copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Alternative Care OptionsOptional Intensive
Health Dimensions Group National Summit
Brent T Feorene MBA Vice President Integrative Delivery Models Health Dimensions GroupShawn M Bloom President and CEO National PACE AssociationDr William Mills CEO Chronic Care Management Medical Advisor Kindred HealthcareSteven Landers MD MPH President and CEO Visiting Nurse Association Health Group
Tuesday February 23 2016
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
You now know ushellipbut we need to know one another too
1
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out
of your mindhelliprdquo
Roberto GoizuetaFormer CEO Coca-Cola
2
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 3
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (National Transitions of Care Coalition NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Top Five Trends in Integrated Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Health and Human Services set goals for Medicare fee-for-service (FFS) payments linked to quality and alternative payment models in 2016 and 2018 targets
Health Care Transformation Task Force
Several of nationrsquos largest health care systems and payors joined by purchasers and patient stakeholders have committed 75 of their business into value-based arrangements by 2020
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 5
PAC Plays Key Role in Value-Based Care
Medicare Acute
Hospital Discharges
43 Sent to Post-acute
Skilled Nursing41
Home Health37
Acute Rehab10
Outpatient9
LTACH2
With the bulk of post-hospital patients SNF amp HHA represent key settings for controlling total costs and managing outcomes
Health systems often have limited control of costs and outcomes sent to non-affiliated post-acute settings
Source MedPAC Testimony 2013
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 6
bull First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF LTACH IRF) fell by 30 use of HHA stayed about same
bull Recent letter to JAMA about NYUrsquos Model 2 BPCI program shows 49 and 34 reductionsin discharges to institutional PAC for cardiac valveand joint replacement episodes respectively
bull Two mature joint replacement bundling programs show 40ndash50 drop in discharges to SNFs
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Source CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4 Year 1 Evaluation amp Monitoring Annual Report The Lewin Group February 2015
Caution Early results are heavily influenced by ortho bundles and possible selection bias nonetheless the results and our experience indicates that
bundling can drive market shifts
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
You now know ushellipbut we need to know one another too
1
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out
of your mindhelliprdquo
Roberto GoizuetaFormer CEO Coca-Cola
2
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 3
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (National Transitions of Care Coalition NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Top Five Trends in Integrated Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Health and Human Services set goals for Medicare fee-for-service (FFS) payments linked to quality and alternative payment models in 2016 and 2018 targets
Health Care Transformation Task Force
Several of nationrsquos largest health care systems and payors joined by purchasers and patient stakeholders have committed 75 of their business into value-based arrangements by 2020
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 5
PAC Plays Key Role in Value-Based Care
Medicare Acute
Hospital Discharges
43 Sent to Post-acute
Skilled Nursing41
Home Health37
Acute Rehab10
Outpatient9
LTACH2
With the bulk of post-hospital patients SNF amp HHA represent key settings for controlling total costs and managing outcomes
Health systems often have limited control of costs and outcomes sent to non-affiliated post-acute settings
Source MedPAC Testimony 2013
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 6
bull First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF LTACH IRF) fell by 30 use of HHA stayed about same
bull Recent letter to JAMA about NYUrsquos Model 2 BPCI program shows 49 and 34 reductionsin discharges to institutional PAC for cardiac valveand joint replacement episodes respectively
bull Two mature joint replacement bundling programs show 40ndash50 drop in discharges to SNFs
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Source CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4 Year 1 Evaluation amp Monitoring Annual Report The Lewin Group February 2015
Caution Early results are heavily influenced by ortho bundles and possible selection bias nonetheless the results and our experience indicates that
bundling can drive market shifts
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out
of your mindhelliprdquo
Roberto GoizuetaFormer CEO Coca-Cola
2
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 3
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (National Transitions of Care Coalition NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Top Five Trends in Integrated Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Health and Human Services set goals for Medicare fee-for-service (FFS) payments linked to quality and alternative payment models in 2016 and 2018 targets
Health Care Transformation Task Force
Several of nationrsquos largest health care systems and payors joined by purchasers and patient stakeholders have committed 75 of their business into value-based arrangements by 2020
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 5
PAC Plays Key Role in Value-Based Care
Medicare Acute
Hospital Discharges
43 Sent to Post-acute
Skilled Nursing41
Home Health37
Acute Rehab10
Outpatient9
LTACH2
With the bulk of post-hospital patients SNF amp HHA represent key settings for controlling total costs and managing outcomes
Health systems often have limited control of costs and outcomes sent to non-affiliated post-acute settings
Source MedPAC Testimony 2013
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 6
bull First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF LTACH IRF) fell by 30 use of HHA stayed about same
bull Recent letter to JAMA about NYUrsquos Model 2 BPCI program shows 49 and 34 reductionsin discharges to institutional PAC for cardiac valveand joint replacement episodes respectively
bull Two mature joint replacement bundling programs show 40ndash50 drop in discharges to SNFs
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Source CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4 Year 1 Evaluation amp Monitoring Annual Report The Lewin Group February 2015
