

Creating a Virtual Continuing Care Hospital (CCH) to Improve Functional Outcomes and Reduce Readmissions and Burden of Care. Opportunity Statement Creating a Virtual Continuing Care Hospital (CCH) to Improve Functional Outcomes and Reduce Readmissions and Burden of Care Robert D. Rondinelli, MD, PhD Paulette Niewczyk, MPH, PhD AlphaFIM, FIM, SigmaFIM,

More information

Journey in managing practice variation in Diabetes and Hypertension (Part 2/2)

Journey in managing practice variation in Diabetes and Hypertension (Part 2/2) Journey in managing practice variation in Diabetes and Hypertension (Part 2/2) For Part 1 of this presentation, go to http://rightcare.berkeley.edu/sacramento-university-of-best-practices Parag Agnihotri,

More information

Improving Patient Safety Across Michigan and Illinois

Improving Patient Safety Across Michigan and Illinois Improving Patient Safety Across Michigan and Illinois Readmissions Collaborative Kickoff January 20, 2016 1 Agenda Readmissions Collaborative Structure and Overview Business case for readmissions Using

More information

Advancing Popula/on Health and Consumerism

Advancing Popula/on Health and Consumerism Advancing Popula/on Health and Consumerism 44,954 Senior Enrollees 274,345 Commercial Enrollees 66,070 Commercial ACO Members Popula/on Health Risk Stra/fica/on: Keep Pa/ents Healthy, Happy & at Home Tier

More information

MEDICARE UPDATES: VBP, SNF QRP, BUNDLING

MEDICARE UPDATES: VBP, SNF QRP, BUNDLING MEDICARE UPDATES: VBP, SNF QRP, BUNDLING PRESENTED BY: ROBIN L. HILLIER, CPA, STNA, LNHA, RAC-MT ROBIN@RLH-CONSULTING.COM (330)807-2850 MEDICARE VALUE BASED PURCHASING 1 PROTECTING ACCESS TO MEDICARE ACT

More information

Glendale Healthier Community Care Coordination Collaborative. Health Services Advisory Group (HSAG) March 06, 2018

Glendale Healthier Community Care Coordination Collaborative. Health Services Advisory Group (HSAG) March 06, 2018 Glendale Healthier Community Care Coordination Collaborative Health Services Advisory Group (HSAG) March 06, 2018 Today s Agenda and Packet Materials Welcome and Introductions Community Readmissions and

More information

Advanced Illness Management Leveraging Person Centered Care and Reengineering the Care Team Across the Continuum

Advanced Illness Management Leveraging Person Centered Care and Reengineering the Care Team Across the Continuum Advanced Illness Management Leveraging Person Centered Care and Reengineering the Care Team Across the Continuum Betsy Gornet, FACHE Chief Advanced Illness Management Executive Sutter Health / Sutter Care

More information

August 25, Dear Ms. Verma:

August 25, Dear Ms. Verma: Seema Verma Administrator Centers for Medicare & Medicaid Services Hubert H. Humphrey Building 200 Independence Avenue, S.W. Room 445-G Washington, DC 20201 CMS 1686 ANPRM, Medicare Program; Prospective

More information

PREPARING FOR RISK-BASED OUTCOMES OF BUNDLED CARE

PREPARING FOR RISK-BASED OUTCOMES OF BUNDLED CARE CPAs & ADVISORS experience support // PREPARING FOR RISK-BASED OUTCOMES OF BUNDLED CARE Jackie Nussbaum MHA, CPC, CHFP, FHFMA Director Eric Rogers M.Ed. RT Managing Consultant THE CHANGING HEALTH CARE

More information

Reducing Readmissions: Potential Measurements

Reducing Readmissions: Potential Measurements Reducing Readmissions: Potential Measurements Avoid Readmissions Through Collaboration October 27, 2010 Denise Remus, PhD, RN Chief Quality Officer BayCare Health System Overview Why Focus on Readmissions?

