Facing the Post-Acute Care Acuity Challenge

Post-Acute Care Collaborative Facing the Post-Acute Care Acuity Challenge Adjusting to the New Post-Acute Population Julia Burgdorf Senior Analyst burgdorj@advisory.com

Road Map A Changing Population Sector by Sector 3 The Threat of Rising Acuity Preparing for the New Quality Mandate 5 The Advisory Board Company advisory.com

3 Is Post-Acute the New Acute? We have to accept as an industry the paradigm shift. What used to be hospital med-surg unit work five years ago is now going to be the typical short-stay patient in SNF. Richard Tuvell, Director of Quality, Reliant Senior Care 5 The Advisory Board Company advisory.com Source: Post-Acute Care Collaborative interviews and analysis.

4 Rising Patient Acuity Poses Challenges Post-Acute Patients Increasingly Complex, High-Need Proportion of PAC Admissions with MCC -3 55% 5% 45% 4% 35% 3% 5% Proportion of PAC patients with MCC increased by 9% from -3 Rising Patient Needs 4. % Average SNF resident ADL needs in 5, an increase from 3.9 in 5 Increase in number of counties where at least 75% of seniors 3 have multiple chronic conditions, from 8 to % 3 PAC LTACH IRF SNF HHA % Increase in Medicare home health patients with or more ADL needs, from to 3 ) Multiple Complications or Comorbidities. ) Activities of Daily Living. 3) Medicare beneficiaries. Source: American Health Care Association, Trends in Nursing Facility Characteristics, March 5, www.ahcancal.org; Hoyer, Meghan, Nation s Sickest Seniors Reshape Health Care, USA Today, June 5, 5, www.usatoday.com; Alliance for Home Health Quality and Innovation, Home Health Chartbook 5, www.ahhqi.org; Post-Acute Care Collaborative interviews and analysis.

Rising Acuity in Long-Term Acute Care Hospitals 5 Complications and Comorbidities in LTACH 5% 5% 5% 49% 48% 47% 46% 45% 48% Proportion of Medicare Patients Discharged to LTACH with Major Complications and Comorbidities -3 5% 5% 5% 3 Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file, -3.

Rising Acuity in Long-Term Acute Care Hospitals 6 Changing Expectations for LTACH Patient Population 6 Final Rule Narrows LTACH Cases, Adds 5-Day LOS Flexibility Bifurcated LTACH Payment Model in 6 Final Rule Patient Appropriateness Criteria Informs Two-Tiered Payment System Patient Criteria Meets Criteria: LTCH PPS Payment Counts Toward 5-Day LOS 3+ Days of ICU Care 96+ Hours on a Ventilator Does Not Meet Criteria: Lower of IPPScomparable rate or % estimated cost Does Not Count Toward 5-Day LOS 3 CMS Process to Determine the IPPS Comparable Rate Find IPPS rate for comparable MS-DRG Adjust for wage index, geography, etc. Divide by MS- DRG s average length of stay Multiply by covered days of LTACH stay ) Patients with a psychiatric or rehabilitation diagnosis are automatically included in site neutral rate. ) For cost reporting periods beginning FY6 and FY7, a blended rate is applied. The full IPPScomparable rate is applied in FY8. 3) Applies only to facilities certified as LTACHs before December, 3. Source: Centers for Medicare and Medicaid Services, IPPS and LTCH PPS 6 Final Rule, https://s3.amazonaws.com/public-inspection.federalregister.gov/5-949.pdf; Post-Acute Care Collaborative interviews and analysis.

Rising Acuity in Inpatient Rehabilitation Facilities 7 Complications and Comorbidities in Inpatient Rehab Proportion of Medicare Patients Discharged to IRF with Major Complications and Comorbidities -3 34% 33% 33% 3% 3% 3% 3% 3% 9% 9% 8% 7% 3 Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file, -3.

Rising Acuity in Inpatient Rehabilitation Facilities 8 Declining Volumes for Orthopedic Patients Bilateral or Multiple Major Joint Procedures of Lower Extremity (DRGs 46, 46) PAC volume: 7,75; 3 PAC volume:,975 3 53% 3% 5% 5% 35% 5% LTACH IRF SNF HHA Hospice 3 Major Joint Replacement or Reattachment of Lower Extremity (DRGs 469, 47) PAC volume: 7,75; 3 PAC volume:,975 4% 46% 4% % 46% 43% LTACH IRF SNF HHA Hospice Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file, -3.

