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Post-Acute Care Collaborative

Building Strong Post-Acute Partnerships to

Enhance Patient Management

Jared Landis

Practice Manager

Post-Acute Care Collaborative

202-266-6925

[email protected]

In Collaboration with Hancock, Daniel,

Johnson & Nagle

©2014 The Advisory Board Company • advisory.com

2

Source: Rau J, “Medicare Fines 2,610 Hospitals in Third Round of Readmission Penalties,” October 2,

2014, Kaiser Health News, kaiserhealthnews.org; Post-Acute Care Collaborative interviews and analysis.

1) Value-Based Purchasing.

2) Bundled Payments for Care Improvement.

3) Accountable Care Organizations.

PAC Partnerships Supports Major Hospital Goals

Greater Patient Satisfaction Maximized Reimbursement Improved Clinical Quality

High-quality PAC optimizes

downstream outcomes,

minimizes readmission risk

Positive PAC experience raises

patient satisfaction scores for

the entire care episode

Strong PAC outcomes, low

costs improve hospital revenue

under new payment programs

2M Medicare beneficiary

30-day all-cause

readmissions, 2013

$26B Medicare costs

resulting from

readmissions, 2013

18% 30-day all-cause

readmission rate for

Medicare patients, 2013

Acute/post-acute

collaboration creates

a smoother care

transition for patients

Superior PAC treatment

allows patients to return

home more quickly

Reduced readmissions help

avoid hospital financial

penalties under CMS

readmissions penalties

Reduced downstream costs

help avoid hospital financial

penalties under VBP1

efficiency domain

PAC performance impacts

shared savings opportunity

under BPCI2 and in ACOs3

Quality PAC providers

offer a better in-setting

patient experience

mailto:[email protected]


3

Difficult to Maximize a Diverse Range of Services

Growing Competition Blurring Traditional Service Lines

Source: Redfoot, D. “Assisted Living: The Next Generation”, July 2006, AARP; Post-Acute Care Collaborative interviews and analysis.

“Distinctions such as “medical model” versus “social model” or “residential” versus “institutional”

no longer describe the emerging reality of a greater array of housing and service options to

meet the wide array of consumer needs and preferences.”

Donald Redfoot, Senior Policy Advisor, AARP

Public Policy Institute

”

An Intertwined Post-Acute Care Spectrum

Senior Living Community Services Skilled Nursing Hospitalization

Wellness

Programs

Geriatric

Assessment Case/Disease

Management

Independent

Living

Assisted

Living

Home Health

Care

Palliative

Care

Hospice

Inpatient

Rehab

Home Care

Subacute

Rehab

Outpatient

Therapies

Long-Term

Acute Care

Personal

Care

Adult Day

Care


4

Post-Acute Costs Attracting Significant Attention

Source: Newhouse, J. & Garber, A. “Geographic Variation in Medicare Services”, New England Journal of Medicine, available at www.nejm.org/doi/pdf/10.1056/NEJMp1302981;

Chandra, A., Dalton, M., Holmes, J., “Large Increases in Spending on Postacute Care In Medicare Point to the Potential for Cost Savings in these Settings”, Health Affairs, August

2013, available at: http://content.healthaffairs.org/content/32/5/864.full.pdf+html; “Geographic Variation in Spending, Utilization and Quality: Medicare and Medicaid Beneficiaries”,

Acumen LLC, May 2013, available at: www.iom.edu; “Chairman Brady Announces Hearing on the President’s and Other Bipartisan Proposals to Reform Medicare Post-Acute Care

Payments”, available at http://waysandmeans.house.gov; Post-Acute Care Collaborative interviews and analysis.

Comparative Growth in 365-Day Episode Spending

13.3% 21.9% 12.6%

250.4%

164.2%

99.9% 85.3%

43.3% 21.3% 16.0%

31.4% 18.1%

Heart Attack CHF Hip Fracture

Acute Post-Acute Outpatient Physician

Inflation Adjusted,1994 to 2009

MedPac, IOM Reports

Pinpoints post-acute as greatest

contributor to variability in

health care spending

House Ways and Means,

Senate Finance Committees

IMPACT Act of 2014 signed into law;