Caution Early results are heavily influenced by ortho bundles and possible selection bias nonetheless the results and our experience indicates that
bundling can drive market shifts
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 3
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (National Transitions of Care Coalition NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Top Five Trends in Integrated Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Health and Human Services set goals for Medicare fee-for-service (FFS) payments linked to quality and alternative payment models in 2016 and 2018 targets
Health Care Transformation Task Force
Several of nationrsquos largest health care systems and payors joined by purchasers and patient stakeholders have committed 75 of their business into value-based arrangements by 2020
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 5
PAC Plays Key Role in Value-Based Care
Medicare Acute
Hospital Discharges
43 Sent to Post-acute
Skilled Nursing41
Home Health37
Acute Rehab10
Outpatient9
LTACH2
With the bulk of post-hospital patients SNF amp HHA represent key settings for controlling total costs and managing outcomes
Health systems often have limited control of costs and outcomes sent to non-affiliated post-acute settings
Source MedPAC Testimony 2013
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 6
bull First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF LTACH IRF) fell by 30 use of HHA stayed about same
bull Recent letter to JAMA about NYUrsquos Model 2 BPCI program shows 49 and 34 reductionsin discharges to institutional PAC for cardiac valveand joint replacement episodes respectively
bull Two mature joint replacement bundling programs show 40ndash50 drop in discharges to SNFs
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Source CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4 Year 1 Evaluation amp Monitoring Annual Report The Lewin Group February 2015
Caution Early results are heavily influenced by ortho bundles and possible selection bias nonetheless the results and our experience indicates that
bundling can drive market shifts
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Health and Human Services set goals for Medicare fee-for-service (FFS) payments linked to quality and alternative payment models in 2016 and 2018 targets
Health Care Transformation Task Force
Several of nationrsquos largest health care systems and payors joined by purchasers and patient stakeholders have committed 75 of their business into value-based arrangements by 2020
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 5
PAC Plays Key Role in Value-Based Care
Medicare Acute
Hospital Discharges
43 Sent to Post-acute
Skilled Nursing41
Home Health37
Acute Rehab10
Outpatient9
LTACH2
With the bulk of post-hospital patients SNF amp HHA represent key settings for controlling total costs and managing outcomes
Health systems often have limited control of costs and outcomes sent to non-affiliated post-acute settings
Source MedPAC Testimony 2013
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 6
bull First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF LTACH IRF) fell by 30 use of HHA stayed about same
bull Recent letter to JAMA about NYUrsquos Model 2 BPCI program shows 49 and 34 reductionsin discharges to institutional PAC for cardiac valveand joint replacement episodes respectively
bull Two mature joint replacement bundling programs show 40ndash50 drop in discharges to SNFs
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Source CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4 Year 1 Evaluation amp Monitoring Annual Report The Lewin Group February 2015
Caution Early results are heavily influenced by ortho bundles and possible selection bias nonetheless the results and our experience indicates that
bundling can drive market shifts
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 5
PAC Plays Key Role in Value-Based Care
Medicare Acute
Hospital Discharges
43 Sent to Post-acute
Skilled Nursing41
Home Health37
Acute Rehab10
Outpatient9
LTACH2
With the bulk of post-hospital patients SNF amp HHA represent key settings for controlling total costs and managing outcomes
Health systems often have limited control of costs and outcomes sent to non-affiliated post-acute settings
Source MedPAC Testimony 2013
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 6
bull First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF LTACH IRF) fell by 30 use of HHA stayed about same
bull Recent letter to JAMA about NYUrsquos Model 2 BPCI program shows 49 and 34 reductionsin discharges to institutional PAC for cardiac valveand joint replacement episodes respectively
bull Two mature joint replacement bundling programs show 40ndash50 drop in discharges to SNFs
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Source CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4 Year 1 Evaluation amp Monitoring Annual Report The Lewin Group February 2015
Caution Early results are heavily influenced by ortho bundles and possible selection bias nonetheless the results and our experience indicates that
bundling can drive market shifts
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 6
bull First CMS evaluation of BPCI for small number of ortho bundlers showed that institutional PAC (SNF LTACH IRF) fell by 30 use of HHA stayed about same
bull Recent letter to JAMA about NYUrsquos Model 2 BPCI program shows 49 and 34 reductionsin discharges to institutional PAC for cardiac valveand joint replacement episodes respectively
bull Two mature joint replacement bundling programs show 40ndash50 drop in discharges to SNFs
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Source CMS Bundled Payments for Care Improvement (BPCI) Initiative Models 2-4 Year 1 Evaluation amp Monitoring Annual Report The Lewin Group February 2015
Caution Early results are heavily influenced by ortho bundles and possible selection bias nonetheless the results and our experience indicates that
bundling can drive market shifts
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Value-Based Movement Redefining the Value Statement
Medical care delivery in patientrsquos residence
Alternative for follow-up visit to busy PCP office with
access and scope limitations
Integrated collaborative care in a SNF using physicians and advanced practice providers
Offering ED physicians clincally appropriate options to inpatient admission
Acute Care
MedicalHouseCalls
EDDiversion
ComplexCareClinic
ALF
Home Care Technology
Care Transitions
Psycho-social
Support
7
HomeHealth SNF
Offering a high-quality lower-cost alternative to SNF
CareManagement
Providing skilled care in patientrsquos residence