Rising Acuity in Skilled Nursing Facilities 9 Complications and Comorbidities in SNF Proportion of Medicare Patients Admitted to SNF with Major Complications and Comorbidities -3 39% 38% 38% 37% 36% 35% 35% 36% 34% 33% 33% 3% 3% 3 ) Major Complications and Comorbidities. Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file, -3.

Rising Acuity in Skilled Nursing Facilities SNFs Diversify Patient Types Coronary Bypass with MCC (DRG 33) PAC volume: 3,69; 3 PAC volume:,598 4% 7% 3% 48% % LTACH IRF SNF 3 3% 8% 43% 36% % HHA Hospice Revision of Hip or Knee Replacement with MCC (DRG 466) PAC volume: 7,75; 3 PAC volume:,975 3% 9% 57% 9% % LTACH IRF 3 3% 6% 63% 7% % SNF HHA Hospice Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file, -3.

Rising Acuity in Home Health Complications and Comorbidities in Home Health Proportion of Medicare Patients Admitted to Home Health with Major Complications and Comorbidities -3 35% 34% 34% 33% 33% 3% 3% 3% 3% 3% 9% 8% 3 ) Major Complications and Comorbidities. Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file, -3.

Rising Acuity in Home Health 3 Trends in Discharge Destination: Cardiac Acute Myocardial Infarction (Heart Attack) (DRGs 8, 8) PAC volume: 7,54; 3 PAC volume: 7,887 % 4% 48% 35% % % 4% 44% 37% 4% LTACH IRF SNF HHA Hospice Heart Failure and Shock (DRGs 9, 9, 93) PAC volume: 34,89; 3 PAC volume: 3,448 3 % % 4% 49% 7% % 3% 38% 5% 8% LTACH IRF SNF HHA Hospice Source: Post-Acute Care Collaborative analysis of MedPAR discharge data file, -3.

3 Making the Case to Others Post-Acute Care Collaborative Interactive Resources on Acuity Trends Demonstrate Sector- Specific Acuity Shifts Evaluate Current Patient Population Predict Future Clinical Needs Use our acuity trend powerpoints, including talking points, to show your sector s changing acuity Access tools like the SNF Performance Profiler and Hospital Performance Profiler to see patient conditions Consult the Inpatient Market Estimator to see likely volume changes in patient diagnoses/needs Source: Post-Acute Care Collaborative interviews and analysis.

4 Not the Numbers You re Looking For Hospital Length of Stay Not to Blame for Rising PAC Acuity Hospital Average Length of Stay in Days 9-4 5.7 5.7 5. 5. 5.4 5. 4.5 4.5 4.47 4.47 4.53 All Patients Patients Over 65 3 4 Median LOS has remained stable for both groups: 3 days for all patients, 4 days for patients over 65 Source: Crimson claims data, 9-4; Post- Acute Care Collaborative interviews and analysis.

5 Baby Boomer Surge Beginning Number of Medicare Beneficiaries to Increase Dramatically US Population Distribution, by Age 75M Baby Boomers Aging of Population Medicare-Eligible Population 55M 4M ~7,/day Newly eligible Medicare beneficiaries 3% Percentage of population covered by Medicare in 3 Source: U.S. Census Bureau, available at: http://www.census.gov, accessed on September 3, ; Kaiser Family Foundation, available at: http://www.kff.org/medicare/h8_78.cfm, accessed on September 3, ; Health Care Advisory Board interviews and analysis.

