Emerging Issues in Post Acute Care Trends

Lavonne Elston, PT Senior Director of Operations & Strategic Initiatives

Skilled Nursing & Rehabilitation Kingston HealthCare Company

April 28, 2016

Disclosures

No Disclosures.

Current Health Care Environment

2016 Health Care

Trends

Technology

Value- Based

Payment

Population Health

Alternative Payment Models

MACRA &

IMPACT

President’s FY 2017 Budget

Proposed spending and revenue changes estimated net effect of $2.9 trillion federal deficit reduction over next 10 years Medicare spending would be reduced by a net $419 billion -Opioid abuse -Medicaid expansion -Cancer Research

IMPACT ACT: What is it?

The Improving Medicare Post-Acute Care Transformation Act of 2014 or IMPACT Act of 2014 (H.R. 4994). • Signed into law October 6, 2014 • Intended to change and improve Medicare's post-acute care (PAC)

services and how they are reported.

IMPACT ACT

• The Act requires the submission of standardized assessment data by: – Long‐Term Care Hospitals (LTCHs): LCDS – Skilled Nursing Facilities (SNFs): MDS – Home Health Agencies (HHAs): OASIS – Inpatient Rehabilitation Facilities (IRFs): IRF‐PAI • The Act requires that CMS make interoperable standardized patient assessment and quality measures data, and data on resource use and other measures to allow for the exchange of data among PAC and other providers to facilitate coordinated care and improved outcomes.

IMPACT ACT: Major Deliverables

Standardized Assessment Data across PAC settings will allow for: • Comparable information used to evaluate and differentiate between

appropriate care settings for and by individuals and their caregivers

• Continued beneficiary access to the most appropriate setting of care

• CMS to compare quality across PAC settings (longitudinal data)

• PAC payment reform (site neutral or bundled payments)

IMPACT ACT: Major Deliverables

Standardized and Interoperable Assessment Data across PAC settings will: • Allow for improvements in hospital and PAC discharge planning and the

transfer of health information across the care continuum

• Support service delivery reform

IMPACT ACT Major Deliverables Timeline

2014-2016 2017 2018 2019 2020 2021 2022

Use of quality data to inform

discharge planning

Standardized assessment data required for PAC providers begins

CMS & MedPAC Reports on PAC

Prospective Payment

Standardized quality and resource use measure

reporting for PAC Providers begins

Study on Hospital

Assessment Data

PAC Settings: IMPACT Timeline Quality Domains HHA SNF IRF LTCH

Functional Status 1/1/2019 Finalized 10/1/2016: Percent of Patients or Residents with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function (NQF #2631)* Self Care & Mobility Score

Skin Integrity Proposed 1/1/2016 (HH), Finalized 10/1/2016 (SNF, IRF, LTCH): Percent of Residents or Patients with Pressure Ulcers that are New or Worsened (Short‐Stay) (NQF #0678)

Medication Reconciliation

1/1/2017 10/1/2018 10/1/2018 10/1/2018

Major Falls 1/1/2019 Finalized 10/1/2016: Percent of Residents Experiencing One of More Falls with Major Injury (Long Stay) (NQF #0674)

Patient Preferences 1/1/2019 10/1/2018 10/1/2018 10/1/2018

Functional Data by Setting

No Standardized

Tool LTCH CARE IRF-PAI SNF-MDS

HHC-OASIS

FLR (No Standardized

Tool)

Acute Care

?

Out Patient

?

Post Acute Care CARE Item Set

IMPACT Act: Oct 1, 2018 for SNF, IRF, and LTCH, January 1, 2019 for HHC

Standardization: “As Is” Transitions “To Be”

Interoperability

The Data Element Library Database

The Data Element Library (DEL) database is in the process of being loaded and will include: PAC assessment data elements and mapped relationships. Content to the Data Element Library database will be updated over time as new and modified standardized data elements, new assessment instrument versions, and new and updated HIT mappings are added.

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Changing Face of Payment

• Volume of services • No tie to outcomes

• Requires data submission to avoid penalty • No benchmarking

• Benchmarking outcomes, quality measures • +/neutral/‐payment adjustment

Value‐based Payment

Pay for Reporting

Fee for Service

Transition Timelines Alternative Payment Models • 30% of payments tied to alternative payment models by 2016;

50% by the end of 2018 • Linking Payment to Outcomes • 85% of fee for service payments tied to outcome measures by end of 2016; 90% by end of 2018

The Health Care Transformation Task Force • 75% of payments into value‐based models by January 2020

Value‐based Payment

Cost

What is defined as Value?