Offering an Integrated Solution to Population Health Management
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 8
bull Medical model not bound by traditional delivery locales or roles
bull Certain population segments require medical care outside of the acute and ambulatory settings
bull Focus on timely access and collaborative team-based care to achieve success in a future defined by value
bull Post-acute medicine delivers care in patient-centered health home model integrating and collaborating with other health care and community-based services
Post-Acute Medicine
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 9
SeniorDual Population Force Move Toward Value-Based Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 10
Medicare Advantage (MA) penetration grew by more than 30 in
the last 5 years
Growth concentrated in 15 stateshellip
48 counties have more than 25000 Medicare-eligible persons and
gt50 MA penetration
Despite enrollment growth remains ldquoblack
boxrdquo for many post-acute providers due to small scale by any one
plan
Medicare Advantage Is Growing Nationally
Source HDG analysis of cmsgov files as February amp September 2015
CMS announced Value-Based Insurance Design (VBID) on September 1 2015to allow plans in seven states greater flexibility in benefit design
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Environmentalamp SocialFactors
20
Family History amp Genetics
30
Personal Behaviors 40
Source Determinants of Health and Their Contribution to Premature Death JAMA 1993
Medical Care
10
Social Determinants of Care
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Robert Wood Johnson Foundation survey of 1000 PCPs
bull For 85 social needs directly contribute to poor health
bull 4 out of 5 not confident can meet social needs limiting ability to provide quality care
bull 1 in 7 prescriptions for social needsbull Psychosocial issues treated as
physical concerns
20
Health is driven by multiple factors that are intricately linkedmdashof which medical care is one component
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 12
Essential intervention categories for reaching the Triple Aim1 Medication management
2 Transition planning
3 Patient and family engagementeducation
4 Health care providers engagement
5 Follow-up care
6 Information transfer
7 Shared accountability acrossproviders and organizations
Seven Essentials of Engaged Intervention
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Triple Aim
Better patient care
Healthy people
communities
Lower cost
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 13
bull Preferred PAC network (acute to PAC)
bull Joint venture Interlude
Ascension Health amp Envision
PACE with CCRC and senior housing
Humana and AMC Health
bull PAC network alignment (PAC to PAC)
Partnerships
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 14
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Environmentalamp SocialFactors
20
Family History amp Genetics
30
Personal Behaviors 40
Source Determinants of Health and Their Contribution to Premature Death JAMA 1993
Medical Care
10
Social Determinants of Care
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Robert Wood Johnson Foundation survey of 1000 PCPs
bull For 85 social needs directly contribute to poor health
bull 4 out of 5 not confident can meet social needs limiting ability to provide quality care
bull 1 in 7 prescriptions for social needsbull Psychosocial issues treated as
physical concerns
20
Health is driven by multiple factors that are intricately linkedmdashof which medical care is one component
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 12
Essential intervention categories for reaching the Triple Aim1 Medication management
2 Transition planning
3 Patient and family engagementeducation
4 Health care providers engagement
5 Follow-up care
6 Information transfer
7 Shared accountability acrossproviders and organizations
Seven Essentials of Engaged Intervention
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Triple Aim
Better patient care
Healthy people
communities
Lower cost
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 13
bull Preferred PAC network (acute to PAC)
bull Joint venture Interlude
Ascension Health amp Envision
PACE with CCRC and senior housing
Humana and AMC Health
bull PAC network alignment (PAC to PAC)
Partnerships
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 14
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 12
Essential intervention categories for reaching the Triple Aim1 Medication management
2 Transition planning
3 Patient and family engagementeducation
4 Health care providers engagement
5 Follow-up care
6 Information transfer
7 Shared accountability acrossproviders and organizations
Seven Essentials of Engaged Intervention
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
Triple Aim
Better patient care
Healthy people
communities
Lower cost
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 13
bull Preferred PAC network (acute to PAC)
bull Joint venture Interlude
Ascension Health amp Envision
PACE with CCRC and senior housing
Humana and AMC Health
bull PAC network alignment (PAC to PAC)
Partnerships
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 14
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 13
bull Preferred PAC network (acute to PAC)
bull Joint venture Interlude
Ascension Health amp Envision
PACE with CCRC and senior housing
Humana and AMC Health
bull PAC network alignment (PAC to PAC)
Partnerships
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 14
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 14
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 15
Behavioral Health
AdultDay Care
Complex CareClinic
Home Care Private Duty amp DME
Skilled Nursing Facility Patient-Centered
Health CareNeighborhood
Palliative Care ClinicHospice
Telemedicine Telemonitoring
Geriatric Assessment amp
Consultation
Area Agencyon Agingamp OtherCommunityAgencies
House Calls
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 16
bull Most markets dominated by local and regional providers
bull Consolidation has slowed significantly
bull Squeezing reimbursement and regulatory requirements have challenged the industry
Competitive Dynamics of Post-acute Care Industryhellip
1 Value-based movement
2 Social determinants of care
3 Engaged intervention (NTOCC)
4 Integrated care partnerships
5 Strategic pivotsrepositioning
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Innovations occurring in community-based services includendash National home care investments in hospital-at-home medical
house call programs and care coordination
ndash Growth in post-acute care management companies focused on medically complex patientsmdashpost-acute networks