6 Chronic Disease Increasingly Taking a Toll Projected Growth of Population with Chronic Disease (Percentage Growth Compared to 3) Projected Number of Patients with Diabetes (In Millions).5% 8% 4% 6% 6% 8% 8 7 6 5 4 3 63. 58.4 53. 46.8 3.3 39.7.3 6.6 3.9 75.7 7. 67. 59.7 55.6 5 48. 43.7 38.7 9 5 Cardiovascular Disease Hypertension Asthma Diagnosed Diabetes Total Diabetes 5 ) The Body Advisory Mass Index; Board projected Company figures advisory.com for and 3559. Source: Dall T, et al, An aging population and growing disease burden will require a large and specialized health care workforce by 5, Health Affairs, 3, no. (3): 3-; Boyle JP, et al., Projection of the year 5 burden of diabetes in the US adult population, Population Health Metrics,, 8, 9-4; CDC; Advisory Board interviews and analysis.

7 Acuity Will Continue to Rise Contributors to Ongoing Acuity Shift Aging population, greater numbers of seniors needing care Upward trend in prevalence of chronic illness 3 Payers, referrers sending patients to lower-cost settings Waiting It Out Not an Option Not making investments to manage high patient acuity just isn t an option. Even though it s tough and you re not getting reimbursed for it yet, you just have to do it. You either make the investments or you ll become all Medicaid, get gobbled up by a chain, or just go bankrupt. It is not an option. Renee Pruzansky, COO, AristaCare Source: AristaCare, Cranford, NJ: Post-Acute Care Collaborative interviews and analysis.

Road Map 8 A Changing Population Sector by Sector 3 The Threat of Rising Acuity Preparing for the New Quality Mandate 5 The Advisory Board Company advisory.com

9 A Closer Look at Patient Acuity Defining High-Acuity for Post-Acute Settings VOLUME x PRICE High-acuity patients have clinical needs requiring above-average intensity of support or nursing care Complex Patients Patients with numerous comorbidities, often including behavioral health challenges High prevalence of these patients requires extensive staff time Staff understand how to care for each diagnosis separately, but struggle to manage all conditions together Key Threats to Quality Patient deterioration occurs suddenly and unexpectedly; early signs can go un-observed by overwhelmed caregivers Staff implement care plans for select clinical needs which conflict with the patient s other clinical needs New Patient Types Patients with conditions or requiring treatments not previously seen in a setting Even a single patient of a new type requires extensive staff knowledge Staff lack skills and experience managing patients with specific diagnoses or treatment regimens Source: Post-Acute Care Collaborative interviews and analysis.

Post-Acute Settings Not Structured for Higher Acuity Commonly Cited Barriers to Achieving Strong Outcomes for High-Acuity Patients Low Clinician-to- Patient Ratios High Staff Turnover Low Availability of Qualified Staff Margin Pressure Financial Responsibilities to Shareholders Strict Regulatory Guidelines Source: Post-Acute Care Collaborative interviews and analysis.

Why Is Acuity A Threat? Seen by Many Providers As A Cost-Driver Common Investments Prompted by Rising Acuity Reason Investment is Necessary Hire Additional RNs Increase critical thinking power among staff Schedule More Staff Hours Ensure all patient care needs are met Purchase New Equipment Appropriately manage new patient types Provide Additional Staff Training Improve staff clinical knowledge, skills Source: Post-Acute Care Collaborative interviews and analysis.

Unpacking the Problem of Acuity At Its Core, An Attempt to Improve Clinical Quality Common Acuity Investments Reason for Investment Hire Additional RNs Increase critical thinking power among staff Schedule More Staff Hours Ensure all patient care needs are met Underlying Goal: Quality Purchase New Equipment Appropriately manage new patient types Rising acuity is high-cost because of investments required to ensure quality of care for complex patients Provide Additional Staff Training Improve staff clinical knowledge, skills Source: Post-Acute Care Collaborative interviews and analysis.

New Quality Mandate 3 Policymaker Action Foreshadows Payment Overhaul IMPACT Act of 4 in Brief Standardizing Data Reporting Required Domains and Sample Metrics To Guide Patient Placement Three Stated Purposes Patient Assessment Special services required Cognitive function Quality Measures Changes in skin integrity Medication reconciliation Resource Use Measures Medicare spending per beneficiary Rate of discharge to community 3 Compare quality across PAC settings Inform hospital discharge planning Create foundation for future PAC payment reform (likely via site-neutral or bundled payments) New Discharge Planning Requirements To meet CMS conditions of participation, hospitals and PAC providers must incorporate PAC quality and resource use data into discharge planning procedures by January, 6 ) Acute care and critical access. Source: Senate Committee on Finance, Improving Medicare Post-Acute Care Transformation Act of 4, 4, www.govtrack.us/congress/bills/3/hr4994; House Ways and Means Committee, Bipartisan, Bicameral Effort Underway to Advance Medicare Post-Acute Reform, 4, www.finance.senate.gov/newsroom/ ranking /release/? id=cc98f5-db43-45d8-955-3959ac6d997; Post-Acute Care Collaborative interviews and analysis.