More information

Health Reform and IRFs

Health Reform and IRFs American Medical Rehabilitation Providers Association 8 th Annual AMRPA Educational Conference New Orleans, LA Health Reform and IRFs Planning Today for Success Tomorrow October 14, 2010 Agenda Introduce

More information

Banner Health Friday, February 20, 2015

Banner Health Friday, February 20, 2015 Banner Health Friday, February 20, 2015 Leveraging the Power of Clinical and Business Intelligence: A Primer Presented by: Dr. Maxine Rand, DNP, RN-BC, CPHIMS, Director, Clinical Education, Practice and

More information

4/22/2018. Redesign and Reimage Long Term Care for the Future. Health Care Landscape Change. Disclosure of Commercial Interests

4/22/2018. Redesign and Reimage Long Term Care for the Future. Health Care Landscape Change. Disclosure of Commercial Interests Redesign and Reimage Long Term Care for the Future Lisa Thomson Chief Strategy and Marketing Officer www.pathwayhealth.com Disclosure of Commercial Interests We consult for the following organization:

More information

Session 10: Integrating Data and Analytics into Provider Workflows Improves ACO Quality and Financial Performance

Session 10: Integrating Data and Analytics into Provider Workflows Improves ACO Quality and Financial Performance Session 10: Integrating Data and Analytics into Provider Workflows Improves ACO Quality and Financial Performance Joan Valentine, MSA, RN Executive Vice President Visiting Physicians Association David

More information

Medicare Skilled Nursing Facility Prospective Payment System

Medicare Skilled Nursing Facility Prospective Payment System Final Rule Summary Medicare Skilled Nursing Facility Prospective Payment System Program Year: FY2019 August 2018 1 TABLE OF CONTENTS Overview and Resources... 2 SNF Payment Rates... 2 Wage Index and Labor-Related

More information

How to Win Under Bundled Payments

How to Win Under Bundled Payments How to Win Under Bundled Payments Donald E. Fry, M.D., F.A.C.S. Executive Vice-President, Clinical Outcomes MPA Healthcare Solutions Chicago, Illinois Adjunct Professor of Surgery Northwestern University

More information

SNF REHOSPITALIZATIONS

SNF REHOSPITALIZATIONS SNF REHOSPITALIZATIONS David Gifford MD MPH SVP Quality & Regulatory Affairs National Readmission Summit Arlington VA Dec 6 th, 2013 Use of Long Term Care Services 19% 4 35% 2 20% 1 23% 1 20% 3 1. Mor

More information

Patient Navigator Program

Patient Navigator Program Using Patient Navigators and Education to Improve Post-Acute Transitions Emerging innovators in post-acute care delivery models are finding ways to provide patient-centered, quality care to integrate today

More information

Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability

Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability Leveraging the Accountable Care Unit Model to create a culture of Shared Accountability How we improved Patient Safety and Quality Outcomes at Northwest Hospital Our Journey to Shared Accountability Implementation

More information

CAHPS Focus on Improvement The Changing Landscape of Health Care. Ann H. Corba Patient Experience Advisor Press Ganey Associates

CAHPS Focus on Improvement The Changing Landscape of Health Care. Ann H. Corba Patient Experience Advisor Press Ganey Associates CAHPS Focus on Improvement The Changing Landscape of Health Care Ann H. Corba Patient Experience Advisor Press Ganey Associates How we will spend our time together Current CAHPS Surveys New CAHPS Surveys

More information

HOSPITALS & HEALTH SYSTEMS: DATA-DRIVEN STRATEGY FOR BUNDLED PAYMENT SUCCESS 4/19/2016. April 20, 2016

HOSPITALS & HEALTH SYSTEMS: DATA-DRIVEN STRATEGY FOR BUNDLED PAYMENT SUCCESS 4/19/2016. April 20, 2016 HOSPITALS & HEALTH SYSTEMS: DATA-DRIVEN STRATEGY FOR BUNDLED PAYMENT SUCCESS April 20, 2016 Eddie Marmouget National Industry Partner emarmouget@bkd.com Eric Rogers Managing Consultant erogers@bkd.com

More information

Home Health. Improving Patient Outcomes & Reducing Readmissions. Home Health: Improving Outcomes & Reducing Readmissions

Home Health. Improving Patient Outcomes & Reducing Readmissions. Home Health: Improving Outcomes & Reducing Readmissions Home Health Improving Patient Outcomes & Reducing Readmissions Home Health: Improving Outcomes & Reducing Readmissions Benefits of Home Health Care Scientific evidence proves people heal more quickly,