ndash National providers pursuing exclusive contracts with commercial payors
ndash Technology
bull HHAsSNFs positioning themselves as post-acute coordinators
bull Payors crossing over into provider side of equation
hellipBring Competitive Responses
17
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Dual Strategy
Solutions Provider
Vendor
Strategic Delineation
18
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
bull Large marketgeographic dominate providers
bull Hospital-based providers that are valued by their system
bull Providers with aligned interest of payors and referring partners
minus Lowest-cost provider
minus Focused on same quality metrics as partners
bull Proven partner with verifiable data
Which Post-acute Vendors Will Win
19
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 20
bull Focus operational strategies on building care coordination infrastructure
bull Have or willing to buildbuy capability to manage at-risk or high-cost patients
bull Ability to communicate their value proposition as a solutions provider
bull Capable or moving towards an ability to manage risk
Strategic PivotsRepositioning Solutions Provider
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Care TransformationRequired for The Shift to Value-based Payment
21
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 22
bull Poor communication among primary providers specialists health and community providers patients and families
bull Failure to catch problems early
bull Failure to address psychosocial issues
bull Lack of coordinated longitudinal care management
bull Ineffective transitional care management
bull Insufficient management of multiple medications
bull Deviations from evidence-based care
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Source Academy Health 2012
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 23
Robust care redesign that targets avoidable hospitalizations in all settings and transitions
Know outcomes and costs to the DRG level
Prepare the patient and family for the next level of care and get them there as quickly and safely as possible
Risk stratify using data analysis and customizing intensity of interventions
Four Key Elements to Transforming Care
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Readiness for Value-Based Transformation
37
ldquoThere are risks and costs to action But they are far less than the long-range risks of
comfortable inactionrdquoJohn F Kennedy
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 39
Physician Alignment and Accessbull Assures immediate access to office-based primary care or house calls as well as
primary care management in acute and post-acute venues
Robust IT Platform and Just-in-Time Business Intelligencebull Provides cross continuum information in real time for pre-acute acute post-acute and
home-based encounters
Risk-Adjusted Enterprise Care Managementbull Includes stratifying population and tailoring care management as well as longitudinal
management of beneficiaries
Developing Network of Post-Acute Providersbull Standardized evidence-based care across the acutepost-acute continuum and
seamless optimal patient experience
What Are ACOs Doing Now
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 260
Characteristics of Most Effective HospitalPost-acute Care Partnerships
bull Physician integrationmdashphysician participation in care across settingsbull Agreed-upon clinical protocolsbull Clearly defined expectations
Clinical Collaboration
bull Regularly established forum for communication and performance improvement for example joint operating committeeCommunication
bull Hospital volume concentrated in small number of post-acute providers to allow for increased clinical collaborationConcentration
bull True partnership around improving patient outcomes and reducing utilization
bull Process to review and improve care on an ongoing basisPartnership
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Obtain data and develop analytic capacity to support articulation of your organizationrsquos value proposition
Undergo clinical and operational transformation by implementing standardized care pathways and protocols for reduction of avoidable hospitalizations
Engage referring health systems and at-risk payors about your value proposition
Define path to implement VBP arrangements for majority of your payors
27
Value-Based Transformation Checklist
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 28
To prepare for value-based care define your value proposition in three key areas and then reach out to value-based payors
Ability to Manage Readmissions Capabilities to manage the patient aggressively in situ including telemonitoring and medical management strategies all within expected norms
Patient Outcomes (Versus Inputs) Relative to Peers Performance better than your peer group on key outcomes
Episodic Management CapabilitiesCapacity to manage seamlessly across multiple settings effectively communicate with the bundler
Define Your Value Proposition
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Future Investment
bull Network alignment and development
bull Care transformation
bull Care teamsInterdisciplinary teams
bull Technology
Analytics
EHR
Reporting
eSNF
Telehealth
bull Engaged physicians
29
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Assessment Evaluate Your Ability to Add Value
Clinical services Operational Talent
Competitors Payors Vendors
Access to investment
capital
30
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
copy HDG 2016 February 23 2016HDGConsulting HDGSummit
Not Taking Risk May Not Be an Option in the Future
31
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
PACEProgram of All-inclusive
Care for the ElderlyAn Overview
wwwNPAonlineorg
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
What Is PACEProgram of All-Inclusive Care for the Elderly
An integrated system of care for the frail elderly that is
bull Community-based
bull Comprehensive
bull Capitated
bull Coordinated
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
bull 55 years of age or older
bull Living in a PACE service area
bull Certified as needing nursing home care
bull Able to live safely in the community with the services of the PACE program at the time of enrollment
The PACE Model Who Does It Serve
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Honors what frail elders wantbull To stay in familiar surroundings
bull To maintain autonomy
bull To maintain a maximum level of physical social and cognitive function
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Integrated Service Delivery and Team Managed Care
Masters Degree Social
Worker Activity Coordinator
Primary Care Physician
Transportation
