Managing Cost and Outcome of Post Hospital Care

Managing Cost and Outcome of Post Hospital Care Reg Warren, PhD The National Predictive Modeling Summit September 22-23, 23, 2008

The dilemma for post hospital care? 2008 Medicare Advantage enrollment: 8.5 million* 2.2 million hospital admissions in 2008 (260 admits/k) 750,000 of hospitalized seniors will receive post acute care 250,000 of those will not go to the most appropriate setting MCO s will spend $12.4B on SNF and Home Health in 2008* Challenges Misalignment of incentives: per diem High degree of practice variation Lack of common measurement across care settings Over-utilization unnecessarily exposes members to institutional risks and over-burdens taxpayers *Kaiser Foundation 2008 2

Managing Cost and Outcome of Post Hospital Care Diagnosis vs. Function A Predictive Model Regression Severity adjustment Application Real-time decision support Retrospective comparison Influence on cost and outcome 3

Model Constructs People People go go to to the the Hospital Hospital because because they they are are Sick: Sick: Disease Driven Acute Acute Treat the the Illness People People get get postacute postacute care care because because they they are are frail frail and and Care Care Dependent: Dependent: Function Driven Postacute Restore the the Ability 4

Functional Measurement Functional Independence Measure (FIM) (18 126) Eating Grooming Bathing Dressing Upper Body Dressing Lower Body Toileting Bladder Management Bowel Management Bed, Chair, WC Transfer Toilet Transfer Tub/Shower Transfer Walk/WC Stairs Expression Comprehension Social Interaction Problem Solving Memory 5

Function Burden of Care Functional needs Drives >90% of skilled utilization Admit function- predict outcome 5 points FIM equate to one hour caregiver burden/day SNF admission: FIM 65 (6 hrs care/day) HH admission: FIM 85 (2 hrs care /day) 6

Calibrate the Continuum Home Postacute Acute Acute Discharges Sr. Sr. Population Population Many Many Acute Acute Rehab Rehab cases cases would would get get the the same Other same result result in in SNF SNF HH HH Cost Cost can can remain remain stable stable even even with with increased increased referrals referrals HH 20% 20% of of SNF SNF patients patients would would get get the the same same result result at at home home SNF SNF SNF LOS LOS can can be be reduced reduced by by 30% 30% without without impacting impacting functional functional result result 7

Discharge Site and Functional Level (FIM 18-126) 126) Discharge Site Considerations Home Alone OP Therapy/Home Safety Home with Assist OP (Outpatient) Therapy Home w/assist or ALF Home Health Services Home, SNF, Custodial, B&C w/ 24-hour Assistance FIM Score >108 >90 >80 <79 Diagnosis, medical complexity or other social, caregiver or medical issues may influence the functional level at which the patient is discharged. 8

Managing Cost and Outcome of Post Hospital Care Diagnosis vs. Function The Predictive Model Regression Severity adjustment Application Real-time decision support Retrospective comparison Influence on cost and outcome 9

Leader in post-acute outcome measurement since 1995 Manage over 900,000 Senior lives in SNF, Acute Discharge, Acute Rehab, Home Health Database of 250,000+ post-acute cases Over 50,000 new records added each year California, Colorado, Washington, Maryland, District of Columbia, Virginia and Tennessee Kaiser Permanente, PacifiCare, Health Net, Group Health Coop, and AmeriGroup MHS Participant 10

Not everything that counts can be counted, and not everything that can be counted counts Albert Einstein 11

Improvement in Function in SNF: Predictable 80 yr old female with 140 CHF, cellulitis, UTI and prior stroke 120 100 80 60 40 Correlations DISFIM 20 0 0 20 ADMFIM 40 60 80 ADMFIM Pearson Correlation Sig. (2-tailed) N DISFIM Pearson Correlation Sig. (2-tailed) 100 120 N **. Correlation is significant at the 0.01 level (2 il d) ADMFIM DISFIM 1.000.818**..000 500 500.818** 1.000.000. 500 500 12

Length of SNF Stay: Less Predictable 120 100 80 ADMFIM EPISODE Correlations Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N ADMFIM EPISODE 1.000 -.265**..000 500 500 -.265** 1.000.000. 500 500 **. Correlation is significant at the 0.01 level (2-tailed). 60 40 EPISODE 20 0 0 20 40 60 80 100 120 ADMFIM 13

Specific Relevant Conditions (Groupers) Feeding tube (Peg/J vs. NG) Restricted Weight Bearing Pressure Wound: II, III or IV Vascular/ surgical wound IV Vent Severe Obesity (BMI>50) Hemodialysis 14

