What is Value-Based Care

Genesis HealthCare Value-Based Care Initiatives and BPCI Model 3 Aug 4, 2017 Copyright 2017 by Genesis HealthCare LLC. All Rights Reserved. What is Value-Based Care 2 Value-based care delivery is an approach to care management that focuses on: Integration of clinical services within our setting and across settings Patient engagement in her/his goals for care Achievement of the health care Triple Aim Patient = Health Outcomes Value Cost 3 1

CMS Evaluation of Payment Models Based on Triple Aim SNF success in value-based care delivery will be measured by its universally consistent achievement of sustained positive outcomes, efficiently delivered CMS Goals for U.S. Health Care Adoption of Alternative Payment Models 2016 30% 2018 50% In 2016, at least 30% of U.S. health care payments are linked to quality and value through APMs. In 2018, at least 50% of U.S. health care payments are so linked. Better Care, Smarter Spending, Healthier People CMS announced on March 3 rd that it had already reached the 2016 30% goal for quality-based payments Shifting Payment Practices Low Risk/Low Accountability to High Risk/High Accountability for Quality Accountability for Quality Fee- For- Service Episodes Shared of Care Savings Pay-for- Performance Financial Risk Shared Risk Global Payments 2

Clinical/Population Based Payments Clinical Episodes Triggered by an anchor hospital stay for select conditions/drgs & lasting 30-90 days: Bundled Payment for Care Improvement (BPCI) Program o 90 days from Post-Acute Admission o Accumulated Claims vs. Target Price = Gain/Loss Comprehensive Joint Replacement (CJR) Program o Hospital Stay + 90 Days Post-Acute Care o Accumulated Claims vs. Target Price = Gain/Loss Measurement = Per Episode Population Based Cost management for a large patient population based on attribution & measured yearly: Institutional Special Needs Plan (ISNP) o examples include Bravo/Optum programs Medicare Shared Savings Program (MSSP) - ACOs o Similar to ISNP, but an upside-only program (Track 1) managed by the Genesis ACO o Savings measured vs. Historical Benchmark o Minimum ~3% savings must be achieved Measurement = Per Member How BPCI Works BPCI Model 2/CJR Hospital Stay + 90 days Post-Acute Care BPCI Model 3 90 days from Post-Acute Admission Episode of care triggered by acute inpatient admission Target Price established: blend of historical performance and market averages by DRG, less 3% CMS guaranteed discount; Includes all Medicare Part A and B services provided during the episode of care Accumulated Claims vs Target Price = Gain/Loss How is Genesis participating in the New World 3

Bundled Payment for Care Improvement (BPCI) 32 facilities across 13 States (Including 2 in Florida) MODEL 3 38 out of 48 episode families, Includes 134 DRGs primarily those with higher post-acute utilization 60+% of total Medicare admissions attributed with approximately $110M in annual Medicare spend under management Majority of Costs are Controllable Average claims costs are $25,250 per episode, ranging from $17,500 for single lower joint replacements (15% readmission rate and 21 SNF days) to over $31,000 for stroke (39% readmission rate and 42 SNF days) Readmission are typically split: 50% from SNF, 50% from home 18% 6% 6% 1%3% 2% SNF Readmission HHA Professional 64% DME Other Inpatient Outpatient Genesis HealthCare Strategy Align to the Triple Aim Identify patterns and connections within and across systems and develop approaches that respond to the needs of populations 1 Triple Aim GHC Tactical Approach Improving the Patient Experience of care Improving the Health of Populations Reducing the per capita Cost of Health Care Patient Engagement Care Delivery Models Partnering upstream and downstream to shift focus from provider and setting to at-risk cohorts Tracking and trending key measures of patient health and well-being ID clinical capabilities in-house that reduce unplanned transfer to hospital and LOS Preparation for effective post-discharge self-care management 1 Nash, D.B., Reifsnyder, J., Fabius, R.J. & Pracilio, V.P. (2011). Population Health. Sudbury, MA: Jones & Bartlett. 12 4

