Opportunity, Risk & Reward Care Redesign Cross Continuum Connections Built on a Foundation of Clinical Innovation Elisa Bovee, MS OTR/L, Vice President of Clinical Strategies 2017 LeadingAge New York Annual Conference The Power of Purpose! Elisa Bovee, MS OTR/L Clinical Strategy Division Health Care Reform Care Redesign Market Analysis PDPM Analysis and crosswalk I am a patient advocate of function, through teaching caretakers in long-term care. Elisa s #highercalling September 13, 2018 1 2 HealthPRO Heritage National healthcare solutions firm specializing in Care ReDesign for top of market clients Today s Discussion Leaders will develop tactical solutions to fortify strategic collaborative partnerships; to navigate changing environments EVALUATE: Trends & marketplace developments STRATEGIZE: The traditional approach? vs. An innovative, comprehensive, outcomes driven clinical approach? EVOLVE: Technology, evidence based programs & Care ReDesign advancements ACTION: Your to do list 3 4 1
NIC Data: Skilled Nursing Data thru December 2017 Hospitals Seek Out Strategic partnerships with healthcare organizations to remain financially viable Providers Focus Beyond operational metrics to be sustainable Networks Expect Providers to deliver on clinical efficacy, efficiency & outcomes to provide competitive edge & fortify long term partnerships Partners Demand Objective results & outcomes (discharge disposition & rehospitalization statistics) 5 5 Collaborate, Communicate, Share Ideas & Data Strategies Patient Hospital PAC Remember, today is the tomorrow you were worried about yesterday ~ Dale Carnegie Patient satisfaction Lower cost per episode Reduction in readmissions Narrowing networks Increased census for SNFs Yesterday Silos of High Cost Care Low Satisfaction Scores Lack of Outcomes Data Today Data Driven Network Narrowing Partnerships with Qualitative Expectations Value Based Reimbursement Tomorrow Payment Redesign Redesigning Service Delivery Expanding Service Offerings 7 8 2
What the Future Will Look Like... Program Alignment if You re Competing to Win Outcome Measures Organizational Capability Measures Efficiency Measures Performance Measures Re hospitalization rates by diagnosis Percent of patients discharged home; with home care/wellness/op referrals Clinical Capabilities profile Admission/Discharge risk scores Average response time to referrals Average LOS by payer/program/diagnosis Therapy intensity (minutes/week) Functional Status Changes (*CARE Tool)/LOS Cost/episode by diagnostic group Care coordination measures Patient engagement measures Industry Trends CMS mandates Payment reform Advancing managed care markets Expanding risk arrangements Narrowing networks Cross Continuum Challenges Hospital Penalties Metrics Network Narrowing SNF Penalties Key Performance Metrics Upstream & Downstream Preferred Partners Payment Reform Senior Living Service Offerings Outcomes Measures Innovative Partnerships Home Health Clinical Competencies Care Coordination Rehospitalization Mitigation Outcomes Payment Reform Internal Scorecards Quality Measures sepsis/uti, falls, cognition 5 Star Ratings listed by criteria Control group/peer benchmarking/ hospital & national standards The Value Proposition: High Quality, Cost Effective Service Delivery Communicate Upstream & Downstream Declining Hospital LOS National & State trend indicates need for SNF Care ReDesign Medicare Fee For Service through Q4 2017 Q2 2017: PA 4.95 National 4.98 Downstream Strategies Ensure clinical competencies to care for higher acuity patients Partner Understand hospital s pain points (query ACO leaders / DRG data) Appeal to Differentiated Referral Source Goals Fortify Networks Hospitals, SNFs, HHAs, Senior Living, Payers /Conveners Collaborate Address Common Challenges & Share Opportunities IL State LOS 4.73 12 3
Advanced Clinical Capabilities Underutilization of PAC Services Patients at Risk? % patients who did not receive PAC services were readmitted within 3 days 13 14 Declining SNF Medicare FFS LOS: Q2 2017: PA 22.2 National 24.9 Q4 2017: IL: 25.88 National: 24.70 Know Where You Stand Performance Data is Vital! Impact on: Patient satisfaction? Marketplace competition? Clinical competency? etc. Leaders & Innovators: Proactive strategic plan TODAY inclusive of Care ReDesign 15 16 4