precursor to post-acute payment

reform


5

Efficient Placement a Persistent Challenge

Opportunity Exists to Re-Evaluate Discharge Destination Decisions

5% 3%

15%

9%

18%

31%

11%

HHA SNF IRF LTACH

Proportion of Medicare Patients

Placed in an Avoidably High-Cost Setting

Study Findings By Post-Acute Setting

OP Therapy HHA SNF IRF

42%

30%

20%

14%

Appropriate

Setting

Clinical Appropriateness

For each disease state,

determine with evidence-based

analysis the most appropriate

care setting for patient conditions

Care Setting Cost

For each disease state,

measure cost of caring for the

patient in each setting, incorporate

ALOS to understand total cost

Source: Dobson, DaVanzo and Associates, “Clinically Appropriate and Cost Effective Placement,” available at

www.healthreformgps.org/wp-content/uploads/cacep-report.pdf; Post-Acute Care Collaborative interviews and analysis.


6 Pay-for-Performance

Source: The Wall Street Journal, “Keeping Patients from Landing Back in the Hospital,” http://www.wsj.com/articles/SB119741713239122065;

CNN Money, “US to Hospitals: Clean Up Your Act,” http://money.cnn.com/2010/04/29/news/economy/healthreform_hospital_fines/; The

Washington Post, “Medicare rule would decrease payments to hospitals with high re-admission rates,” https://www.washingtonpost.com/

national/health-science/medicare-rule-would-decrease-payments-to-hospitals-with-high-re-admission-rates/2011/07/28/gIQAYwDpjI_story.html;

MedPage Today, “Hospitals Still Don’t Feel Readmission-Driven Pay Cuts,” http://www.medpagetoday.com/PublicHealthPolicy/Medicare/36659;

Reuters, “Q-Centrix Survey Reveals that Hospitals Underestimate Likelihood of Readmission Penalties,” www.reuters.com/article/2015/

06/29/idUSnMKWl3 4fPa+1c2+MKW20150629; Kaiser Family Foundation, “Aiming for Fewer Hospital U-Turns,” http://kff.org/medicare/issue-

brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/; Post-Acute Care Collaborative interviews and analysis.

1) As an adjusted percentage of a hospital’s IPPS payment.

The Hospital Readmission Reduction Program

December 2007

“Keeping Patients from

Landing Back in the Hospital,”

The Wall Street Journal

July 2011

“Medicare Rule Would Decrease

Payments to Hospitals with High

Readmission Rates,” The

Washington Post

December 2012

“Hospitals Still Don’t Feel

Readmission-Driven Pay

Cuts,” MedPage Today

June 2015

“Q-Centrix Survey Reveals

that Hospitals Underestimate

Likelihood of Readmissions

Penalties,” Reuters

April 2010

“US to Hospitals: Clean Up

Your Act,” CNN Money

October 2012

CMS Readmission

Penalty Program begins

The Cost of Waiting to Act

CMS estimate of total

readmission

penalties, FY2015

$428M Average penalty for

readmissions among

hospitals penalized in FY20151

-0.63% Percent of hospitals

penalized during FY2015

for readmissions

78%

Select Hospital Readmissions Program Headlines


7

SNF VBP Incenting SNFs to Reduce Inappropriate Readmissions

Source: CMS, “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2016, SNF Value-

Based Purchasing Program, SNF Quality Reporting Program, and Staffing Data Collection,” August 2014, https://www.federalregister.gov/articles/2015/

08/04/2015-18950/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities; Kramer A, et al., “Development of

Potentially Avoidable Readmission and Functional Outcome SNF Quality Measures,” 2014, www.medpac.gov/documents/contractor-reports/

mar14_snfqualitymeasures_contractor.pdf?sfvrsn=0; Post-Acute Care Collaborative interviews and analysis.

Driving Two-Way Accountability for Readmissions

1

2

3

2% cut in per diem

rate for all SNFs

Readmissions

performance score

calculated, SNFs ranked

High-performing SNFs

reimbursed

Attributable to

preventable conditions

24%

SNF Readmission Rates

High—And Avoidable

Underperforming SNFs to Face

Reimbursement Cuts

47%

All-cause,

all-condition

readmission

rate

Measures 30-day, potentially

preventable readmission rates

Measure Finalized: NQF #2510


8

HHAs in Nine States1 to Experience VBP Beginning in 2016

Source: Centers for Medicare and Medicaid Services, “CY 2016 Hoe Health Prospective Payment System

Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements,”

www.gpo.gov/fdsys/pkg/FR-2015-11-05/pdf/2015-27931.pdf; Post-Acute Care Collaborative interviews and analysis.