Regression: Length of Skilled Stay Independent Variable* Random Error (constant) Coefficient Patient s Actual Value Result 24.08 + Admission FIM -.196 X 65-12.74 + 11.34 Age.034 82 2.78 Days Post Onset Condition (IV/Stage II) X.074 6.444 + 14.56 = = = X = = 10.87 1 10.87 X + 14.12 82 y/o female Hip fracture Acute: 6 days *sig p<.05 Predicted Episode LOS = 25.43 15

How powerful is the model? Disability DPO Age Condition Grouper 38% 60% 2% Therapy Intensity SMTX Model Treatment Unknown 16

SMTX Best Practice (25% most efficient facilities) Actual Practice Pt. #30: CVA,75 yrs, DPO 12, Adm FIM 30, and Med Complex 4 Pts #2-30 Pt. # 1: UTI, 82 yrs, DPO 31, Adm FIM 57, and Med Complex 3 Q u e r y LOS: 15 days DC FIM: 50 LOS: 11 days DC FIM: 81 LOS: 21 days DC FIM: 50 LOS: 14 days DC FIM: 81 REGRESSION Best Practice Calculation LOS: 13 days DC FIM: 62.5 Actual Calculation LOS: 18 days DC FIM: 62 EACH patient is case adjusted: Impairment Group Age DPO Adm FIM Grouper Condition VARIANCE LOS: 28% DC FIM: 1% 17

High Practice Variation Admission Discharge Treatment Actual Result No Recovery Expectations Assessment Discharge Planning Full Recovery Postacute Episode Postacute Episode 19

Real-Time Decision Support 20

Reduced Practice Variation Traditional Timeframe Admission Discharge Value Added Assessment Most Likely Result Expectations Discharge Planning Treatment Actual Result Postacute Episode 21

Retrospective Comparison Severity-Adjusted Comparison Efficiency Quality 22 Cases in SMTX Rehab Start Lag Optimal Rehab Cycle Acutal Rehab Cycle Rehab Cycle Variance Discharge Lag Rehab ALOS Expected Discharge FIM Actual Discharge FIM FIM Discharge Variance % Discharged to Community Therapy Hrs per Day Jan-Mar 2006 Jefferson Ave 45 1.4 7.9 10.2 28% 1.1 12.7 101.2 96.0-5% 0.83 0.97 Mercy Court 67 1.3 11.7 12.1 3% 0.8 14.2 77.0 76.1-1% 0.83 1.43 St Allens Garden Ridge San Angelo Pacific Crest CareBrook Total/Average

50 40 30 20 10 0-10 SNF LOS Variance Trend SNF LOS Variance Trend July Aug Sep Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Month 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Percent Variance/Query Therapy Hours/Day 25% reduction in skilled days cycle dcfim Hours/Day Client Q3, 2006 Source: SMTX 24

Functional recovery Across Settings: SNF thru HH to Follow-up* 11-01 to 9-079 Total FIM Score 140 130 120 110 100 90 80 70 60 50 115.5 105.8 96.7 93.2 73 SNF Admit SNF DC HH Admit HH DC Follow-up Assessment SNF: all dc home HH: all admitted from SNF Follow up: all records (N=1967) Source: SMTX 25

Improving Acute DC Placement 80% No difference in HH and SNF outcome or acute readmit 70% 60% 58% 58% 61% 63% 60% 67% 64% 57% 50% 49% 40% 30% 40% 34% 37% 32% 28% 30% 28% 30% 31% 20% 10% 11% 8% 5% 7% 9% 10% 5% 6% 12% 0% Jan (N=291) Feb (N=264) Mar (N=260) April (N=247) May (N=284) Jun (N=321) July (N=334) Aug (N=317) Sep (N=195) Home Skilled Other 26

Influence on Utilization Average Medicare Plan LOS: 22 days SNF Admits/k: 50-65 SNF Days/k: 900-1100 PMPM: $33 Predictive Model Results LOS: 16 days SNF admits/k: 40-50 SNF days/k: 600-800 PMPM: $22.50 27

Reducing Practice Variation Using Predictive Models Pre-Implementation One Year Post-Implementation Patient Health Improvement (Functional Improvement Measurement) SNF Days of Treatment $5,655 average cost per case 23 point average gain in Functional Improvement Measurement ( FIM ), an internationally recognized scale of disability SNF Days of Treatment $4,485 average cost per case (20.7% decrease) 23 point average gain in FIM (unchanged) 28

Cost efficiency.cost efficiency.cost efficiency