Reality Check Network changes Benchmarks more competitive KPIs drive financial future Risk relationships Need for Performance Scorecards etc. Only organizations with experience and systems in place will survive. Other PAC communities may not endure the evolution. For SNF Leadership How to adapt to changes? Plan for cross continuum play? Prepared to track & manage Outcomes? Ready for risk? Successful Program Design Operational Readiness Roles & Responsibilities Communication Education/orientation Data collection Partnership development Root cause analysis *Modified from Best Practices for Facilitating SNF Transitions of Care, 1/2018 Remedy Partners / HealthPRO Heritage Discharge Process* Best Practices Post discharge, downstream services & resources Medication management As per Final Rule guidelines Processes for communication Coordinating telephonic reinforcement post discharge 17 19 18 Early Discharge Planning Meeting Early Resident/Rep Planning Meeting Process for scheduling upon admission Be Consistent Discussion around Risk Factors Care Plan Updates Documentation of DC Planning Requirements in EMR Remove Silos of Care discuss by risk and need Relay Anticipated DC date based on Rehab, Nursing and SS recommendations Initiate Home Health Coordination Explain needs and plans to/for Next Site of Care Re Hospitalization Mitigation Frequent communication Root cause analysis meetings Post discharge follow up calls ER Diversion Program Risk stratified programs 30 day all cause re hospitalizations from both hospital & SNF Nursing 24/7 Additional support services House calls Telehealth programs Transitional therapy programs (NSOC) 19 20 5
Home Health Evolution Advanced clinical capabilities profile Medical & APRN coverage Use of telemedicine Vendor status for ancillary services; Timeliness Internal & external care transitions process including liaison expectations Rehab Services: SOC / Coverage Service delivery patterns Current partners in provision of care across the continuum (i.e.: hospice) Integration of EMR / Data collection procedures Innovative Solutions: Assisted Living Transition Model Success MJR Respite Stay HMO Transitional Program Medicare A Observation Stay Option High Risk Home Hospital to AL Option Program Offerings in Senior Living MJR Respite Stay process for hospital to AL admission with Home Health versus OPT Therapy (14 days or less) HMO Transitional Program private pay stay for up to 30 days if home with no caregiver is next step Medicare A Observation Stay Option Process for MD evaluation of AL appropriateness for private pay stay prior to DC home after observation stay in hospital High Risk Home Hospital to AL Option those high risk patients who are being sent home with no caregiver with CHF, COPD, AMI, MJR with a high risk for readmission transition to AL for less than 14 days 22 Final Rule for SNF FY 2019 What is your Strategy? FINAL Rule for SNF FY 2019 Patient-Driven Payment Model (PDPM) Revision of both SNF PPS RUG & initially proposed RCS-1 Reimbursement implementation FINAL for October 1, 2019 (FY 2020) Effective Oct 1 st 2019 23 24 6
PDPM Defined This rate structure Considers patients total clinical profile & cognitive & functional status Considers individual therapy disciplines Includes adjustments for LOS for PT,OT & NTA Is NOT driven by therapy minutes Reimbursement for all Medicare days regardless of services provided Case Mix Adjusted Payment Positive Nursing and Negative Therapy Impact from RUG- IV to PDPM Nursing = RUG-IV and Section GG NTA = Nursing Extensive Services PT & OT = ICD-10 coding + Section GG SLP Presence of Acute Neurologic Condition (ICD-10), SLP-Related Comorbidity (ICD-10), and/or Cognitive Impairment + Swallowing Disorder/Mechanically Altered Diet National Impact Detail PDPM Assessment Schedule Improvements to PDPM from RCS-1 PT and OT Components ST Components Nursing Components Reduced from 30 to 16 Reduced from 18 to 12 Reduced from 43 to 25 PT & OT on 2 components (Clinical Category & Functional Status) Cognitive Function only applies to ST component Revised CPS scoring to include cognitively intact Coding compliance for Depression & Restorative Nursing Reduction in administrative burden 1 scheduled assessment IPA now OPTIONAL ARD is when provider choses No more COTs, EOTs, SOTs Where will your time be spent? Section GG to assess functional status & IMPACT Act compliance PT and OT Variable per diem adjustment from 1% q 3 days after Day 14; to 2% q 7 days after Day 20 Revised components for NTA to better capture clinical complexity & services Mapped ICD-10 codes to primary reason for SNF stay vs SNF admission IPA (interim payment assessment) OPTIONAL* ARD will be the date the facility choose to complete the assessment relative to the triggering event that causes a facility to choose to complete the IPA. Payment related to the IPA begins the day of the ARD of the IPA. IPA will not be susceptible to assessment penalties, given the optional nature of the assessment Group & Concurrent reinstated combined 25% cap per discipline 28 7
