How to Establish an Accountable Post-Acute Preferred Provider ...

How to Establish an Accountable Post-Acute Preferred Provider Network November 14, 2016

How to Establish an Accountable Post-Acute Preferred Provider Network Maura McQueeney, MPH, DNP President, Baystate VNA & Hospice/ Post-Acute Care, Baystate Health Lissy Hu, MD, MBA Chief Executive Officer, CarePort Health

2

Shifting Payment Landscape

3

MACRA Readmissions

IMPACT

Act Bundled

Payments

CJR

ACO

Background Problem discovery 2013 – Multiple vendor and provider relationships coming and going from the medical center and outlying hospitals

Strategic Question How should we partner for results in BCPI and ACO when we do not OWN post acute facilities? Embed MDs($)? Embed Mid levels($)? Partner for quality results ?

Decision Develop clear, post - acute partner scorecard, be transparent with results, select a preferred network based upon quality BEYOND star ratings, define monitoring and sustainable outcomes, create written agreements

Methods How we created an accountable preferred post acute network

Results and Takeaways Sharing our success tips

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Overview

Baystate Health

• Largest health system in Western Massachusetts

• One academic medical center, two community hospitals, 973 beds

• Owns a health insurance company – Health New England

• 250 Physician Practices

• Acquiring surrounding community hospitals to secure competitive boundaries

• Next Generation ACO

• Early entrant into MSSP TJR bundle

• Strategically not in the long-term care “space”

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• Strategic Post-Acute Care Committee (SPACC)

• Complex web of relationships and potential for conflict of interest

• Need to organize relationships around quality in context of BPCI and ACO

DME, Lab Services, Imaging Services

SNF Liaisons

HHA Liaisons

Hospital SNF HHA

Creating a Central Nervous System: SPACC

Strategic Post-Acute Care Committee (SPACC)

• SVP for Quality and Population Health

• President, VNA & Hospice

• Physician leader of ACO

• Geriatrician representing post-acute medicine

• Director of Quality (oversees BPCI program)

• Director for Post-Acute Integration

• Heart & Vascular service line director

• VP, Strategic Planning

• Director of Case Management

• Ad hoc members: Lab and Imaging, Medical Director of

Health New England (insurance organization)

• Identified relevant post-

acute stakeholders (ACO,

BPCI)

• Hired Director for Post-Acute

Integration

• Instituted monthly meetings

for group to discuss SNF

selection criteria, quality

measurement, and

performance improvement

Getting Started

Collaborative Partner Facility ProfileCollaborative Partner Facility Profile

Facility Name

Facility Address

City State Zip

Phone

Contact 1 name

Contact 1 Title

Contact 1 e-mail

Web Site

Ownership Type (private, profit, nonprofit, parent company)

What is your ability to manage pts with psychiatric

diagnoses

Individual Facility DemographicsIndividual Facility Demographics

Category Response Yes/No (Yes

= 1; No = 0)Comments/additional Information

License Types (please list all) LTC

Number of Sub Acute Beds Short Stay all private rooms

Number of LTC Beds

Number of LTACH Beds

Number of Specialty Services Beds (vent, rehab)

MDs Contracted-Internist, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)

1 Community PCP

MDs Contracted-Geriatrician, and days per week on unit

LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0

MDs Contracted-Specialty MD, and days per week on unit


MDs Contracted-Internist, and days per week on unit Sub

Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)1 Community PCP


Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0



Midlevel (RN/PA) Practitioner Contracted and days per

week on unit LTC (Enter 1 if once/week; 2 if 3-5 days; 3 if daily)1


week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)?? 1

24/hr day RN (Y/N)? 1 Staff: 50% RN

Nursing Model: Primary Nursing Model (Y/N)? 1

Nursing Model: Consistent Alignment (Y/N)? 1

RN Specialty Certification: Rehabilitation (Y/N)? 1 RN, Cardiac Specialist

RN Specialty Certification: Geriatrician (Y/N)? 0

Full time, licensed (RN, SW, OT, PT) Case Manager or

Navigator (Y/N)?1

Dietician available (Y/N)? 1

Special diet available: low sodium, ADA etc. (Y/N)? 1

Special diet available: TPN (Y/N)? 1

Certified Wound Care Nurse available (Y/N)? 1 Hospital CWOC NP

Palliative and Hospice Care (Y/N)? 1Palliative MD at to support;

Hospice w/ Affiliate

Pharmacy Name Formulary available (Y/N)? 1

Contracted Payers and Plans (list)