New Quality Mandate 4 Driving Two-Way Accountability for Readmissions SNF VBP Incenting SNFs to Reduce Inappropriate Readmissions SNF Readmission Rates High And Avoidable Underperforming SNFs to Face Reimbursement Cuts 4% All-cause, all-condition readmission rate % cut in per diem rate for all SNFs Readmissions performance score calculated, SNFs ranked 3 High-performing SNFs reimbursed 47% Attributable to preventable conditions Measure Finalized: NQF #5 Measures 3-day, potentially preventable readmission rates Source: CMS, Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 6, SNF Value- Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection, August 4, https://www.federalregister.gov/articles/5/ 8/4/5-895/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities; Kramer A, et al., Development of Potentially Avoidable Readmission and Functional Outcome SNF Quality Measures, 4, www.medpac.gov/documents/contractor-reports/ mar4_snfqualitymeasures_contractor.pdf?sfvrsn=; Post-Acute Care Collaborative interviews and analysis.

New Quality Mandate 5 Value-Based Purchasing Coming to Home Health HHAs in Nine States to Experience VBP Beginning in 6 Home Health Value-Based Purchasing Program Components Quality Measurement Performance Comparison Payment Adjustment HHA quality performance measured and reported annually, 6- Included metrics assess clinical quality, efficiency, patient satisfaction, and new measures of quality Quality metrics compared to HHA s baseline scores and cohort averages Total performance score based on improvement, relative achievement Beginning in 8, payments adjusted to reflect quality performance Maximum adjustment ranges from 3% in 8 to 8% in ) Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska, North Carolina, Tennessee, Washington. ) Metrics not currently collected but required under HH VBP include rates of advanced care planning, shingles vaccination, and influenza vaccination for home health staff. We expect that tying quality to payments through a system of value-based purchasing will improve the beneficiaries experience and outcomes [and] will incentive quality improvement and encourage efficiency, leading to a more sustainable payment system. CMS 6 Home Health Final Rule Source: Centers for Medicare and Medicaid Services, CY 6 Hoe Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements, www.gpo.gov/fdsys/pkg/fr-5--5/pdf/5-793.pdf; Post-Acute Care Collaborative interviews and analysis.

New Quality Mandate 6 Quality Is Not Negotiable Emerging Reasons for Pursuing Clinical Excellence,6 Outcomes Transparency Patients and families can access providers quality information from CMS s Compare pages and now Yelp Number of SNFs with severe quality deficiencies,59 Changing Referrer Priorities Hospitals, physician groups are accountable for post-discharge outcomes; e.g. ACOs, CCJR Number of hospitals penalized through Hospital Readmissions Reduction Program for fiscal year 5 PAC Value-Based Payment SNF VBP approved to begin in 8, Home Health VBP has been proposed for the same timeframe 8% Maximum proposed adjustment to home health Medicare payments, based on provider performance ) Accountable Care Organizations. ) Comprehensive Care for Joint Replacement Model. Source: ProPublica, Nursing Home Inspect, http://projects.propublica.org/nursing-homes/; Centers for Medicare and Medicaid Services, www.cms.gov; US News and World Report, Half of Nation s Hospitals Fail Again to Escape Medicare s Readmission Penalties, http://health.usnews.com/health-news/hospital-of-tomorrow/articles/5/8/5/half-of-nationshospitals-fail-again-to-escape-medicares-readmission-penalties; Post-Acute Care Collaborative interviews and analysis.