Process for GG Documentation Who is responsible? Timing of collection Accuracy Triple Check Nursing Component Impact Most are in reduced physical function and clinically complex Understand RUGs IV nursing categories and services Documentation to support services Appropriate capture of SCL and SCH Nursing Category Distribution Image courtesy of AANAC 2018 Nursing Functional Score Calculation 1. Average scores for bed mobility and transfers Average Bed Mobility Average Transfers Bed Mobility Sit to Lying (GG0170B1) Lying to sitting at side of bed (GG0170C1) Transfers Sit to Stand (GG0170D1) Chair/Bed to chair transfer (GG 0170E1) Toilet Transfer (GG0170F1) 2. AND THEN.add four components together: Eating (GG0130A1) Toileting (GG0130C1) Average Bed Mobility Average Transfers Important Section GG scoring of 0-5 most optimal Consider the strategy timing of this assessment, most usual performance before any treatment has occurred 31 Process for capturing extensive services Clinical capabilities needed Imperative in market share Readmission mitigation process in place Educate physicians about the changes Identify the costs associated with the NTA categories and ensure effective and efficient resource utilization Improve hospital to SNF communication NTA Component Impact 8
Clinical Categories - Diagnosis is Key FINAL Elements Determine PT and OT Case Mix Primary Diagnosis or reason for treatment in the SNF First line of I8000 Select inpatient surgical procedure category in sub-item within item J2000 to augment the patient s PDPM clinical category. Accurate, supportive documentation & ICD-10 coding required Therapy, MDS & billing must align Coordination of interdisciplinary documentation Triple Check Process assures accuracy before billing PT / OT Clinical Categories Major Joint Replacement or Spinal Surgery Other Orthopedic Non Orthopedic Surgery or Acute Neurologic SLP Clinical Categories Acute Neurological Non Neurological Clinical Capacity Clinical diagnosis (reason for treatment in the SNF) First line of I8000 of MDS Functional Score Revised Section GG of MDS Sums performance in 6 functional areas More functional = higher score Medical Management 33 34 PT/OT Functional Score Calculation Therapy Component Impact Bed Mobility Sit to Lying (GG0170B1) Lying to sitting at side of bed (GG0170C1) 1. Average scores for bed mobility, transfers, walking Average Bed Mobility Average Transfers Average Transfers Walking Sit to Stand (GG0170D1) Chair/Bed to chair transfer (GG 0170E1) Toilet Transfer (GG0170F1) 2. AND THEN.add six components together: Eating (GG0130A1) Oral Hygiene (GG0170B1) Toileting (GG0130C1) Average Bed Mobility Average Transfers Average Walking Important Those providing supportive Section GG scoring based on therapy Staff must code accurately GG score of 10 23 is most optimal Walking Walk 10 feet (GG0170I1) Walk 50 feet with 2 turns (GG0170J1) Walk 150 feet (GG0170K1) 35 Use of specific ICD-10 codes and process to obtain codes timely from day 1 or even preadmission Coding of SLP related comorbidities and cognitive impairment SLP involvement will be imperative for the category with both swallowing disorders and MAD coded Ensure proper MDS coding of the swallowing items today! Average PT, OT & SLP Case Mix 1.49 Nationally 9
Communicating and Capturing Example Coding SLP related comorbidities Nursing, MDS and Therapy assessment Daily Clinical Meeting discussions Daily PPS meeting Pre-transmission reviews Triple check Be aware of compliance risk for auditing Let go of the status quo Accept need for change CROSS CONTINUUM COMMUNICATION Regular meetings, shared pathways Risk based care plans & service delivery Share metrics, scorecards, improvement planning Evaluate relationships with existing liaisons Strategies Care ReDesign Plan for future VISIONARY SERVICES Be nimble & grow! Health literacy Evidence based programs to align with referral sources Palliative & hospice services Diagnostic programming Innovative Senior Living Models of Care 38 The more things change the more they stay the same. Catch the wave now; don t get left behind: When to implement Care ReDesign? Innovators must embrace a strategic plan & timeline Start NOW Thank you for joining us! Find out more on our blog at healthpro-heritage.com/blog. Contact us if you have any questions. Elisa Bovee, MS OTR/L VP Clinical Strategies ebovee@healthpro-heritage.com 978-973-2805 Julie Bringas Sr. VP of Business Development jbringas@healthpro-heritage.com 39 10