1) Arizona, Florida, Iowa, Maryland, Massachusetts, Nebraska,

North Carolina, Tennessee, Washington.

2) Metrics not currently collected but required under HH VBP

include rates of advanced care planning, shingles vaccination,

and influenza vaccination for home health staff.

Value-Based Purchasing Coming to Home Health

Quality Measurement

• HHA quality performance

measured and reported

annually, 2016-2020

• Included metrics assess

clinical quality, efficiency,

patient satisfaction, and

new measures of quality2

Performance Comparison Payment Adjustment

• Quality metrics compared

to HHA’s baseline scores

and cohort averages

• Total performance score

based on improvement,

relative achievement

• Beginning in 2018,

payments adjusted to

reflect quality performance

• Maximum adjustment

ranges from 3% in 2018

to 8% in 2022

Home Health Value-Based Purchasing Program Components

We expect that tying quality to payments through a system of

value-based purchasing will improve the beneficiaries’ experience

and outcomes… [and] will incentive quality improvement and

encourage efficiency, leading to a more sustainable payment system.

CMS 2016 Home Health Final Rule


9

Introducing CMS’s First Mandatory Bundle

Episodic Payments

Source: “Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals

Furnishing Lower Extremity Joint Replacement Services,” Centers for Medicare and Medicaid Services,

s3.amazonaws.com/public-inspection.federalregister.gov/2015-29438.pdf; Post-Acute Care Collaborative analysis.

1) Not already counted in a BPCI model 1, 2, or 4.

The Future of Bundled Payments?

Comprehensive Care for Joint Replacement (CJR) Model in Brief

All traditional Medicare,

lower extremity joint

replacement patients1

in 67 selected markets

are included in the

bundle

Acute care hospitals will

bear financial risk;

hospitals participating in

BPCI Models 1, 2, or 4

are excluded

Providers’ episodic costs

will be compared to a

target price; providers

would gain added

reimbursement or owe

CMS based on cost,

quality performance

The CJR Model in Numbers

MS-DRGs subject to bundled

payment: 469 and 470 (lower

extremity joint replacement)

2 Number of markets in which

CMS plans to implement

mandatory bundling

67 Net savings expected by

CMS from the program

between 2016 and 2020

$343M

Program includes

provisions for

gainsharing with PAC

partners, waivers for

3-day stay rule, home

visit and telehealth

reimbursement

Eligibility Accountability Financial Risk Waivers


10 Accountable Care Organizations

ACO Model Proliferating Across Markets


11

2

3

4

1

Road Map

Aligning Post-Discharge Care Management Roles

Forging Productive Clinical Partnerships

Seeking a Post-Acute Strategy

Towards Holistic Infrastructure


12

Health System Post-Acute Strategy Still in Nascent Stages

Source: Post-Acute Care Collaborative interviews and analysis.

1) Value-Based Purchasing.

Shifting from Recognition to Execution

“Who should own PAC strategy

at our hospital?”

“What are best practices for

partnering with PAC providers?”

“How do we select the

best post-acute partners?”

Representative PAC Questions from

Advisory Board Hospital Members Paying Attention to

Post-Acute Care No

Longer Optional

Comprehensive Care

for Joint Replacement

(CCJR) Model

Medicare Spending Per

Beneficiary Penalties

2016: Mandatory bundles

create downstream

financial risk

2015: VBP1 Program

expands to include

episodic efficiency


13

Major Drivers of Post-Acute Cost Variability Understood


Attempting to Inflect Post-Acute Cost

In-Setting Utilization

PAC provider delivers more or

higher-cost services than

clinically necessary

Readmissions

Patient accrues avoidable

costs associated with

additional hospitalization

Primary Opportunities to Influence Post-Acute Spending

Hospital Post-Acute Home End-of-Life

Patient Placement

Patient placed into higher-

acuity, higher-cost setting

than clinically necessary

End-of-Life Care

Patient does not

access cost-saving

hospice benefits


14

SNF, Hospitalizations Cloud Other Spend Categories

Source: Milliman; Post-Acute Care Collaborative interviews and analysis.

