Skills, Technologies & Attributes Case Managers Need to Succeed In Value- Based Care January 19, 2017 Kimberly S. Hodge, MSN, RN, ACNS-BC, CCRN-K Learning Objectives After attending this presentation, participants will be able to: Verbalize a working definition of value-based care Discuss how value-based care may impact case managers Identify skillsets and attributes case managers need in value-based care Suggest how technology can support a value-based care environment List one or two examples of outcomes to consider when measuring success in value-based care
Value-Based Care Value-Based Care (VBC) Healthcare system: rising costs, chronic disease, and an aging population effects Shift from fee-for-volume to fee-for-value Value has been defined as health outcomes achieved per dollar spent (M.E. Porter) VBC aligns payment to providers and practitioners to value
Value-Based Programs in Medicare Provide incentive payments to providers and practitioners for quality Quality strategy includes reforming how health care is both delivered and paid for Value-based programs support: Better care for individuals Better health for populations Lower costs Source: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/value-based-programs/value-based-programs.html Value-Based Programs in Medicare First programs to link quality to payment Hospital Value-Based Purchasing (HVBP) Program Hospital Readmission Reduction (HRR or HRRP) Program Value Modifier (VM) Program (also called the Physician Value-Based Modifier or PVBM) Hospital Acquired Conditions (HAC) Program Other programs End-Stage Renal Disease (ESRD) Quality Initiative Program Skilled Nursing Facility Value-Based Program (SNFVBP) Home Health Value Based Program (HHVBP)
VBC Across the Continuum Clinical and financial incentives driving alignment across continuum Case Mgrs. Policymakers PAC Patients/ Caregivers Hospitals/ Health Systems Health Plans ACOs VBC and Risk Payer takes full financial risk Provider takes full financial risk RISK Risk Traditional Traditional Fee-forservice fee- forservice One-sided Pay Pay-forperformanceShared Savings For One Sided shared Performance savings Bundled / / Episode episode Payments payments Two-sided Two Sided shared Shared Savings savings Partial Capitation capitation Global Capitation capitation Medicare Medicaid Commercial Low plans, etc. Value-Based Purchasing Hospital Readmissions Reduction Program MSSP ACOs (Track 1) BPCI CJR BPCI Advanced MSSP ACOs (Track 1+, 2 & Hig 3) h Pioneer ACOs Next Generation ACOs High Increased risk = need for effective and efficient transition management and care coordination
Transition planning and care coordination across the continuum Pre-acute/Community/Home Acute Post-Acute Pre-acute/Community/Home Move discussions beyond just the next step in a patient s journey Focus Discussion: Post-Acute Care in a VBC World Post-acute care (PAC) Long term care hospitals (LTAC), inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), home health agencies (HHA) Impact on patient outcomes, quality, and cost Setting Fee-for-volume Readmissions Traditional care models Patients and families making informed PAC decisions
The Future of VBC Testing of care delivery and payment models Integrated networks, coalitions, alliances Improvement, innovation and transformation fueled by disruptors and non-conformists Care redesign and transformation Case Management in Value-based Care
Case Management in a VBC Era Value-based care requires that case managers: Assume ownership for patients before, during, and after stays Hardwire seamless patient transitions Support the patient and family through their post-acute care discharge plan and provide information that allows them to make informed decisions Drive clinical standardization to reduce variation Embody evidence-based practice Educate themselves on the quality and cost of PAC, including patient outcomes associated with different settings Use data to drive decisions Know role in VBC arrangements Case Management Success Drivers in VBC Identify and close preventive care gaps Teach patients and families how to manage chronic conditions Develop and implement clinical pathways using the most current evidence Participate in medication reviews and facilitate reconciliation Handover patients providing the next clinician with pertinent information needed to safely assume care
Case Management Success Drivers in VBC Integrate community, parish, palliative and behavioral care services into the longitudinal plan of care Know medical cost and utilization trends to assess the impact of interventions and modify to achieve outcomes Assess and mitigate for social and financial determinants known to impact outcomes ETC Effective VBC Preparation: The Benefits 1. Empowerment 2. VBC trailblazer, not follower 3. Competitive edge 4. Optimal patient outcomes 5. Exceptional quality 6. Reach financial goals 7. SATISFIED PATIENTS
Case Management Skills and Attributes to Thrive in VBC VBC Requires New Capabilities Workflow Re-engineering Care Redesign High-quality Provider Network Evidence-based Clinical Decision Support Patient & Caregiver Engagement Social & Community Support Patient Assessment & Care Plan Development and Execution Technology & Telehealth Solutions Data Analytics & Reporting Quality, Outcomes, Finances Risk & Need Stratification Information Sharing Across Continuum
and a blend of skill sets and attributes Identify the patient population and opportunities Design and implement a care model Create and sustain partnerships and relationships around a common goal: PATIENTS Drive appropriate utilization Measure model impact Focus on continuous improvement Embrace innovation; be a disruptor! Technology to Support Value-Based Care
Technology Pre-acute/Community/Home Acute Post-Acute Pre-acute/Community/Home Patient Engagement & Monitoring Patient Risk and PAC Need Stratification Patient-specific PAC Care Planning High-Quality PAC Network Management & Evaluation Patient Engagement & Monitoring Readmission Risk Assessment Key Attributes of Readmission Risk Tools
Readmission Risk Assessment Model Adaptability Results from static assessments will cap over time Patient-level factors must be considered Few consistent standards exist for evaluating risk prediction models Many strategies lack internal adaptability; a consequence of using outdated patient population data Hospitals have different focus areas not often accounted for in current approaches Recommendation: Include patient-level factors in predicting readmission risk Decision Support Simply identifying a patient as at-risk isn t enough What types of in-hospital or post-acute interventions are most appropriate? Recommendation: Take further step than risk identification to identify specific recommendations for action Enable these decisions with streamlined connective technology Further increase caregiver efficiency and enhance patient experiences and outcomes
Clinical Workflow Integration Ability to integrate with existing systems Attention must be paid to the integration of risk management tool into the clinical workflow Timeliness of information collection In some instances, risk assessment modeling calls for data that is not available until close to discharge Recommendation Clinicians must stratify patients based on their post-discharge needs as close to admission as possible More time to arrange for best post-acute care interventions, educate and engage patients Integrate readmission risk assessment into daily workflow Data Historical data does not predict future readmissions With increasing pressure on hospitals to reduce readmissions, this approach also runs the risk of becoming extremely costly Disease-specific models are too myopic Neglects other at-risk patient populations Many readmitted patients have multiple chronic conditions and comorbidities. How can clinicians determine which tools to use on patients? Recommendation: Consider assessments that utilize current data and clear definitions of predictors
Measuring VBC Impact Measuring VBC success is reliant on 4 key components Patient Outcomes Financial Outcomes VBC Success Quality Outcomes DATA, DATA, DATA.
Questions? Kimberly Hodge, MSN, RN, ACNS-BC, CCRN-K Director of Clinical Performance, West Coast BPCI khodge@navihealth.com Thank you navihealth.com navihealth Essential Insights For news, insights and analysis from the experts transforming healthcare, subscribe to our weekly newsletter: navihealth.com/nei