Defining and Driving Value: Provider and Payer Perspectives NAHC Financial Managers Meeting June 2013 Serving the Midcoast of Maine in Knox Waldo Lincoln Counties 1
Who we are... Medicare Certified & State of Maine Licensed (Medicaid) Home Health Provider Medicare Certified & State of Maine Licensed (Medicaid) Hospice Provider State of Maine Licensed Private Duty Provider Characteristics That Make Homecare Indispensible 1. Decades Old Traditional Characteristics Care delivery is comprehensive and multidisciplinary Care is available twenty-fours each day 2
Characteristics That Make Homecare Indispensible 2. Care in the home that reinforces, in an environment familiar to the patient, t teaching that began in the physician s office or hospital which enhances the patient s ability to embrace learning. Characteristics That Make Homecare Indispensible 3. The integration of community health principles i A focus on health promotion and teaching on environmental, psychosocial, economic, cultural, and personal health factors affecting individual and family health status. 3
Characteristics That Make Homecare Indispensible 4. In-home assessments that provide a holistic view of patients, t their capabilities, and the in-home support available for the patient to succeed. Characteristics That Make Homecare Indispensible 5. Medication reconciliation which goes hand-in-hand h d with teaching and management in the home setting. 4
Characteristics That Make Homecare Indispensible 6. A focus on the improvement of the patient s t functional status. t Emphasizing fall prevention, aides in the restoration of independence, and greatly reduces emergency department visits and hospitalizations. Characteristics That Make Homecare Indispensible 7. Agencies began stratifying the risk of re- hospitalization ti and teaching patients t about red flags in December 2005 as part of the National Eight Scope of Work of the Quality Improvement Organizations. 5
Characteristics That Make Homecare Indispensible 8. Agencies have reduced re- hospitalizations ti by reducing risk through h telemonitoring. Re-admission rate for heart failure patients is considerably lower than that of an agency s general patient population. Characteristics That Make Homecare Indispensible 9. Standardized practices and tools across the continuum of care. 6
Characteristics That Make Homecare Indispensible 10. Nationally certified Staff OASIS Home Health Coding Wound, Ostomy and Continence Care Diabetes Education Pediatrics Lymphedema Palliative Care Hospice Cardiovascular Geriatric Psychiatric Infusion Vestibular Rehabilitation Chronic Care Management Characteristics That Make Homecare Indispensible 11. Agencies have been using an electronic patient t record for over a decade. d 7
Home care Competencies Community Health and Wellness Population Health Assessment beyond physical to social, emotional, and environmental Reinforcement of physician/hospital teaching Hidden medications vitamins, herbs, remedies influenced by financial, psychosocial, culture or religion Core Competencies Patient and home assessments Including ADLs and IADLs Rehabilitation Fall Prevention Medication reconciliation and teaching Chronic care management Patient teaching Patient self-management 8
Transition Years Mastering the Future Medicare movement from a passive payer of claims to a prudent purchaser of healthcare services. Home Health Prospective Payment Episodic Care OASIS Home Health Compare HHCAHPS Value Based Purchasing 9
Tracking and Trending Homecare Compare Patient Experience QAPI Financial Operational Percent of hospital discharges with a homecare referral Referral conversion rate The importance of measuring 10
Home Health Compare Overall rating of care given by HHA provider Willingness to recommend the HHA to friends and family How often home health patients had to be admitted to the hospital Multifactor Fall Risk Assessment conducted Depression Risk Assessment conducted Influenza Immunization received Pneumococcal Vaccine ever received QAPI Average Length of stay Comfort 48 hours after admission Willingness to recommend Avoided unwanted hospitalization Rating of weekend/evening responsiveness % of excellence 11
Patient Experience HHCAHPS Family Evaluation of Hospice Care Discharge Phone Calls Financial Benchmarks Revenue per Episode Visits per Episode Supply Costs Hospice ADCL Hospice Supply Costs Private Duty Hours and Cost to Supply Average Visits per Day 12
Operational Benchmarks % of Hospital Discharges Conversion Rate % of TeleHealth Usage Days to Submission RAP/EOE Our Value Together 13
