How to Establish an Accountable Post-Acute Preferred Provider Network. November 14, 2016

How to Establish an Accountable Post-Acute Preferred Provider Network November 14, 2016

How to Establish an Accountable Post-Acute Preferred Provider Network Maura McQueeney, MPH, DNP President, Baystate VNA & Hospice/ Post-Acute Care, Baystate Health Lissy Hu, MD, MBA Chief Executive Officer, CarePort Health 2

Shifting Payment Landscape MACRA Readmissions CJR ACO Bundled Payments IMPACT Act 3

Overview Background Problem discovery 2013 Multiple vendor and provider relationships coming and going from the medical center and outlying hospitals Strategic Question How should we partner for results in BCPI and ACO when we do not OWN post acute facilities? Embed MDs($)? Embed Mid levels($)? Partner for quality results? Decision Develop clear, post - acute partner scorecard, be transparent with results, select a preferred network based upon quality BEYOND star ratings, define monitoring and sustainable outcomes, create written agreements Methods How we created an accountable preferred post acute network Results and Takeaways Sharing our success tips 4

Baystate Health Largest health system in Western Massachusetts One academic medical center, two community hospitals, 973 beds Owns a health insurance company Health New England 250 Physician Practices Acquiring surrounding community hospitals to secure competitive boundaries Next Generation ACO Early entrant into MSSP TJR bundle Strategically not in the long-term care space 5

Creating a Central Nervous System: SPACC Strategic Post-Acute Care Committee (SPACC) Complex web of relationships and potential for conflict of interest Need to organize relationships around quality in context of BPCI and ACO DME, Lab Services, Imaging Services Hospital SNF HHA HHA Liaisons SNF Liaisons

Getting Started Strategic Post-Acute Care Committee (SPACC) SVP for Quality and Population Health President, VNA & Hospice Physician leader of ACO Geriatrician representing post-acute medicine Director of Quality (oversees BPCI program) Director for Post-Acute Integration Heart & Vascular service line director VP, Strategic Planning Director of Case Management Ad hoc members: Lab and Imaging, Medical Director of Health New England (insurance organization) Identified relevant postacute stakeholders (ACO, BPCI) Hired Director for Post-Acute Integration Instituted monthly meetings for group to discuss SNF selection criteria, quality measurement, and performance improvement

City State Zip Contact 1 name Assessing Skilled Nursing Contact 1 Title Facilities Contact 1 e-mail Web Site Ownership Type (private, profit, nonprofit, parent company) nonprofit Phone What is your ability to manage pts with psychiatric diagnoses Psych serivce in 2-3 x/week Assessed 30 facilities with high-volume of Baystate patients Collected facility staffing levels, process expectations, outcome reporting expectations through site visits and interviews Major criteria included CMS star rating (3 and above), 24-hour nursing care, physician staffing levels, readmission rates, ability to take difficult patients, and willingness to partner Individual Facility Demographics License Types (please list all) Category Response Yes/No (Yes LTC = 1; No = 0) Number of Sub Acute Beds Short Stay all private rooms Number of LTC Beds Number of LTACH Beds Number of Specialty Services Beds (vent, rehab) MDs Contracted-Internist, and days per week on unit LTC 1 Community PCP (Enter 1 if once per week; 2 if 3-5 days; 3 if daily) MDs Contracted-Geriatrician, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily) 0 MDs Contracted-Specialty MD, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily) 0 MDs Contracted-Internist, and days per week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily) 1 Community PCP MDs Contracted-Geriatrician, and days per week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily) 0 MDs Contracted-Specialty MD, and days per week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily) 0 Midlevel (RN/PA) Practitioner Contracted and days per week on unit LTC (Enter 1 if once/week; 2 if 3-5 days; 3 if daily) 1 Midlevel (RN/PA) Practitioner Contracted and days per week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)?? 1 24/hr day RN (Y/N)? 1 Staff: 50% RN Nursing Model: Primary Nursing Model (Y/N)? 1 Nursing Model: Consistent Alignment (Y/N)? 1 RN Specialty Certification: Rehabilitation (Y/N)? RN Specialty Certification: Geriatrician (Y/N)? 0 Full time, licensed (RN, SW, OT, PT) Case Manager or Navigator (Y/N)? 1 Dietician available (Y/N)? 1 Special diet available: low sodium, ADA etc. (Y/N)? 1 Special diet available: TPN (Y/N)? 1 Comments/additional Information 1 RN, Cardiac Specialist Certified Wound Care Nurse available (Y/N)? 1 Hospital CWOC NP Palliative MD at to support; Palliative and Hospice Care (Y/N)? 1 Hospice w/ Affiliate Pharmacy Name Formulary available (Y/N)? 1 Contracted Payers and Plans (list) Medicare (Y/N)? 1 Medicare Advantage (Y/N)? 1 Medicaid (Y/N)? 1 Medicaid Pending (Y/N)? 1 CCA (Y/N)? 1 HNE (Y/N)? 1 Fallon (Y/N)? 1 BC/BS (Y/N)? 1 AARP (Y/N)? 0 Others (% Agency on Short Stay Unit?) Sub$Total 23 Process Expectations: Pre-Admission to Discharge No agency