Value = Outcomes

Value

Value for the patient is created by provider’s combined efforts over the full cycle of care. The benefits of any one intervention for ultimate outcomes will depend on the effectiveness of other interventions throughout the care cycle. Porter. NEJM 2010

Functional Outcomes Degree of health or recovery

– Functional level achieved

– Pain level achieved

– Extent of return to physical activities

– Ability to return to work

• Time to recover and time to return to normal activities

– Time to return to physical activities

– Time to return to work

• Sustainability of health or recovery and nature of recurrences

– Maintained functional level – Ability to live independently

Alternative Payment Models • Not fee‐for‐service

• Accountable care organizations • Bundling of services • Comprehensive Care Joint Replacement Model

CJR: Comprehensive Joint Replacement

Comprehensive Joint Replacement is a mandatory bundled payment program to reduce the cost care for hip and knee joint replacement surgeries

CMS has Mandated this in 67 Markets, which includes Toledo

This bundle includes the inpatient hospital stay, any skilled nursing home days, HHC, OP, through 90 days post surgery

Millions in cost savings

Improved Outcomes

What is the goal of the bundle?

Hospitals carry the full risk for CRJ

CMS will communicate a target price to each individual hospital in year one. By year five prices will be set regionally

5 Year Phase in for risk or reconciliation ◦ Reconciliation Payments – will receive a % back of any cost savings

◦ Risk – will be responsible to pay a % of any stop loss

Waivers

• Can waive the SNF 3 day rule if SNF is rated 3 stars or higher on Nursing Home Compare • Can waive “incident to” rule for physician services to allow clinical staff of a physician to furnish home visits. (only for non HHA covered patients) • Telehealth‐ waives originating site requirements so service may be originated in patient’s home

Pre Acute Care/Inpatient Post Post Acute Care

Low variation, minimal cost

savings opportunities

High variation, significant cost

savings opportunities

IRF SNF Home Health OP

Episode Cost: Acute Care + 90 Days Post Discharge

Re-Hospitalization Rates

Length of Stay

CMS 5 Star

Rating

Key Metrics

Best in Class Metrics

RTH costs an average of $20,000

Lowest cost center, focused care, reduced LOS

5 Star Quality Rating System Changes

April 2016-6 CMS will start posting 6 new quality measures (QMs) (Only applies to Medicare A residents)

• % short stay residents d/c to community (Claims based) • % short stay residents who have had ER visit (Claims based) • % short stay residents re-hospitalized in 30 days (Claims based) • % short stay residents who improved in function (MDS) • % long stay residents whose ability to move I worsened (MDS) • % long stay residents who received antianxiety or hypnotic med (MDS)

Why This Matters New Payment Demands New Systems of Care Many Sites Many Teams

Standardized Exchange of Data Elements for Patient Care Within, between and across sites and team (e.g., to support care coordination)

Re-use for Quality Measurement Within sites, transitions between sites, coordination across entire episodes of care

Re-use for Public Health Reporting Re-use to Generate System “Intelligence” so the System can Learn

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Focus on Value Impact on Care Delivery • Patients may pass through care settings faster

• Patients will need certain skills or abilities to

transition to the next care setting

• Each care setting does not have to provide services to meet every possible need

Episode–Based Care

Care Path Utilization:

Following best practices

Care Coordination:

Working seamlessly together

Connected Care:

Providing care in appropriate

venue

Clinical Teams, Patient, & Family Engagement

Right Patient: Increased use of function and outcomes to identify which patients go where and when. Effective Placement: A Persistent Challenge Right Setting: Move patient to lowest cost setting: discharge planning on or before admission, patient and caregiver education Right Care: Evidence based, effective treatment, timely care of clinical needs. Re-hospitalization in first 1-2 days may indicate too soon hospital discharge, later in post acute stay may indicate symptoms not managed timely.

Right Patient, Right Setting, Right Care

Communication and Collaboration • Communicate with previous care setting in order to begin where they left off • Collaborate with the next care setting to know what the patient will need • Determine the transition plan within the first few days • Assess health literacy of patient/family • Identify subtle functional declines early • Follow up with patient after transitioning from this setting

Seamless Transitions

Changing to VBP Means Changing Communications • Requires effective communication between sites

• To create safer transitions of care for those with the most complex issues

• To improved coordination of care across all sites with a shared care plan

• These new connections will rely on the electronic exchange of standardized

and interoperable information

Care Transition

Determine: – What the patient needs to be able to do in the transition environment – What environmental or structural challenges exist in the transition environment – What adaptations to the transition environment need to be made; what adaptations to tasks must be made to allow transition – How much and what type of caregiver support is available – How much and what type patient and caregiver training is required • Document the above findings

CMS Quality Strategy

Better Care Healthier

People Smarter

Spending

THANK YOU