Road Map 7 A Changing Population Sector by Sector The Threat of Rising Acuity 3 Preparing for the New Quality Mandate 5 The Advisory Board Company advisory.com

8 Balancing a Difficult Equation The Post-Acute Outcomes Challenge Admissions and Patient Mix Operations and Care Delivery + = Clinical Outcomes Patient acuity is rising and will continue to increase Source: Post-Acute Care Collaborative interviews and analysis.

9 Balancing a Difficult Equation The Post-Acute Outcomes Challenge Admissions and Patient Mix Operations and Care Delivery + = Clinical Outcomes Expectations are continually rising for PAC providers to achieve and sustain high quality Source: Post-Acute Care Collaborative interviews and analysis.

3 Balancing a Difficult Equation The Post-Acute Outcomes Challenge Admissions and Patient Mix Operations and Care Delivery Clinical Outcomes + = Beyond PAC control Expectations continually rising Changing internal operations and structure is the only way to improve outcomes for sicker patients. Source: Post-Acute Care Collaborative interviews and analysis.

3 A Moment of Reckoning Select Hospital Readmissions Program Headlines December 7 Keeping Patients from Landing Back in the Hospital, The Wall Street Journal July Medicare Rule Would Decrease Payments to Hospitals with High Readmission Rates, The Washington Post June 5 Q-Centrix Survey Reveals that Hospitals Underestimate Likelihood of Readmissions Penalties, Reuters April US to Hospitals: Clean Up Your Act, CNN Money October CMS Readmission Penalty Program begins December Hospitals Still Don t Feel Readmission-Driven Pay Cuts, MedPage Today The Cost of Waiting to Act $48M CMS estimate of total readmission penalties, FY5 78% Percent of hospitals penalized during FY5 for readmissions -.63% Average penalty for readmissions among hospitals penalized in FY5 ) As an adjusted percentage of a hospital s IPPS payment. Source: The Wall Street Journal, Keeping Patients from Landing Back in the Hospital, http://www.wsj.com/articles/sb974733965; CNN Money, US to Hospitals: Clean Up Your Act, http://money.cnn.com//4/9/news/economy/healthreform_hospital_fines/; The Washington Post, Medicare rule would decrease payments to hospitals with high re-admission rates, https://www.washingtonpost.com/ national/health-science/medicare-rule-would-decrease-payments-to-hospitals-with-high-re-admission-rates//7/8/giqaywdpji_story.html; MedPage Today, Hospitals Still Don t Feel Readmission-Driven Pay Cuts, http://www.medpagetoday.com/publichealthpolicy/medicare/36659; Reuters, Q-Centrix Survey Reveals that Hospitals Underestimate Likelihood of Readmission Penalties, www.reuters.com/article/5/ 6/9/idUSnMKWl3 4fPa+c+MKW569; Kaiser Family Foundation, Aiming for Fewer Hospital U-Turns, http://kff.org/medicare/issuebrief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/; Post-Acute Care Collaborative interviews and analysis.

3 Redefining Quality to Meet Rising Expectations Hallmarks of a High-Quality Post-Acute Provider Outdated Approach to Quality Keys to Quality Success Implement targeted quality improvement methodologies only when an adverse event occurs Take a Proactive Approach to Improvement Measure success by staff compliance with quality improvement tactics Focus on Outcomes, Not Just Process Set goals solely aimed at reducing clinical deterioration and physical injury 3 Embrace Quality Beyond the Baseline Source: Post-Acute Care Collaborative interviews and analysis.

33 Developing a Proactive Approach to Quality The First Three Steps to Better Clinical Outcomes 3 Problem: Staff are overburdened; unable to meet patient needs before they become emergent Problem: Staff lack knowledge, accountability to improve organization s overall quality Problem: PAC providers fail to equip the organization for future quality demands Solution: Maximize the Productivity, Impact of Clinical Staff Solution: Empower Staff to Drive Quality Improvement Solution: Grow Infrastructure to Meet New Quality Expectations Upcoming Webinars Addressing These Solutions How to Prepare Your Staff for the New Post-Acute Patient July 4, 3:PM-4:PM EST How to Get the Post-Acute Outcomes You Want by Building the Care Pathways You Need June, 3:PM-4:PM EST Source: Post-Acute Care Collaborative interviews and analysis.

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