HNE (Y/N)? 1 Fallon (Y/N)? 1 BC/BS (Y/N)? 1 Process Expectations AARP (Y/N)? 0 Others (% Agency on Short Stay Unit?) No agency Sub$Total 23 Process Expectations: Pre-Admission to Discharge Process Expectations: Pre-Admission to Discharge Category Response Yes/No (Yes = 1; No = 0) Preadmission Process: Liaison on site at BH (Y/N)? 1 Preadmission Process: Response Time for Decision (Enter 1 if 60 mins; 2 if 30 mins) Warm Hand-Off: Documented RN-to-RN Communication on Admit (Y/N)? Warm Hand-Off: Documented RN-to-RN Communication upon Discharge (Y/N)? INTERACT** Tool Used or Alternative Tools (Enter # points in Y/N column) 2 0 Comments/additional Information Home Care Liasion at center for weekly 1 meetings 5 INTERACT III Electronic Medical Record (Y/N)? 0 Complete by 2014 Member of Data Exchange (Y/N) 0 Direct Admits from Home, MD Office, and other Community Sites: 24/7 Clinical RN Supervisor (Y/N)? Direct Admits from Home, MD Office, and other Community Sites: Med List (Y/N)? Direct Admits from Home, MD Office, and other Community Sites: Payor Confirmation (Y/N)? List 24/7 Ancillary Contracted Services (lab, imaging, pharmacy services) (Enter 1-3) List 24/7 Ancillary Contracted Services (lab, imaging, pharmacy services) with 2 hour turnaround for reports (Enter 1-3) Rehab Services provided: frequency (Enter 1 for once per week, up to 7 = daily) Rehab Services provided: coverage by all payors (Y/N)? 1 Physician or Mid-level Rounds: Describe (Enter 1 for once per week, up to 7 = daily) IDT Rounds: MD involved (Y/N)? 0 IDT Rounds: Patients & Families involved (Y/N)? 0 IDT Rounds: RN involved (Y/N)? IDT Rounds: Social Worker involved (Y/N)? 1 IDT Rounds: Done 48 hours after admit (Y/N)? Reporting Expectations: Outcomes Reporting Expectations: Outcomes Sub$Total 29 1 1 1 3 Mobilex, O2 Solutions 3 7 Contract w/ 1 1 MCR Meeting 0 72 hr meeting