Medicare (Y/N)? 1

Medicare Advantage (Y/N)? 1

Medicaid (Y/N)? 1

Medicaid Pending (Y/N)? 1

CCA (Y/N)? 1

HNE (Y/N)? 1

Fallon (Y/N)? 1

BC/BS (Y/N)? 1

AARP (Y/N)? 0

Others (% Agency on Short Stay Unit?) No agency

Sub$Total 23

nonprofit

Psych serivce in 2-3 x/week

Process Expectations: Pre-Admission to DischargeProcess Expectations: Pre-Admission to Discharge

DRAFT 7 (9/24/13)/

• Assessed 30 facilities with high-volume

of Baystate patients

• Collected facility staffing levels, process

expectations, outcome reporting

expectations through site visits and

interviews

• Major criteria included CMS star rating

(3 and above), 24-hour nursing care,

physician staffing levels, readmission

rates, ability to take difficult patients,

and willingness to partner

Assessing Skilled Nursing Facilities



Preadmission Process: Liaison on site at BH (Y/N)? 1

Preadmission Process: Response Time for Decision (Enter

1 if ≤ 60 mins; 2 if ≤ 30 mins)2

Warm Hand-Off: Documented RN-to-RN Communication on

Admit (Y/N)?0

Warm Hand-Off: Documented RN-to-RN Communication

upon Discharge (Y/N)?1

Home Care Liasion at center for weekly

meetings

INTERACT** Tool Used or Alternative Tools (Enter # points

in Y/N column)5 INTERACT III

Electronic Medical Record (Y/N)? 0 Complete by 2014

Member of Data Exchange (Y/N) 0

Direct Admits from Home, MD Of fice, and other Community

Sites: 24/7 Clinical RN Supervisor (Y/N)?1

Direct Admits from Home, MD Office, and other Community

Sites: Med List (Y/N)?1


Sites: Payor Confirmation (Y/N)?1

List 24/7 Ancillary Contracted Services (lab, imaging,

pharmacy services) (Enter 1-3)3 Mobilex, O2 Solutions


pharmacy services) with 2 hour turnaround for reports

(Enter 1-3)

3

Rehab Services provided: frequency (Enter 1 for once per

week, up to 7 = daily)7 Contract w/

Rehab Services provided: coverage by all payors (Y/N)? 1

Physician or Mid-level Rounds: Describe (Enter 1 for once

per week, up to 7 = daily)1

IDT Rounds: MD involved (Y/N)? 0

IDT Rounds: Patients & Families involved (Y/N)? 0

IDT Rounds: RN involved (Y/N)? 1 MCR Meeting

IDT Rounds: Social Worker involved (Y/N)? 1

IDT Rounds: Done ≤ 48 hours after admit (Y/N)? 0 72 hr meeting

Sub$Total 29

Reporting Expectations: OutcomesReporting Expectations: Outcomes


= 1; No = 0)Comments/Additional Information

CMS Star rating (most recent) (Enter rating in Y/N) 3 AHCA:/ :/ /App/in;/JCAHO/

DPH (Date of last survey, status and deficiencies) 2013 DPH Score :

Flag on Admission to BMP: To PCP (Y/N)? 1

Flag on Admission to BMP: By Diagnosis (Y/N)? 1

Population reports available: List

D/C Dx, dispostion and HC provider ,

PCP, LOS, Referral info: adm, lost,

declined

ALOS – Sub Acute (Enter 1 if ≤ 15 days) 0 Ortho: 19; Cardiac: 18

30 Day Re-hospitalization Rates Subacute- average of last

3 months (Enter 1 if ≤ 20%; 2 if ≤ 15%; 3 if ≤ 10%)3 9%

Mortality Rate – Sub Acute TBD

Patient Satisfaction benchmarked with national database

(Y/N)? 1

If Yes, please record database Vendor and Quartile rank for

Overall Satisfaction MyInnerview: 98%

If No, please record how Patient Satisfaction is measured

AND last 6 months trend for Overall Satisfaction

Will you be able to schedule a Baystate Health Post Acute

Team site visit within the 4 weeks (Y/N)? 1

Sub$Total 10

For Internal Use OnlyFor Internal Use Only

Category Response Yes/ No Comments/Additional Information

STAAR Attendance 1

Baystate MD Affiliation/Presence 1 Cardiac:

Top 70% referral 2012 0

Citizenship (difficult patient placement) 0

Affiliation (ACO, PHO, other) 0

Total 62

**INTERACT- Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification,

assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal o f INTERACT

is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous

complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

Collaborative Partner Facility ProfileCollaborative Partner Facility Profile

Facility Name

Facility Address

City State Zip

Phone

Contact 1 name

Contact 1 Title

Contact 1 e-mail

Web Site

Ownership Type (private, profit, nonprofit, parent company)