Developing a Uniform Genesis Value-Based Care Delivery Model Critical Elements to Shift from FFS to a Value-Based Payment Model Identification of Hospitalization Final DRG Risk for Readmissions Evaluation Medication Reconciliation Setting patient & family expectations early Effective and meaningful 72 Hour Patient/Family Mtgs Effective Use of MBI (Modified Bartel Index) PAM (Patient Activation Measure) 72-Hour Patient/Family Meeting JOHN DOE 5

Developing a Uniform Genesis Value-Based Care Delivery Model Critical Elements to Shift from FFS to a Value-Based Payment Model Readmission Reviews Root Cause Analysis Incorporate Value Based Care Root Cause Analysis case review into the Center QAPI meetings. Transitions in care - Case management across the full episode of care to include: Pre-Admission (Clinical Admissions Director and/or NP Care Navigator) During SNF stay (CRC & Inter-Professional Team) Post Discharge (Transitional Care Nurse) or in LTC (Wellness Coach or Nurse Navigator) Cross-Setting Care Management in Value-Based Care Delivery Pre-Admission Transition Support SNF Care Delivery Transition Support Community Care Delivery Patient identified & assessed Care Plan initiated Care Plan developed Care Plan implemente d Care Plan monitored Seamless patient experience across care settings 17 Historical Patient Transitions Hospital SNF - Home Patient enters hospital Patient arrives at center Home Health referral based on history not quality 1-3 days before D/C Transition to home The CHALLENGE - Traditional Referral Relationships fragmented and lack coordination to manage the experience 6

Optimal Patient Transitions Hospital SNF GPS NP meets Patient Patient enters hospital CAD Accepts Optimal Patient Transitions SNF - Home Patient arrives at Center Information to TCN Evaluated for risk & next level of care on admission Informed of choice of chosen Home Health Providers Preferred Home Health referral within 72 hours of admission Chooses other HH / Refuses Preferred HH Collaboration if changes Vitality to You if not homebound Notification sent to V2U UM Meetings NP, TCM, V2U, HH Participate High Risk for Rehospitalizatio n Awareness Complete Discharge info Transition to Home Secure Physician Appointment Confirm Sign HH orders Post Transition Needs and Non Compliance dd d Optimal Patient Transitions Home Complications Physician Appt Confirm Sign HH orders Transition to Home with Home Health High Risk for Rehospitalizatio n Awareness Clinician Direct TCN / NP Contact Alert of BPCI Patient placed in EMR Physician notified Monthly Deep Dive of Data Patient Declines Contact TCN and NP to assist in transfer discussion If Decline Discussion with Patient to return to center to avoid Hospital Portal Record Transfer Clinical team call TCN with any issues Patient agrees Order received and to return to transfer set up Center Direct Admit Transportation discussed Patient to Center Saved from Hospitalization Weekly brief updates during UM V2U Coordination Successful Progress where possible Regular TCN updates Return to HH ASAP Deep dive discussion 7

Leveraging BPCI Best Practices JUMP Genesis Rehab Integration Developed and implemented Vitality To You (V2U) Medicare Part B rehab in the community Respiratory Services provided in SNF and Home Rehab Steering Committee What have we learned? 8

SNF Days per Episode has steadily decreased Rehospitalizations continue to remain primary focus and challenge Staff Turnover creates significant operational challenges 2 Businesses under 1 roof (BPCI vs. Traditional Medicare) We have some talented and creative folks working for us! Don t be this guy! 9

The New World Order Some images contained in this presentation were from websites: https://images.google.com/?gws_rd=ssl and http://www.shutterstock.com/ References made in this presentation to "Genesis," "the Company," "we," "us," and "our," refer to each of Genesis HealthCare s wholly owned subsidiaries, acting as employer. 10