1) Well-managed benchmarks represent cost and utilization targets derived from claims data in a highly

effective managed care environment (e.g., staff model HMO or globally capitated provider group; targets

are developed from over two billion claims from Milliman clients, published HMO data, clinical chart

reviews, and actuarial judgment). Loosely managed benchmarks are derived from providers that have

some utilization review, pre-authorization, and case management but are generally not tightly managed.

Payer Benchmarks Show Clear Target Areas

Opportunity

Rank Spend Type

PMPM Savings

Opportunity

1 P81 - OTH Prescription Drugs $72.90

2 I11a - HIP Medical - General $63.30

3 I12 - HIP Surgical $59.66

4 I31 -HIP SNF $39.84

5 O12a-HOP Surgery - Hospital

Outpatient $22.52

Milliman Benchmarks of “Well-Managed”1 Settings


15

• Each team includes

one SNFist physician

and three APs1

• Teams serve at SNFs

with high volumes of

Advocate referrals

with aim of reducing

costs and controlling

quality

Tight Length of Stay Management Creates Downstream Readmissions

Source: Advocate Health System; Post-Acute Care Collaborative interviews and analysis.

1) Advanced practitioners.

2) Length of stay.

Be Careful What You Wish For

SN

F A

ve

rage L

en

gth

of S

tay

Today

Began effort to reduce SNF

LOS2 via SNFist program

Found that

reducing LOS too

far caused spike in

readmissions

Arrived at “sweet spot”

LOS by balancing LOS

reduction with quality

control requirements

Advocate SNFist

Program

Advocate’s Refocuses on Quality, Not LOS Cuts


16

Source: Kaiser Family Foundation, “Aiming for Fewer Hospital U-Turns,” 2015, www.kff.org/medicare/issue-brief/aiming-for-

fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/; Kramer A, et al., “Development of Potentially

Avoidable Readmission and Functional Outcome SNF Quality Measures,” 2014, www.medpac.gov/documents/contractor-

reports/mar14_snfqualitymeasures_contractor.pdf?sfvrsn=0; Post-Acute Care Collaborative interviews and analysis.

High-Cost Conditions and Diseases Clearly Visible

Prevalent Conditions Associated with

Potentially Avoidable Readmissions for

Medicare SNF Population, 2012

Current Medicare Incentives Aligned

with Diagnosis-Specific Approach

“Usual Suspects” Commonly

Associated with Hospitalizations

24.7

23

22.7

19.7

18.3 17.8

18.5

17.6 17.3

15

17

19

21

23

25

27

Medicare Readmission Rates, 2008-2013

July 2008-

June 2011

July 2009-

June 2012

July 2010-

June 2013

Heart Failure Heart Attack Pneumonia

31.3%

30%

23.9%

14.7%

All Other

CHF

Respiratory

Illnesses

Sepsis


17

Social barriers,

e.g. lack of transportation

to PCP appointment

Source: Mercy Medical Center; Post-Acute Care Collaborative interviews and analysis.

Separate Condition-Specific Programs Duplicative

Overlapping Interventions Needed

Across Conditions

Interventions Needed for

Successful Management

Individual Goal-Setting

Treatment Plan Adherence

Preventive Care Utilization

It didn’t make sense for us to have three separate

programs. Chronic disease is chronic disease.

Chief Accountable Care Officer,

Mercy Medical Center

CHF COPD Diabetes

Meet Your Typical CHF Patient

Polypharmacy

risking non-adherence,

adverse interactions

Multiple chronic

conditions in

addition to CHF


18


Road Map for Flexible Acute/PAC Partnerships

Three Imperatives for Success

Mechanisms for

Cost-Effective Care

Tracking performance;

designing, deploying

high-yield incentives

Network Curation and

Management

Identifying the right

partners and creating

platforms for collaboration

Information

Exchange

Sharing patient information

and building care

coordination infrastructure


19

The Bedrock to Support Every Goal

Sample Requirements for Success Under Medicare Payment Programs

Network Curation

and Management

Information

Exchange

Mechanisms for

Cost-Effective Care

Selection of and

collaboration with high-

quality, low-cost partners

PAC partner alignment

to payment reform goals

AC

O3

BP

CI2

R

RP

1

Common Themes Across Every Health System Initiative


1) Readmissions Reduction Program.