More information

The STAAR Initiative

The STAAR Initiative The STAAR Initiative A quality effort at the heart of system redesign Amy E. Boutwell, MD, MPP The Center for Innovative Healthcare Strategies amy@innovativehealthcarestrategies.org Please note: Dr Boutwell

More information

Exhibit 1. Medicare Shared Savings Program: Year 1 Performance of Participating Accountable Care Organizations (2013)

Exhibit 1. Medicare Shared Savings Program: Year 1 Performance of Participating Accountable Care Organizations (2013) Exhibit 1. Medicare Shared Savings Program: Year 1 Performance of Participating Accountable Care Organizations (2013) 24 percent (52 ACOs) earned shared savings bonus 27 percent (60 ACOs) reduced spending,

More information

Stakeholder input is gathered in several ways. Patients are given the opportunity to provide feedback, the SWOT analysis is based on information from

Stakeholder input is gathered in several ways. Patients are given the opportunity to provide feedback, the SWOT analysis is based on information from Strategic Plan 27 Executive Summary The following is a summary of the information shared in this Operations Review and Plan. This plan highlights operational achievements and challenges, clinical outcomes

More information

Transitions Through the Care Continuum: Discussions on Barriers to Patient Care, Communications, and Advocacy

Transitions Through the Care Continuum: Discussions on Barriers to Patient Care, Communications, and Advocacy Transitions Through the Care Continuum: Discussions on Barriers to Patient Care, Communications, and Advocacy Scott Matthew Bolhack, MD, MBA, CMD, CWS, FACP, FAAP April 29, 2017 Disclosure Slide I have

More information

Making CJR Work for You. A Roadmap for Successful Implementation of Medicare Bundles

Making CJR Work for You. A Roadmap for Successful Implementation of Medicare Bundles December 10, 2015 Making CJR Work for You A Roadmap for Successful Implementation of Medicare Bundles https://innovation.cms.gov/initiatives/cjr Sheldon Hamburger shamburger@thearistonegroup.com (248)

More information

The Impact of Health Care Reform on Long- Term Care

The Impact of Health Care Reform on Long- Term Care The Impact of Health Care Reform on Long- Term Care AMY RUNGE, CPA Moss Adams LLP Partner & National Practice Leader, Long-Term Care MARCY BOYD, CPA Moss Adams LLP Partner September 22, 2014 1 The material

More information

Health System Transformation. Discussion

Health System Transformation. Discussion Health System Transformation Patrick Conway, M.D., MSc CMS Chief Medical Officer Deputy Administrator for Innovation and Quality Director, Center for Medicare & Medicaid Innovation Director, Center for

More information

Quality Outcomes and Data Collection

Quality Outcomes and Data Collection Quality Outcomes and Data Collection Presented By: Joanne Jones Director, Clinical Consulting Services August 30, 2016 Quality Measurement in LTC CMS Nursing Home Compare 5 Star Rating System New measures

More information

Working Together for a Healthier Washington

Working Together for a Healthier Washington Working Together for a Healthier Washington Laura Kate Zaichkin, Administrator, Office of Health Innovation & Reform Health Care Authority April 29, 2015 Why do we need health system transformation? Because

More information

Optimizing Care for Complex Patients with COPD

Optimizing Care for Complex Patients with COPD Optimizing Care for Complex Patients with COPD Janice Gasaway, RN, MN, Director Quality & Safety Elvin Perkins, MBA, Chronic Disease Project Manager 1 Cone Health System: Who We Are Regional Health System

More information

A Journey from Evidence to Impact

A Journey from Evidence to Impact 1 TRANSITIONAL CARE MODEL A Journey from Evidence to Impact Mary D. Naylor, Ph.D., RN 2015-2016 UCSF Presidential Chair Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions

More information

Advancing Accountability for Improving HCAHPS at Ingalls

Advancing Accountability for Improving HCAHPS at Ingalls iround for Patient Experience Advancing Accountability for Improving HCAHPS at Ingalls A Case Study Webconference 2 Managing your audio Use Telephone If you select the use telephone option please dial