Our Value Together Reduction of Health Care Spending Cost cutting efforts short term Lean Management Supply costs Data sharing and Analytic Strategy to improve outcomes and reduce cost ACH within 30 days, 60 days, 90 days Hospital Avoidance Improved Chronic Disease Management Care Coordination Clinical Tools and EHR Quality Improvement and Quality Improvement Techniques and Education including Board education Improved physician relationships Our Value Together Reduction of Health Care Spending Partnerships/Value of homecare in the healthcare continuum Skilled Teaching continued Patient Engagement continued Chronic Care Management Telemonitoring Participation in bundled payment schemes Shared pathways and protocols Stakeholder engagement Shared Decision Making 14
Moving in the Same Direction Medicare movement from a passive payer of claims to a prudent purchaser of healthcare services. Hospitals Prospective Payment System DRGs Hospital Compare Process Outcomes HCAHPS Re-admissions Value Based Purchasing (now) Home Health Care Prospective Payment System OASIS Case Mix Weight Quality Outcomes Home Health Compare Quality Outcomes Process Outcomes HHCAHPS Acute Care Hospitalization Value Based Purchasing Moving in the Same Direction HCAHPS HHCAHPS Communication Medication Management Patients who reported that their nurses Always communicated well. Patients who reported that staff Always explained about medicines before giving it to them. How well did the home health team communicate with patients Did the home health team discuss medicines, pain, and home safety with patients SCRIPTING 15
Moving in the Same Direction Federal Value Based Purchasing Instead of payment that asks, How much did you do?, the Affordable Care Act clearly moves us toward payment that t asks, How well did you do?, and more importantly, tl How well did the patient do? Don Berwick FY2013 20 measures for VBP calculation 12 Clinical Process of Care measures (70%) 8 Patient Experience of Care dimensions (30%) FY2014 24 measures for VBP calculation 13 Clinical Process of Care measures (45%) 8 Patient Experience of Care dimensions (30%) 3 Outcome measures (25%) FY2015 26 measures for VBP calculation CMS Quality Based Initiatives Timeline 2010 2011 2012 2013 2014 2015 2016 2017 Reporting hospital quality data for annual payment update 2% Value based Purchasing 2% 1% 1.25% 1.5% 1.75% 2% Readmissions 3% 1% 2% 3% 3% 3% Hospital Acquired Conditions 1% 7% At Risk Meaningful Use* 1% *Medicare payments are reduced 1% starting in 2015 with an increasing percentage point each year thereafter up to 5% in 2018 16
The Triple Aim Population Health Flu clinics Patient/family education Pandemic preparedness Blood pressure clinics Foot care clinics 17
Experience of Care Top 20 percentile nationally Nationally measured and reported Per Capita Cost Average daily costs Acute care $1600/day Skilled Nursing Facility - $357/day Homecare - $2200/60 day episode of care Hospice routine $156/day 18
OUR KEY VALUE Acute Care Hospitalization Improvement in Medication Management Improvement in Ambulation Treated Heart Failure Patient s Symptoms Medication Teaching Checked Patient s Risk of Falling Our Value Together Reduction of Health Care Spending Back of the Envelop Calculations MaineHealth COMPARED WITH 2008 COMPARED WITH 2011 2008 rate = 16.2% FY 2012 rate = 15.2% 215 fewer readmissions Savings of $2.1 M FY 2011 rate = 15.5% FY 2012 rate = 15.2% 59 fewer readmissions Savings of $568,000 19
Patients can undo a month s worth of expensive and intensive care just going home and going about their normal routines. John Charde, MD Re-Admission Profile 20
Our Value Together Reduction of Health Care Spending Reducing Re-hospitalizations within the First Seven Days Close attention to medication management Care coordination Knowledge of red flags All Aimed at Reducing Acute Care Hospitalizations Risk Stratification for Re-Admission Uniform implementation of the Transitions of fcare Bundle Risk stratification Discharge checklist Medication reconciliation Patient/family education Timely communication Timely follow-up of patients after discharge 21
Hospital Avoidance Initiative Patient Centered Medical Home Maine Medical Partners, Cape Elizabeth & PrimeCare Biddeford Project aims Improve care coordination Enhance communication and health information exchange Improve access to home health benefits Improve quality outcomes Avoid and reduce unnecessary hospitalization Hospital Avoidance Initiative Hospital to Home Standardized Teaching Tools Patient education booklet with heart failure zones Free Scale Program Telehealth Monitoring Heart Failure Pathway Home Diuretic Protocol 22