2) Bundled Payments for Care Improvement.

3) Accountable Care Organization.

De

gre

e o

f In

teg

ration

Ability to track and share

information about patients





Selection of and



Selection of and








20

2

3

4

1

Road Map





21

Building Strong Post-Acute Partnerships

to Enhance Patient Management Partner Alleviates Post-Discharge Challenges

• Identifying Post-Acute Partners

• Evaluating Partners Based on Performance Scorecards

• Cost Containment as the Next Frontier


22

Case in Brief: Harriet Hospital1

• Multi-hospital health system with ACO

contracts

• Mainly Medicare and Medicaid payer mix

• Member working to further develop post-

acute network, identifying and partnering

with high-value SNFs

The question: how can we identify the top

SNFs within our market?

Evaluating the Post-Acute Network

104

26 7

SkilledNursing

HomeHealth

Hospice

Post-Acute Providers Utilized

Identifying Post-Acute Partners

Understanding Current Post-Discharge Relationships

Question: How often does our

system refer patients to post-

acute care?

Question: How often do our

patients receive care from post-

acute care providers?

Question: How often are our

patients readmitted from the post-

acute care setting?

Post-Acute

Care Referrals

Post-Acute

Care Utilization

Post-Acute Care

Readmissions

1) Pseudonym.

Source: Advisory Board interviews and analysis.


23

Seeking Service-Line Specific Partners

Rigorous Selection Process Beyond the Norm of Quality Assessments

1) Electronic Medical Record.

Num

ber

of S

NF

s in E

valu

ation P

ool

• Identify SNF providers

most frequently utilized

• Data source: Epic EMR1

look-back over one year • Analyze providers’

performance on key

quality criteria, review

staffing models, etc.

• Data Source:

Medicare.gov

• Program Director of Orthopedics

leads internal team on tour

• Team conducts visual

assessment, discusses clinical

protocols, interviews SNF

leadership

TriHealth’s SNF Selection Process for Orthopedic Service Line

Assess Current

Discharge Patterns

Analyze Quality,

Performance Data

Conduct “Ortho” Tour

at Remaining SNFs

Time: 3-4 Months

Source: TriHealth; Post-Acute Care Collaborative interviews and analysis.


24

Case in Brief: TriHealth

• Not-for-profit, two-hospital health system located in Cincinnati, Ohio; offering the following

post-acute care services: home health and hospice

• Created initiative to rigorously select SNF partners and align with four main service lines:

orthopedic, pulmonary, advanced wounds and cardiac

• To select preferred SNF partners, TriHealth collects quality data on each SNF receiving

patient discharges within last year, analyzes performance, eliminates SNFs that do not

meet minimum quality standards

• Conducts tours of remaining SNF facilities with internal team including Program Director

of Orthopedics and heads of care management and social work, holds interviews with

SNF leadership and staff, completes overall evaluation form; finally votes to select partner

SNFs

• Performs ongoing outcomes tracking through a platform that aggregates standardized

SNF discharge reports for each patient, real time observation of red flag patterns, reports

data to physician partners every four to six months

• SNF selection pool for orthopedic discharges began at over 100 SNFs, process selected

only 13 partners; 88 percent of discharges now directed to one of the 13 selected SNFS

Source: TriHealth; Post-Acute Care Collaborative interviews and analysis.

Seeking Service-Line Specific Partners (cont.)


25

Individual PAC Provider Behavior Key to Episodic Performance

Evaluating Partners Based on Performance Scorecards

Source: Medicare Payment Advisory Commission, “Report to the Congress: Medicare Payment Policy,”

March 2015, available at: www.medpac.gov/documents/reports/march-2015-report-to-the-congress-

medicare-payment-policy.pdf?sfvrsn=0; Post-Acute Care Collaborative interviews and analysis.

1) Activities of daily living.