Occupational Therapy
PhysicalTherapyPersonal Care
Dietician
Home Care Coordinator
PACE Center Manager
RegisteredNurse
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
bull An interdisciplinary teambull Team managed care vs individual case managerbull Continuous process of assessment treatment planning service
provision and monitoringbull Focus on primary secondary tertiary prevention
Integrated Team Managed Care
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
bull Medicare capitation rate adjusted for the frailty of the PACE enrollees
bull Integration of Medicare Medicaid and private pay payments
Capitated Pooled Financing
Pooled Capitation (PMPM)
Medicare Part D
Medicare Medicaid
Private Pay
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
bull PACE Programs receive approximatelybull 60 of revenue from Medicaid
bull 40 from Medicarebull A small percentage of program revenue comes from private sources or enrollees
paying privately
bull 2015 Mean Medicare PMPM Rate $2279
bull 2015 Median Medicaid PMPM Rate $3568
bull PACE Programs are Medicare D providers
Source of Service Revenue
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
bull Over 216 PACE centers
bull 115 PACE organizations
bull Operating in 32 states
bull Serving over 38000 participants
bull 12 new programs in the development ldquopipelinerdquo
bull CMS recently announced that for-profit sponsors can apply to develop PACE organizations
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
National Census Growth 1996ndash2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Chart1
Column1
4168
5029
5612
6285
7108
7682
8419
10226
12500
13992
15000
16000
18000
20226
22788
25443
28341
30037
37345
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Sheet1
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Column1
1996
3272
1997
4168
1998
5029
1999
5612
2000
6285
2001
7108
2002
7682
2003
8419
2004
10226
2005
12500
2006
13992
2007
15000
2008
16000
2009
18000
2010
20226
2011
22788
2012
25443
2013
28341
2014
30037
2015
37345
PACE Programs Around the Country (2015)
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Provider-based modelbull Tightly controlled care management and utilization systemsbull Serves largely a nursing home eligible population in the
community when enrolledbull Good care outcomes high enrollee satisfaction and low
disenrollment ratesbull Established existing program with a proven track record
PACE Core Competencies
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
NPA received a grant from the SCAN Foundation toldquoExpand seniorsrsquo access to integrated medical care and long term services and supports through new payer relationships with PACErdquobull Case studiesbull Identify federal regulatory requirementschallengesbull Draft ldquovalue propositionsrdquo to help market PACE to new payersbull Released and disseminated findings to members in late 2014
PACE Innovation and Diversification
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
PACE organizations interested in unbundling their core competencies to support growth and expand access to coordinated carebull Veterans pilotbull Contracting with health plans to offer care managementbull Co-location of PACE in senior housing facilitiesbull PACE Innovation Act (passed in July 2015) will enable pilots to serve new
populations under the age of 55 or not yet nursing home eligiblebull Younger disabled individualsbull Individuals with intellectual disabilitiesbull Medically complex or ldquoat-riskrdquo individuals
PACE Innovation and Diversification Strategies
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull New care coordination initiativesbull Accountable Care Organizationsbull Patient Centered Medical Homesbull Community Based Care Transitions and Readmission Reduction programs
bull Best opportunities seem to exist withbull Financial Alignment Demonstrations ndash fully integrated benefitsbull Managed LTSS ndash managed Medicaid benefits (typically linked to an MA plan)
Potential Purchasers
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Inexperienced with managing the acute and specialty care needs of frail elderly populations (Medicaid bias)
bull Unfamiliar with LTSS including nursing facility care and home and community-based services (Medicare bias)
bull Inexperience integrating medical care and LTSS benefitsbull Challenges with care coordination and transitions for the high-need complex population
needing LTSSbull Not accustomed to serving populations that experience high hospitalization and emergency
room utilizationbull Shortage of qualified trained health care and service delivery professionalsbull Meeting network adequacy requirements particularly with regard to LTSS providers and
services
Where Plans Might Need Help
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Exploring the Independence at Home (IAH) program (efforts underway to transition to permanent Medicare benefit)
bull Offering ldquoupstreamrdquo services to support individuals with care transitions post rehab stay home care care coordination and home modifications
bull Seeking collaborative opportunities with acute care providers incentivized to reduce re-hospitalizations
PACE Innovation and Diversification Strategies
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Starting smallbull Building on existing PACE infrastructure
bull A la carte servicesbull Post-acute bundlesbull Inching toward full sub-capitation
bull Developing and reinforcing the PACE ldquovalue propositionrdquo (ie making the case to plans that they should work with us)
How Are PACE Organizations Approaching Relationships
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Value Proposition 1 PACE has the infrastructure to assist payers and health delivery systems in assessing coordinating and providing access to LTSS
bull Value Proposition 2 PACE can help achieve high-quality outcomes to support payers and delivery systems in achieving their performance goals these outcomes not only enhance the quality of care and life for beneficiaries they contribute to the financial performance of the organization
Value Propositions
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Categories and volume of the services offered bull Quality and cost of competing service providersbull Budgets of the payer (eg capitation rates DRGs prospective
payments to hospitals)bull Type of payer arrangement and level of risk assumed
bull Fee for Service bull Partial CapitationBundled Paymentbull Full Sub-Capitation
Approaches to Pricing
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Evaluation ndash few metrics for these arrangementsbull Regulatory questions