Hospital Avoidance Initiative Community Paramedics Falls in the adult/elderly population Home Health Service Access Hospital Avoidance Initiative CABG Bundling Initiative Hospital to home pathway Shared electronic patient record 23
Hospital Avoidance Initiative ADED (Aging Demographic Economic Development Initiative in Lincoln County) Long-term care Access to healthy food Transportation Job opportunities in the sector for seniors and other residents. ED Over Utilization Patients with frequent re-admissions not eligible ibl for home health care Home Health Referral Skilled Care as appropriate Telehealth Safety Net patients 24
Our Greatest Value Care in the Home Patient/Family Centered Care... Total agency involvement in creating a culture of quality patient/family centered care 25
Patient-Family Centered Care Patient/Family Centered Care Involves Every Component of the Agency: Front Loaded Nursing Visits Chronic Care Management Evidence-based Pathways and Protocols Physical Therapy Falls Program Occupational Therapy Cognitive Function Assessment and Plan Social Service working Flex Hours to Meet Family Needs Private Duty care available for Patient/Family Needs Too much focus on acute illness an acquired, transient period of vulnerability risks in the critical 30-day period after discharge might derive as much from the allopathic and physiological stress that patients experience in the hospital as they do from the lingering effects of the original acute illness 26
Contributing Factors Sleep disturbance Nutritional issues Cognitive factors Pain & other discomforts Medications Deconditioning Our Greatest Value Care in the Home High Risk Clinical Indicators Impacting Hospitalization ti Rate Diminished Cognition Dehydration Nutrition History of a fall in last 6 months Arrhythmias Uncontrolled Blood Sugars Co-Morbid Conditions 27
Our Greatest Value Care in the Home FALLS PROGRAM HomeSafe Program Fall Risk Assessment at Start of Care Physical Therapy Intervention Cognitive Assessment as Indicated Environmental Assessment Fall Risk Assessment at Discharge Community Paramedicine Medication Management 59% of our patients are on 10 medications or more 15% of those patients are on 15 or more medications High utilization of Beers List medications 28
KEY PATIENT EXPERIENCE MEASURES Scripting Talk About Medicines Ask to See Medicines Talk About New Medicine Purpose When to Take Medicines Side Effects of Medicines What Do We Have How to best align goals and strategies 29
We need to connect... Physicians Hospitals Connectivity Home Care Other Providers Shift the Paradigm 30
Capitalize on a changing workforce Today 65% of nursing working are in acute care. In ten years that number will flip Selling 31
Tools that Enhance our Value Point of Care Telephony Polycom Telehealth PT/INR Mobile Access Smart Phones Oxygen Saturation Machines VPN Demonstrating Value to: Hospitals Safety Net Patients Home Diuretic Protocol CREST Patients Bundling CABG patients Transitions of CHF patients 32
Demonstrate Value To: ACOs/Managed Care Organizations Patient Centered Medical Homes Community Care Teams Population Health ACO Initiative: Value Oversight Committe Launch an awareness campaign for facilities and organizations so that providers are educated about available hospice services; Develop a resource listing of regional hospice resources; Launch an awareness campaign for the general public about hospice services available to them; Develop tools to help doctors determine when patients life expectancy would be appropriate for hospice referral; Monitor use of hospice, referral patterns and patient and family satisfaction with the intent to give feedback to referring physicians; Evaluate and increase use of hospice services in underserved areas; Promote current hospice bereavement services to support programs to families and staff. 33
Demonstrate Value To: Direct Consumers Patient/Family Education Private Duty 24/7 Availability Electronic Medical Record Telehealth Nationally certified clinicians Home Care is at the Hub of the Health Care Continuum Chronic Acute HOME CARE Long Term Care Preventive Hospice 34
Reflecting Comments? 35
Contact Information Donna DeBlois, Executive Director Kno-Wal-Lin Homecare and Hospice Rockland, Maine ddeblois@penbayhealthcare.org Amy Warrington, Director of Business Operations Kno-Wal-Lin Homecare and Hospice Rockland, Maine awarringto@penbayhealthcare.org 36