Significant Variation in Post-Acute Quality, Cost

Quality Measure (Risk-Adjusted) 75th

Percentile

25th

Percentile

Performance Decrease

from 75th to 25th

Percentile

Patients discharged to the community 46.6% 29.2% 37.3%

Potentially avoidable rehospitalizations

during SNF stay 13.9% 8.0% 42.4%

Potentially avoidable rehospitalizations

within 30 days from SNF 7.2% 3.4% 52.8%

Average mobility improvement across

three mobility ADLs1 52.5% 35.6% 32.2%

Quality Measure Variability Across Skilled Nursing Facility (SNF) Providers

Medicare Fee-for-Service, 2013


26

Scorecard Evaluation Identifies Potential Partners

Hospitals Solidifying PAC Performance Criteria

Performance Metrics Weights Score

30-Day All Cause

Readmissions

Average Length of Stay

All-Inclusive ED Transfers

Fall Rates, Infection Rates,

Wound Management

Case Mix Index

Patient Satisfaction

Staff and Patient Education

Sample PAC Scorecard Criteria Insights from Scorecard

Implementation


1. Proactively approach post-acute

care providers about partnerships –

Choose partnerships with post-acute

care providers who are willing to meet

partnership criteria and provide

performance data.

2. Drive the discussion around

meaningful performance metrics –

Select metrics that both meaningfully

reflect performance and are able to be

tracked.

3. Take a holistic approach to

standardizing metrics – Focus on

crafting a standard set of metrics that

evaluate PAC providers across clinical,

operational, and strategic criteria.


27

Understanding the Impact of Post-Acute Metrics on Cost

Cost Containment as the Next Frontier


1) Average acute setting length of stay before post-acute

facility can safely admit the patient.

2) Length of stay.

The Total Cost of Care Picture

Overall Cost of Care

How Post-Acute

Specialties

Can Impact

Costs

Metrics to

Demonstrate

Impact

Acute Care

Costs

Post-Acute

Care Costs

Outpatient and

Home Care Costs

Reduce

readmissions

Admit

patients earlier

Readmission

rate

Average

onset days1

Shorten

LOS

Average

LOS2

Improve

patient function

Discharge

directly to home

Functional

status at

discharge

Percent

discharged

to home


28

Translating Quality to a Large Scale Financial Impact

Healthcare Cost and Utilization Project, “Statistical Brief #172: Conditions with the Largest Number of Adult Hospital Readmissions by Payer,” Agency

for Healthcare Research and Quality, 2014, http://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf; Florida Office of

Program Policy Analysis and Government Accountability, “Profile of Florida’s Medicaid Home and Community-Based Services Waivers,” 2012,

http://elderaffairs.state.fl.us/doea/Evaluation/Profile%20of%20Florida's%20Medicaid%20Home%20and%20Community-

Based%20Services%20Waiver%20OPPAGA%2012-03.pdf; Vaidya A, “8 Statistics on the Average Cost Per ED Visit,” Becker’s Hospital CFO, May

31, 2013, http://www.beckershospitalreview.com/finance/8-statistics-on-the-average-cost-per-ed-visit.html; Post-Acute Care Collaborative interviews

and analysis.

1) Per month.

How Can We Reach $1 Million Impact?

Cost Savings

Opportunity

Single Occurrence

Cost Assumption Needed to Reach

$1 Million

Hospital

Readmissions $13,333 75

One-Day

Reduction in SNF

Length of Stay

$480 2,083

Readmissions

avoided

ED Diversion $1,062 942 ED visits

prevented

Days eliminated


29 Drive In-Network Utilization

Curbing Out-of-Network Utilization

Preferred Provider Network

Open Network

The Long-Term Ambition

Illustrative

Assess

benefits

structure

Preferred Provider Network

Open Network

Inflect

informal

influence

Low In-Network Utilization Control High In-Network Utilization Control

System-Owned Plan

• 8-10 PAC partners

• 5% of discharges

System-Owned Plan

• 8-10 PAC partners

• 90% of discharges



30

Network Layers Based on Partners’ Performance, Ability to Integrate

Source: Summa Health System; Post-Acute Care Collaborative interviews and analysis.

Tiering the Post-Acute Network

SNF A

SNF B

SNF C

SNF D

SNF E

SNF F

SNF B

SNF C

SNF D

SNF E

SNF G

SNF H

SNF F

SNF G

SNF C

SNF D

SNF E

SNF F

SNF D

SNF E

Summa Health System’s PAC Partner Tiers

Market

Base

Care Coordination Network Partners engaged in quality data

and information sharing

In Process:

Preferred Provider Network Partners identified as best

candidates for full integration

based on quality, geography,

and cost efficiency

Current

Medicare

Advantage

Network

Future

Additional

Preferred

Partners


31

Source Summa Health System; Post-Acute Care Collaborative interviews and analysis.