bull Sec 460104 of the PACE Regulation requires IDT members to serve ldquoprimarily PACE ParticipantsrdquomdashIf your PACE census is 100 you canrsquot serve more than 99 people through other arrangements
bull Possible federalstate regulatorylicensure issues around disaggregated services (eg licensure requirements for home healthadult day)
bull New business lines may requirebull New corporate structures and boardsbull Back-office coordination
Pending Issues
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull The level and nature of new payer interest is market-specific PACE organizations and new payers will need to define their fit through extensive interaction and relationship building
bull Partnerships will be slow to emerge Most of the PACE organizations wersquove talked with have been in conversations with plans for years
bull Plans are taking a cautious approach to these new relationships They might wish to start small At the same time plans struggle to reconcile the scale of their enrollment (large to very large) with the service capacity of PACE organizations (comparatively small)
bull PACE organizations will need to develop new organizational capacities and attributes to partner with new organizations especially in the areas of billing reporting outcomes and accreditation
Key Takeaways
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull 78 YO female with COPD fall riskat or near Medicaid financial eligibility lives alone
bull Falls and breaks ankle while walking dogbull Surgery 5-day hospital stay and 90-day SNF rehabbull Transition home on 90th day managed by PO that operates
Medicare certified HHA and rehab agency PCPs eligible to billMedicare FFS and assume responsibility for primary care
bull PO charges monthly fee for overall coordination and offers a la carte services (nursing social work and home modifications)
Case Study ndash Building Service Relationships Prior to PACE
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
bull Walk-in shower installedbull In-home rehab and skilled home carebull As-needed primary care (billed to Medicare)and nursing (a la carte)bull Ongoing care coordination focused on Rx medical specialists
exercise diet etcbull Strong and trusting service relationship built by PObull Patient now exploring PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Questions
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Post Acute Care as a Health Home
William Mills MDPresident amp CEO Chronic Care ManagementSenior Medical Advisor Kindred Healthcare
February 23 2016
57
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
William Mills MD Disclosures
bull Founder amp Shareholder Chronic Care Management LLC
bull Shareholder Kindred Healthcare (NYSE KND)
58
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Post Acute Care as a Health Home Agenda
Evolution of Post Acute Care
Defining a Population
Assets and Tactics Needed
New Care Pathways
59
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
What Is a Health Home
A Health Home offers coordinated care to individuals with multiple chronic health
conditions
60
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Distribution of Medicare Discharges to Post Acute Care
35 of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Intensity of Service LowerHigher
(1) Kaiser Family Foundation 2011 statehealthfactsorg and AARP 2011 projections(2) Source RTI 2009 Examining Post Acute Care Relationships in an Integrated Hospital System
Medicare Patientsrsquo Use of Post-Acute Services Throughout an ldquoEpisode of Carerdquo
Currently there are 54 million Medicare beneficiaries with an estimated 11000 individuals added to the program each day(1)
Patientsrsquo first site of discharge after acute care hospital stay
Patientsrsquo use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOMEHEALTH
CARE
372 10
11
41
52
9
212 61
61
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Severity of Illness Distribution in Post Acute Care
The APR-DRG system classifies patients by severity of illness physiologic decomposition or organ system loss of function Four SOI levels 1 to 4 indicate minor moderate major or extreme severity of illness Source RTI International March 2008
Incr
easi
ngSe
verit
yDistribution of Patients Discharged to Post-Acute Settings by STAC-DRG SOI1
62
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
Providerbull Relationships with local PAC
providers bull Practice patterns
Clinicalbull Current health statusbull Comorbiditiesbull Prognosisbull Payer coverage rules PAC Facility
bull Specializationbull Proximitybull Capacitybull Relationship with
acute sitesReferring Provider
bull Relationships with local PAC providers
bull Practice patterns
Patientbull Psychosocial supportbull Abilitywillingness for
self-carebull Treatment preferences
63
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Intent
bull To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care improved outcomes and overall quality comparisons
Requirements
bull LTACH IRF SNF and HHA providers must submit to CMS specified quality and resource utilization assessments
IMPACT Act of 2014
64
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Due to multiple converging factors including bull IMPACT Actbull LTAC Criteria and Site Neutral Payments bull Value-Based Purchasing bull Focus on Readmission Prevention and Care Transitionsbull Technological advances including cloud-based platforms and remote
monitoringbull Improved Risk Stratification Methodologiesbull Development of Robust Home-Centered Care Ecosystems bull New Payment Models
Evolution of Post-Acute Care
65
Post acute care providers have a unique opportunity to function as Heath Homes for certain populations
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Defining a Population to Target
66
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Concentration of Risk and $ in US Healthcare
67
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Percentage of All Americans With Multiple Chronic Conditions
by Age Group
Source AHRQMultiple Chronic Conditions Chartbook
32
Percentage of All Americans With Multiple Chronic Conditions
68
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Source Chronic Conditions Among Medicare Beneficiaries Chartbook 2012
Percentage of Hospital Readmissions Within 30 Days of Discharge by Number of Chronic Conditions and Age
Per Capita Medicare Spending for Medicare FFS Beneficiaries by Number of Chronic Conditions
A Higher Number of Chronic Conditions Predicts Utilization and Spending
69
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Assets and Tactics Needed
70
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Current State-of-the-Art Post Acute Care Assets
71
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