What is your ability to manage pts with psychiatric

diagnoses

Individual Facility DemographicsIndividual Facility Demographics



License Types (please list all) LTC

Number of Sub Acute Beds Short Stay all private rooms

Number of LTC Beds

Number of LTACH Beds

Number of Specialty Services Beds (vent, rehab)

MDs Contracted-Internist, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)

1 Community PCP





MDs Contracted-Internist, and days per week on unit Sub

Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)1 Community PCP






week on unit LTC (Enter 1 if once/week; 2 if 3-5 days; 3 if daily)1


week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)?? 1

24/hr day RN (Y/N)? 1 Staff: 50% RN

Nursing Model: Primary Nursing Model (Y/N)? 1

Nursing Model: Consistent Alignment (Y/N)? 1

RN Specialty Certification: Rehabilitation (Y/N)? 1 RN, Cardiac Specialist

RN Specialty Certification: Geriatrician (Y/N)? 0

Full time, licensed (RN, SW, OT, PT) Case Manager or

Navigator (Y/N)?1

Dietician available (Y/N)? 1

Special diet available: low sodium, ADA etc. (Y/N)? 1

Special diet available: TPN (Y/N)? 1

Certified Wound Care Nurse available (Y/N)? 1 Hospital CWOC NP

Palliative and Hospice Care (Y/N)? 1Palliative MD at to support;

Hospice w/ Affiliate

Pharmacy Name Formulary available (Y/N)? 1

Contracted Payers and Plans (list)

Medicare (Y/N)? 1

Medicare Advantage (Y/N)? 1

Medicaid (Y/N)? 1

Medicaid Pending (Y/N)? 1

CCA (Y/N)? 1

HNE (Y/N)? 1

Fallon (Y/N)? 1

BC/BS (Y/N)? 1

AARP (Y/N)? 0

Others (% Agency on Short Stay Unit?) No agency

Sub$Total 23

nonprofit

Psych serivce in 2-3 x/week

Process Expectations: Pre-Admission to DischargeProcess Expectations: Pre-Admission to Discharge

DRAFT 7 (9/24/13)/

Process Expectations



Preadmission Process: Liaison on site at BH (Y/N)? 1

Preadmission Process: Response Time for Decision (Enter

1 if ≤ 60 mins; 2 if ≤ 30 mins)2

Warm Hand-Off: Documented RN-to-RN Communication on

Admit (Y/N)?0

Warm Hand-Off: Documented RN-to-RN Communication

upon Discharge (Y/N)?1

Home Care Liasion at center for weekly

meetings

INTERACT** Tool Used or Alternative Tools (Enter # points

in Y/N column)5 INTERACT III

Electronic Medical Record (Y/N)? 0 Complete by 2014

Member of Data Exchange (Y/N) 0

Direct Admits from Home, MD Of fice, and other Community

Sites: 24/7 Clinical RN Supervisor (Y/N)?1


Sites: Med List (Y/N)?1


Sites: Payor Confirmation (Y/N)?1


pharmacy services) (Enter 1-3)3 Mobilex, O2 Solutions


pharmacy services) with 2 hour turnaround for reports

(Enter 1-3)

3

Rehab Services provided: frequency (Enter 1 for once per

week, up to 7 = daily)7 Contract w/

Rehab Services provided: coverage by all payors (Y/N)? 1

Physician or Mid-level Rounds: Describe (Enter 1 for once

per week, up to 7 = daily)1

IDT Rounds: MD involved (Y/N)? 0

IDT Rounds: Patients & Families involved (Y/N)? 0

IDT Rounds: RN involved (Y/N)? 1 MCR Meeting

IDT Rounds: Social Worker involved (Y/N)? 1

IDT Rounds: Done ≤ 48 hours after admit (Y/N)? 0 72 hr meeting

Sub$Total 29

Reporting Expectations: OutcomesReporting Expectations: Outcomes


= 1; No = 0)Comments/Additional Information

CMS Star rating (most recent) (Enter rating in Y/N) 3 AHCA:/ :/ /App/in;/JCAHO/

DPH (Date of last survey, status and deficiencies) 2013 DPH Score :