IDT Rounds: Patients & Families involved (Y/N)? 0 IDT Rounds: RN involved (Y/N)? 1 MCR Meeting IDT Rounds: Social Worker involved (Y/N)? 1 Outcomes IDT Rounds: Done Reporting 48 hours after admit (Y/N)? Expectations 0 72 hr meeting Sub$Total 29 Reporting Expectations: Outcomes Reporting Expectations: Outcomes Category Response Yes/No (Yes = 1; No = 0) Comments/Additional Information CMS Star rating (most recent) (Enter rating in Y/N) 3 AHCA:/ :/ /App/in;/JCAHO/ DPH (Date of last survey, status and deficiencies) 2013 DPH Score : Flag on Admission to BMP: To PCP (Y/N)? 1 Flag on Admission to BMP: By Diagnosis (Y/N)? 1 Population reports available: List D/C Dx, dispostion and HC provider, PCP, LOS, Referral info: adm, lost, declined ALOS Sub Acute (Enter 1 if 15 days) 0 Ortho: 19; Cardiac: 18 30 Day Re-hospitalization Rates Subacute- average of last 3 months (Enter 1 if 20%; 2 if 15%; 3 if 10%) 3 9% Mortality Rate Sub Acute TBD Patient Satisfaction benchmarked with national database (Y/N)? If Yes, please record database V endor and Quartile rank for Overall Satisfaction If No, please record how Patient Satisfaction is measured AND last 6 months trend for Overall Satisfaction Will you be able to schedule a Baystate Health Post Acute Team site visit within the 4 weeks (Y/N)? For Internal Use Only For Internal Use Only Sub$Total 10 1 1 MyInnerview: 98% Category Response Yes/ No Comments/Additional Information STAAR Attendance 1 Baystate MD Affiliation/Presence Top 70% referral 2012 0 Citizenship (difficult patient placement) 0 Affiliation (ACO, PHO, other) 0 Total 62 1 Cardiac: **INTERACT- Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal o f INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

Scoring Post Acute Providers Developed scorecards with point system, reviewed with SNFs Chose 14 facilities as preferred providers Meet with preferred providers regularly, provide blinded scores and engage in other quality improvement activities Facility Score Card

Readiness to Partner/Collaborate (based on Ease of Placement & Overall Survey Score) Balancing Transparency and Privacy Baystate Health Post-Acute Care Partner Prioritization Matrix 20 18 16 14 12 10 8 6 4 2 0 A E N T Q C P B M I D K L V O J R F G W, 10 H 0 2 4 6 8 10 12 Quality of Care (based on 30-Day Readmits & CMS Star Rating) A B C D E F G H I J K L M N O P Q R S T U V W U S

Implementation Challenges Aligning with case managers who had concerns about patient choice Communicating preferred providers to patients Encouraging patients to select post-acute providers based on quality vs. geography

Changing the Discharge Discourse Standardized communication, developed by SPAC committee, case management leadership and legal: The Baystate preferred skilled nursing facility network is a select group of nursing facilities around the Pioneer Valley that meet quality and safety standards set for by Medicare and endorsed by Baystate Health

Engaging Patients in Post-Acute Decision- Making Baystate adopted an interactive tool for discharge planners and patients to choose post-acute care Preferred providers are highlighted and communicated to patients and families Integrates with case management workflow tools and available on a tablet; search results can be emailed to family members and other decision-makers

Post Acute Search Tool Benefits Case Managers, Patients & Supports Baystate s PAC Strategy Compliance with Impact Act and proposed changes to conditions of discharge planning Proposed rule require[s] that hospitals assist patients in selecting a PAC provider by using and sharing data that includes but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. With CarePort, Baystate has provided its patients with 'first-of-its kind' technology that helps them decide where to go for post-acute care a critical decision, as numerous studies show that post-acute providers vary on quality and their ability to car e for different types of patients, said Joel Vengco, VP/ CIO, Baystate Health. In other words, it s not an easy decision for patients and families to make. Until now."

Tracking Baystate Patients Post-Discharge Integration with regional HIE (PVIX) and six post-acute providers Understanding post-acute outcomes for all Baystate patients Skilled nursing facility readmission rates and length of stay by patient population Leakage vs. Keepage

Sustaining the Network Quarterly Quality Meetings: Sharing best practices Preferred Subset for BPCI Exiting SNF partners

Outcomes 19

Outcomes 20

Outcomes

Success Factors Personal Touch RFPs vs. personal touch because of high turnover of SNF staff For example tenure of nursing staff, will nursing staff know to call hospital? Team Integration work led by SNF insider Innovation in the community Health New England SNFs can take care of patients with medical needs such as IV antibiotics, TPN to avoid readmission. HNE takes care of cost of IV Abx and TPN

On the Horizon Deciding to create a Tier 2 Physician Incentive for SNFist from Next Gen ACO Embedded ACO Physician in the ED Building care coordination teams Navigators vs. liaisons How to make it scalable and cost-effective?

Questions? 24