bull Enhanced AcutePost Acute Alignment eg BPCI
bull Goal Directed Care and Advanced Care Planning
bull Primary Carebull Palliative Carebull Chronic Care Management
Program
bull Portable Care Plansbull Call Patient Support
Centerbull New Payment
Methodologies
72
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
BPCI An Opportunity for Increased AlignmentBPCI Model 1
Retrospective Acute Care Hospital Stay Only
BPCI Model 2Retrospective Acute amp Post
Acute Care Episode
BPCI Model 3Retrospective Post Acute
Care Only
BPCI Model 4Prospective Acute Care
Hospital Stay OnlyComprehensive Care for
Joint Replacement Model73
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Goal-Directed Care and Advanced Care Planning
bull Establishing the goals of care for all PAC patients is important When functioning as a Health Home it is critical
bull Systematic program to focus on goal-directed care including advanced care planning can reduce utilization of health care without adversely affecting patient or family satisfaction or mortality
bull Need for a formal mechanism to promote communication of goals and ACP between sites of service ldquoportabilityrdquo
74
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Home health and
home therapyAcute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
75
Primary Care Tie In with PAC Health
Home
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Integration of a Palliative Offeringinto PAC Health Homes
bull Palliative carendash Provides relief from pain and other symptomsndash Supports quality of life ndash Focuses on patients with serious advanced illness and their families
bull Program should includendash Goal-directed care and
Advanced Care Planning focusndash Access to Palliative Care Specialistsndash Access to Basic Palliative care (cross-training of all Health Home care
team members)76
May begin early in the course of treatment for a serious illness and may be delivered in a number of ways and across the continuum of health care
settings often starting in the PAC site
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Morrison RS et al Cost savings associated with US hospital palliative care consultation programs Arch Intern Med 2008 Sep 8168(16)1783‒90
77
Brumley R et al Increased Satisfaction with Care and Lower CostsResults of a Randomized Trial of In-home Palliative Care JAGS 2007 55 993-1000
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Chart1
Usual Medicare Home Care
Palliative Care Intervention
2128
953
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Daily Cost of Care
Daily Cost of Care
Daily Cost of Care
Sheet1
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Usual Medicare Home Care
Palliative Care Intervention
Daily Cost of Care
$21280
$9530
To update the chart enter data into this table The data is automatically saved in the chart
Providers of a PAC Health Home need systems that bull Improve care coordinationbull Enhance care transitionsbull Empower patients and caregiversbull Increase participation in holistic care planningbull Enable a focus on goals of care and
advanced directivesbull Achieve maximum portability
of care plans
Meeting Triple Aim Goals in a PAC Health Home
Improve Health
Improve Patient
Experience
Cost effective
care
78
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
79
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
New Care Pathways
80
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
LTAC Criteria New Opportunities (and Challenges) for PAC
bull Post-Intensive Care Patients Patients admitted from an acute care hospital with 3 or more days in an Intensive Care Unit (ICU) and ventilator patients in LTACs
bull Complex Medical Patients Other medically complex patients may still be admitted to LTACs and receive a ldquosite neutralrdquo rate that is either at LTAC cost or at a per diem rate equivalent to acute care hospital rates
bull Effective Date and Phase-Inndash Effective date Two-year phase-in of criteria starting on September 1 2016ndash During phase-in cases receiving ldquosite neutralrdquo rate get paid 50 based on
current LTAC rate and 50 based on the ldquosite neutralrdquo rate
81
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
New Revenue from Care
Management PFS
ACOBPCIIAHMSSP
Employed Physician
Call Center added as part of virtual care team in care
management system
Affiliated Physician
Call Center added as part of virtual care team in care
management system
Call Center
Patient with Care
Plan
Home
RCF
Office
LTC
PAC
STACHPatient with Care
Plan Patient with Care
Plan
Patient with Care
PlanPatient
with Care Plan
Patient with Care
Plan
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
82
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Fred Smithrsquos Story
An example of how a Post Acute Care Health Home can function better than
traditional care models
83
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Winning Tactics to Develop a PAC Health Home
bull Target the right population
bull Deliver evidence-based timely coordinated care
bull Develop person-centered portable goal-directed care plans
84
Develop new care pathways supported by emerging
payment models
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Conclusions
bull Post Acute Care Providers have a unique opportunity to develop Health Homes which can help advance the Triple Aim while utilizing a patient-centered goal-directed approach
bull There will be market population condition and payer -specific nuances to navigate as PAC Health Homes develop
bull Payment model testing and innovation must occur to discern the optimal payment structures for PAC Health Homes
85
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Steven Landers MD MPHPresident amp CEO
VNA Health Group
Optional Intensive Alternative Care Options
Health Dimensions Group National SummitTuesday February 23 2016
200PM ndash 430PM
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
A Century of Caring
Responding to Community Needs Since 1912
bull Tending to those in the shadows
bull TB control child labor migrant workers
bull Public Health Nursingbull Medicare and Reagan Era
reformsmdash ldquoPatients go home quicker
and sickerrdquo
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
bull Largest non-profit home care and hospice organization in NJ
bull 2nd Largest VNA in the Country
bull 10000 active patients on any given day at home
bull Statewide presence
VNA Health Group
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Visiting Nurse Association Health Group Inc
Joint Ventures
Robert Wood Johnson Visiting Nurses Inc
Home care and hospice services in Middlesex Monmouth Somerset
and Union Counties(5050 partnership with Robert
Wood Johnson University Hospital)