Flag on Admission to BMP: To PCP (Y/N)? 1

Flag on Admission to BMP: By Diagnosis (Y/N)? 1

Population reports available: List

D/C Dx, dispostion and HC provider ,

PCP, LOS, Referral info: adm, lost,

declined

ALOS – Sub Acute (Enter 1 if ≤ 15 days) 0 Ortho: 19; Cardiac: 18

30 Day Re-hospitalization Rates Subacute- average of last

3 months (Enter 1 if ≤ 20%; 2 if ≤ 15%; 3 if ≤ 10%)3 9%

Mortality Rate – Sub Acute TBD

Patient Satisfaction benchmarked with national database

(Y/N)? 1

If Yes, please record database Vendor and Quartile rank for

Overall Satisfaction MyInnerview: 98%

If No, please record how Patient Satisfaction is measured

AND last 6 months trend for Overall Satisfaction

Will you be able to schedule a Baystate Health Post Acute

Team site visit within the 4 weeks (Y/N)? 1

Sub$Total 10

For Internal Use OnlyFor Internal Use Only

Category Response Yes/ No Comments/Additional Information

STAAR Attendance 1

Baystate MD Affiliation/Presence 1 Cardiac:

Top 70% referral 2012 0

Citizenship (difficult patient placement) 0

Affiliation (ACO, PHO, other) 0

Total 62

**INTERACT- Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification,

assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal o f INTERACT

is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous

complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

Outcomes Reporting Expectations

• Developed scorecards with point system, reviewed with SNFs

• Chose 14 facilities as preferred providers

• Meet with preferred providers regularly, provide blinded scores and engage

in other quality improvement activities

Facility Score Card

Scoring Post Acute Providers

Balancing Transparency and Privacy

A

B

C

D

E

F G

H I

J

K

L M

N

O

P

Q R

S T U V

W, 10

0

2

4

6

8

10

12

14

16

18

20

0 2 4 6 8 10 12

Rea

din

ess

to P

artn

er/C

olla

bo

rate

(b

ased

on

Eas

e o

f P

lace

men

t &

Ove

rall

Surv

ey

Sco

re)

Quality of Care (based on 30-Day Readmits & CMS Star Rating)

Baystate Health Post-Acute Care Partner Prioritization Matrix

A B C D E F G H I J K L M N O P Q R S T U V W

Implementation Challenges

• Aligning with case managers who had concerns about patient choice

• Communicating preferred providers to patients

• Encouraging patients to select post-acute providers based on quality vs.

geography

Changing the Discharge Discourse

Standardized communication, developed by SPAC committee, case management leadership and legal:

“The Baystate preferred skilled nursing facility network is a select group of nursing facilities around the Pioneer Valley that meet quality and safety standards set for by Medicare and endorsed by Baystate Health

Engaging Patients in Post-Acute Decision-Making

• Baystate adopted an interactive tool for discharge planners and patients to choose post-acute care

• Preferred providers are highlighted and communicated to patients and families

• Integrates with case management workflow tools and available on a tablet; search results can be emailed to family members and other decision-makers

Post Acute Search Tool Benefits Case Managers, Patients & Supports Baystate’s PAC Strategy

Compliance with Impact Act and proposed changes to conditions of discharge planning

Proposed rule “require[s] that hospitals assist patients…in selecting a PAC provider by using and sharing data that includes but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures.”

With CarePort, Baystate has provided its patients with ' first-of-its kind' technology that helps them decide

where to go for post-acute care—a critical decision, as numerous studies show that post-acute providers

vary on quality and their ability to car e for different types of patients,” said Joel Vengco, VP/CIO,

Baystate Health . “In other words, it ’s not an easy decision for patients and families to make. Until now."

Tracking Baystate Patients Post-Discharge

• Integration with regional HIE (PVIX) and six post-acute providers

• Understanding post-acute outcomes for all Baystate patients

• Skilled nursing facility readmission rates and length of stay by patient population

• Leakage vs. Keepage

Sustaining the Network

Quarterly Quality Meetings:

• Sharing best practices

• “Preferred” Subset for BPCI

• Exiting SNF partners

Outcomes

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Outcomes

20

Outcomes

Success Factors

• Personal Touch – RFPs vs. personal touch because of high turnover of SNF staff

– For example tenure of nursing staff, will nursing staff know to call hospital?

• Team

– Integration work led by “SNF insider”

• Innovation in the community

– Health New England – SNFs can take care of patients with medical needs such as IV antibiotics, TPN to avoid readmission. HNE takes care of cost of IV Abx and TPN

On the Horizon

• Deciding to create a Tier 2

• Physician Incentive for SNFist from Next Gen ACO

• Embedded ACO Physician in the ED

• Building care coordination teams

– Navigators vs. liaisons

– How to make it scalable and cost-effective?

Questions?

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