More information

Ontario Shores Journey to EMRAM Stage 7. October 21, 2015

Ontario Shores Journey to EMRAM Stage 7. October 21, 2015 Ontario Shores Journey to EMRAM Stage 7 October 21, 2015 ICE BREAKER Agenda System overview & pervasiveness of use Review Clinical Practice Guideline implementation Discuss Patient Portal implementation

More information

QIO Care Transitions Activity: the Good News so far

QIO Care Transitions Activity: the Good News so far QIO Care Transitions Activity: the Good News so far Kim Irby, MPH; kirby@cfmc.org Senior Project Director Colorado Foundation for Medical Care www.cfmc.org/integratingcare This material was prepared by

More information

The Alternative Quality Contract (AQC): Improving Quality While Slowing Spending Growth

The Alternative Quality Contract (AQC): Improving Quality While Slowing Spending Growth The Alternative Quality Contract (AQC): Improving Quality While Slowing Spending Growth Dana Gelb Safran, ScD Senior Vice President, Performance Measurement and Improvement Presented at: MAHQ 16 April

More information

Reducing Hospital Admissions Through the Use of IT. Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods

Reducing Hospital Admissions Through the Use of IT. Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods Reducing Hospital Admissions Through the Use of IT Steven Milligan MD Medical Director of ACO Management Colorado Health Neighborhoods Conflict of Interest Steven Milligan, MD Has no real or apparent conflicts

More information

A Journey from Evidence to Impact

A Journey from Evidence to Impact 1 TRANSITIONAL CARE MODEL A Journey from Evidence to Impact Mary D. Naylor, Ph.D., RN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions and Health University of Pennsylvania

More information

Standardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017

Standardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017 Standardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017 Background Theme 3 builds upon previous key strategic commissioning

More information

Reducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN

Reducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN Reducing Preventable Hospital Readmissions in Post Acute Care Kim Barrows RN BSN Session Objectives At the end of the session the learner will be able to: 1. Discuss the history of hospital readmission

More information

Improving patient outcomes & health economics through connected health innovation

Improving patient outcomes & health economics through connected health innovation Improving patient outcomes & health economics through connected health innovation Session 103, February 21, 2017 Jeroen Tas, Chief Innovation & Strategy Officer, Philips Dr. Kevin Dellsperger, MD, PhD,

More information

Hard Truths Public Board 29th September, 2016

Hard Truths Public Board 29th September, 2016 Hard Truths Public Board 29th September, 2016 Presented for: Presented by: Author Previous Committees Governance Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive Heather McClelland

More information

Driving the value of health care through integration. Kaiser Permanente All Rights Reserved.

Driving the value of health care through integration. Kaiser Permanente All Rights Reserved. Driving the value of health care through integration February 13, 2012 Kaiser Permanente 2010-2011. All Rights Reserved. 1 Today s agenda How Kaiser Permanente is transforming care How we re updating our

More information

Three C s of Change in the Value-Based Economy: Competency, Culture and Compensation. April 4, :45 5:00 pm

Three C s of Change in the Value-Based Economy: Competency, Culture and Compensation. April 4, :45 5:00 pm Three C s of Change in the Value-Based Economy: Competency, Culture and Compensation April 4, 2014 3:45 5:00 pm 1 Introduction Kevin McCune, MD Chief Medical Officer Advocate Medical Group Peg Stone Vice

More information

CHC-A Continuity Dashboard. All Sites Continuity - Asthma. 2nd Qtr-03. 2nd Qtr-04. 2nd Qtr-06. 4th Qtr-03. 4th Qtr-06. 3rd Qtr-04.

CHC-A Continuity Dashboard. All Sites Continuity - Asthma. 2nd Qtr-03. 2nd Qtr-04. 2nd Qtr-06. 4th Qtr-03. 4th Qtr-06. 3rd Qtr-04. PPC1: ACCESS AND COMMUNICATION Element B: Access and Communication Results Item 1: Visits with assigned PCP Continuity data is reviewed each month at our Office Redesign Committee (ORDC). The data is collected

More information

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides

VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE. Training Slides VNAA BLUEPRINT FOR EXCELLENCE BEST PRACTICES TO REDUCE HOSPITAL ADMISSIONS FROM HOME CARE Training Slides 061015 Why Take Action to Prevent Readmissions? Better patient care and patient experience Home

More information