Visiting Nurse Association of Englewood
IncHome care and hospice services in
Bergen County(5050 partnership with Englewood
Hospital and Medical Center)
VNA Health Group of New Jersey LLC
Home care and hospice services in Burlington Essex Hudson Middlesex
Ocean Monmouth
Private Duty Services (VNACJ Inc Personal Care)
(5050 partnership with Barnabas Home Health and Hospice )
VNA Health GroupOrganization Structure
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Visiting Nurse AssociationHealth Group Inc
Institutes
Children and Family Health Institute
Connected Health Institute
Advanced Care Institute
VNA Health Group Organization Structure
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
VNAHGrsquos 4 Product Strategies
1 Partnerships with hospitals and health systems for home health and hospice
2 Solve Medicarersquos biggest problem
3 Success in digital and mobile technology through our Connected Health Institute
4 Keep true to our foundingmission through the Children and Family Health Institute
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
VNAHGrsquos Strategic Plan
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
ldquoSecret Weapons of Home Carerdquo
bull Enhanced view of patient and caregivers
bull Breaks down barriers to care
bull Strengthened relationships
bull Can avoid hazards
bull Can cost less
bull Often desired more
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Aging Chronic Illness
Financesamp Policy
Healthy at Home Never More Relevant
TechnologyConsumerism
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Mega Trends
Administration on Aging US Census Bureau
June 2014
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Mega Trends
Impact of Function Multi-Morbidity PAC Variation Quality
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Mega Trends
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
$1000 $2360
$4123 $5666
$7049
$10679
$3083
$5869 $8047
$11690 $14121
$16764
$0
$3000
$6000
$9000
$12000
$15000
$18000
0 1 2 3 4 5+
Number of Chronic Conditions
No limitationsWith limitations
Mega Trends
Spending Often Doubles for People With Chronic Illnessesand Activity Limitations
Johns Hopkins RWJ 2010
(G Anderson)
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Home Centered Care Is the Answer
bull Substitutive Home Health
bull Transitional Care Supports
bull Long Term Care At Home
bull Medical House Calls
bull Hospital at Home
bull Palliative and Advanced Illness Models
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
Future Is Bright
ldquoThe future belongs to those who believe in the beauty of their dreamsrdquo
Eleanor Roosevelt
ldquoThe future belongs to those who seize the opportunities created by innovationrdquo
Dr Toby Cosgrove
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
Slide Number 92
Slide Number 93
ldquoSecret Weapons of Home Carerdquo
Healthy at Home Never More Relevant
Mega Trends
Mega Trends
Mega Trends
Mega Trends
Home Centered Care Is the Answer
Future Is Bright
Slide Number 102
copy HDG 2016 February 23 2016HDGConsulting HDGSummit 101
Alternative Care OptionsOptional Intensive
Slide Number 2
ldquoIf you think you can run your company the next ten years the way you ran it the last ten years you are out of your mindhelliprdquo
Top Five Trends in Integrated Care
Value- and Outcome-Based Payment Growth
PAC Plays Key Role in Value-Based Care
Early Results Medicare Bundling Will Change Post-acute Care Utilization
Value-Based Movement Redefining the Value Statement
Post-Acute Medicine
SeniorDual Population Force Move Toward Value-Based Care
Medicare Advantage Is Growing Nationally
Social Determinants of Care
Seven Essentials of Engaged Intervention
Partnerships
Hospitals Can Be Attractive Partners
A ldquoHealth Care Neighborhoodrdquo for Those with Advanced and Chronic Illness
Competitive Dynamics of Post-acute Care Industryhellip
hellipBring Competitive Responses
Strategic Delineation
Which Post-acute Vendors Will Win
Strategic PivotsRepositioning Solutions Provider
Care TransformationRequired for The Shift to Value-based Payment
Fragmented Care Has Historically DrivenHigh Costs and Resulted in Poor Outcomes
Four Key Elements to Transforming Care
Readiness for Value-Based Transformation
What Are ACOs Doing Now
Characteristics of Most Effective HospitalPost-acute Care Partnerships
Value-Based Transformation Checklist
Define Your Value Proposition
Future Investment
Assessment Evaluate Your Ability to Add Value
Not Taking Risk May Not Be an Option in the Future
Slide Number 33
What Is PACEProgram of All-Inclusive Care for the Elderly
The PACE Model Who Does It Serve
The PACE Model Philosophy
Integrated Service Delivery and Team Managed Care
Integrated Team Managed Care
Capitated Pooled Financing
Source of Service Revenue
Status of PACE Development (as of December2015)
National Census Growth 1996ndash2015
PACE Programs Around the Country (2015)
PACE Core Competencies
PACE Innovation and Diversification
PACE Innovation and Diversification Strategies
Potential Purchasers
Where Plans Might Need Help
PACE Innovation and Diversification Strategies
How Are PACE Organizations Approaching Relationships
Value Propositions
Approaches to Pricing
Pending Issues
Key Takeaways
Case Study ndash Building Service Relationships Prior to PACE
Case Study ndash Building Service Relationships Prior to PACE
Questions
Post Acute Care as a Health Home
William Mills MD Disclosures
Post Acute Care as a Health Home Agenda
What Is a Health Home
Distribution of Medicare Discharges to Post Acute Care
Severity of Illness Distribution in Post Acute Care
Clinical and Non-clinical Factors Help Determine the Best PAC Setting for a Given Patient
IMPACT Act of 2014
Evolution of Post-Acute Care
Defining a Population to Target
Concentration of Risk and $ in US Healthcare
Slide Number 69
Percentage of Medicare FFS Beneficiaries by Number of Inpatient Admissions and Number of Chronic Conditions
Assets and Tactics Needed
Slide Number 72
Evolving Additional Assets Needed to Achieve Success as a Post Acute Care Health Home
BPCI An Opportunity for Increased Alignment
Goal-Directed Care and Advanced Care Planning
Slide Number 76
Integration of a Palliative Offeringinto PAC Health Homes
Effect of Palliative Care on Costs in Inpatient and Home-Centered Care Settings
Slide Number 79
Portability of Care Plan Critical As Patients May Access Tens of Thousands of Sites of Service
New Care Pathways
LTAC Criteria New Opportunities (and Challenges) for PAC
Model of Portable Person-Centered Care Plans as a Bridge from Volume to Value
Slide Number 84
Winning Tactics to Develop a PAC Health Home
Conclusions
A Century of Caring
VNA Health Group
Slide Number 90
Visiting Nurse Association Health Group IncInstitutes
