Creating a Post-Acute Care Strategy Patricia Blaisdell California Hospital Association 1 Controlling post acute care utilization will be critical to hospital success under CJR. Inpatient Rehabilitation SNF Home Health Outpatient 2 1
WHY Post-Acute? Nearly 40% of LEJR episode cost occurs after the patient leaves the acute care hospital. Over 50 60 % of Medicare LEJR patients are discharged to SNF Hospitals must take steps to manage or influence utilization of post-acute services 3 Successful ortho BPCI was attributable to decreased use of institutional PAC services (IRF, SNF) Average Medicare payments for ortho episodes declined 3% more than for non-bpci participants Admissions to institutional PAC were 4.9 % lower than for ortho non-bpci patients SNF length of stay was 1.3 days less Source: CMS bundled Payments for Care Improvement initiative Model 2 4. Year 2 Evaluation & Monitoring Annual Report, The Lewin Group, August 2016 4 2
Quality of care was maintained for BPCI ortho episodes: No increases in hospital readmissions Similar improvements in functional outcome measures Overall, a greater share of BPCI patients reported improved ability to walk without resting and improved ability to use stairs Source: CMS bundled Payments for Care Improvement initiative Model 2-4. Year 2 Evaluation & Monitoring Annual Report, The Lewin Group, August 2016 5 To control PAC cost, identify the most costeffective care. Consider: 1) Type(s) of post-acute care 2) Amount of post-acute care 3) Outcome achieved 6 3
Low cost High cost PAC Care Level Outpatient Home Health SNF IRF Payment type Per visit Per 60 day episode, or LUPA (< 5 visits) Cost driven by # of visits Services, # of therapy visits Per diem, based on therapy LOS, therapy utilization Case rate, based on patient characteristics Admission Manageable? Somewhat Somewhat Very No 7 Impact of PAC utilization on episode cost $ Hospital + MD + $ PAC = Total SNF ALOS = 21 RUG rate = $600 SNF ALOS = 21 RUG rate = $535 SNF ALOS = 15 RUG Rate = $600 SNF ALOS = 15 RUG Rate = $535 $ 18,600 + $12,600 = $31,200 $18,600 + $ 11,235 = $ 29,835 $18,600 + $9,000 = $27,600 $18,600 + $8,025 = $26,625 8 4
Impact of PAC level of care on episode cost: $ Hospital + MD + $ PAC = Total SNF ALOS = 15 RUG Rate = $535 HHA, Nursing and PT, OT $18,600 + $8,025 = $26,625 $18,600 + $4,000 = $22,600 HHA, Nursing, PT, OT. Patient is readmitted $18,600 + + $4,000 (HH) $10,000 (hospital) = $32,600 9 Goal: Discharge to the least expensive level of care that is safe and that will allow patient to meet desired outcomes Adopt a home first policy Consider home setting, caregiver availability Consider safety and functional status 10 5
Develop your PAC network: Establish partnerships with selected HH and SNF partners Hospital A Hospital A 11 Guiding principles for PAC partnerships Vet your partners make site visits Assess leadership willingness to work together and ability to engage staff, particularly therapy staff Ongoing Communication and collaboration Share data utilization and outcome information Partnership is a two-way street Identify effective ways to work together 12 6
Selection of SNF Partners Identify what is most important to you. Consider: Flexibility on accepting referrals (weekends, 24/7?) Ability to provide specific medical services (e.g., wound care, transfusions) Discharge planning procedures Staffing levels/in-house therapy services RUGs rate and LOS Readmission rate 13 Selection of SNF Partners CMS data files (LOS and RUG) https://www.cms.gov/newsroom/mediareleasedatabase/ Fact-sheets/2016-Fact-sheets-items/2016-03-09.html CMS Nursing Home Compare (staffing, quality outcomes, surveys, star rating) https://www.medicare.gov/nursinghomecompare/search.html 14 7
Selection of HH Partners Identify what is most important. Consider: Flexibility on accepting referrals Episode costs use of LUPA Utilization of therapy services Quality indicators Ability to handle medical conditions Readmission/ED visit rates 15 Selection of HH Partners Home Health Compare https://www.medicare.gov/homehealthcompare/search.html Services provided Quality of patient care (star rating) Patient survey results (star rating) State and national benchmarks 16 8
IRF Utilization Identify when you will admit to IRF Presence of significant medical complexity Unable to be cared for in SNF, or Anticipate extended SNF stay Requires extensive therapy and caregiver training Consider facility discharge status, readmission rate 17 Discharge Planning Determining next level of care: Discharge to the least expensive level of care that is safe, and that will allow patient to meet desired outcomes. Adopt a home first policy Consider home setting, caregiver availability Consider safety and functional status 18 9
LOW COST PAC Care Level Outpatient Home Health SNF IRF Patient medical necessity Requires skilled therapy services Requires skilled services; homebound Has skilled need (e.g., daily therapy) Requires coordinated care and intensive therapy Admission requirements Physician order and oversight Face to face certification 3 day stay, (waived for 3+ star SNFs) Pre admission screening, approved by rehab MD 19 Low cost High cost PAC Care Level Outpatient Home Health SNF IRF Patient mobility and self care Independent with mobility and self care Independent or minimal assist Independent to moderate assist Moderate assist +Co morbidities Home setting Caregiver and transportation available Caregiver available to assist No caregiver at home Needs ongoing medical care 20 10
Referral considerations Informed choice Provide patient with information regarding ability to choose provider and list of eligible providers. Supplement with information regarding preferred provider and facility report card Physician preference engage physician in data review 21 Additional referral and care management considerations Increase focus on functional status Adopt a formal transition management practice Consider pre-surgical education and assessment Increase focus on caregiver training 22 11
Functional status drives readmission rates Readmission models based on functional status consistently outperform models based on medical comorbidities. Shih, et al. Functional Status Outperforms Comorbidities in Predicting Acute Care Readmission in Medically Complex Patients. Journal of Geriatric Internal Medicine May 9, 2015. [Patients] who report unmet need for new ADL disabilities after they return home from the hospital are particularly vulnerable to readmission. Patients functional needs after discharge should be carefully evaluated and addressed. DePalma, et al. Hospital Readmission among Older Adults Who Return Home With Unmet Need for ADL Disability. The Gerontologist, 2012; 53(3): 454-461. 23 Care transition management reduces readmissions Source: Coleman, E., et al. (2006). The Care Transitions Intervention: Results of a Randomized Trial. Archives of Internal Medicine. 24 12
Pending CMS requirements for discharge planning Providers must involve the caregiver/support person in the development of the discharge plan For patients discharged to home, the provider must: Provide written instruction to patient/caregiver as indicated; best practice would include confirmation of patient s/caregiver s understanding Provide written info on warning signs and symptoms, and who to contact if they present 25 Strategies Recognize the culture change foster buy-in along the way Engage therapy and case management staff at all levels in care re-design and implementation 26 13
Questions? 27 Thank you Patricia Blaisdell Vice President, Continuum of Care California Hospital Association pblaisdell@calhospital.org 28 14