Tiering the Post-Acute Network (cont.)

Case in Brief: Summa Health System

• Not-for-profit health system including five hospitals and a Medicare Advantage plan

(SummaCare); headquartered in Akron, OH

• Began building a care coordination network of 25 preferred SNFs in 2002; gradually

tightened participation and quality requirements, added assisted living providers;

this broad network now includes 76 providers

• Readmission rates among participating providers decreased from 22% to 18.6%

across 18 months

• Plan to narrow even further to an additional, more tightly-knit preferred provider

network of 8-15 facilities, selected based on safety and quality outcomes and

metrics, geography and demographics, willingness to collaborate and integrate, and

cost efficiency

• Preferred provider network will be used for ACO and system-owned Medicare

Advantage plan

• Recognizing that broad network will be necessary given role of patient choice and

provider-specialties, maintain relationships with broader care coordination network


32

Baystate Promotes Top Providers But Preserves Choice

Sources: Baystate Medical Center, Springfield, MA;

Cardiovascular Roundtable interviews and analysis; Healthcare

Advisory Board interviews and analysis.

Steerage Not an Insurmountable Issue

Discharge coordinator

distributes list of

preferred SNFs to all

patients

Clearly states that

patient has freedom of

choice over where to be

discharged

Emphasizes preferred

providers’ high quality,

close relationship, and

continuity of care

BPCI CABG discharges

going to a preferred

SNF provider

60% Case in Brief: Baystate Medical Center

• 716-bed hospital based in Springfield, Massachusetts

• Participating in retrospective bundles via BPCI for CABG

• Achieved $1900 reduction in cost-per-episode for CABG,

largely attributed to more efficient SNF usage


33


Characteristics of Optimal Network

Optimal network must be capable of caring

for every type of patient

Optimal network must be capable of

managing highest risk areas

Optimal network must be capable of

providing seamless support across the

full continuum


34

2

3

4

1

Road Map






35

Four Key Post-Acute Actions Necessary for Success


Market Demands Dictate Utilization Changes

4 Bolster Downstream

Support

1 Strengthen Complex

Patient Management

2 Elevate In-Setting

Care

3 Develop Cross-Continuum

Specialty Programs

Suite of Emerging Expectations for PAC Providers

• Additional regulatory

requirements

• Expanded public payer

coverage of select services

Legislative Forces

Factors Driving Additional Demands on Post-Acute Providers

• Opportunity for higher

reimbursement rates

• Emergence of

utilization managers

Commercial Forces

• Rising complexity,

acuity of patient profile

• Rapid growth in

elderly population

Demographic Forces


36 omplex Patient Management

Source: Administration on Aging, “Projected Future Growth of the Older Population,” www.aoa.gov/Aging_

Statistics/future_growth/future_growth.aspx#age; Gerace A, “Assisted Living Adapts to Changing Resident

Acuity”, August 12, 2013, www.seniorhousingnews.com; Post-Acute Care Collaborative interviews and analysis.

Service Demands Driven by Demographics

Key Reasons for Higher Patient Acuity and Complexity

in Post-Acute Care Settings

Population growing

older, with more

chronic conditions

Reimbursement changes

incent shorter LOS,

favor lower-cost settings

Aging Population New Payment Models

6%

18%

50%

26%

4-10

conditions

2-3

conditions

0 conditions

1 condition

Chronic Disease Prevalence Residential Care Facilities, 2010

Seniors as a Portion of the US Population

10%

0%

20%

30%

1990 2050 2010 2030

85+ 75-84 65-84

Actual Projected

Patients, Residents Older and Sicker


37

Source: Hartford HealthCare at Home; Post-Acute Care Collaborative interviews and analysis.

Solving ACO Care Managers’ Challenges

Conversion Rate toMedicare Home Health

25%

Breakeven

Point

50%-60%

Preliminary

Results

Model Sustainability,

Home Health Conversions

Revenue from nurse

investment surpassing costs

100%

Hospital sends at-risk

patient home, without PAC

ACO care manager

identifies patient with needs

not addressable by phone

HHA transition nurse conducts

non-billable home visit, reports

status to ACO care manager

HHA provides appropriate

services to fill gaps

Telehealth

(non-billable)

Private

Duty

(self-pay)

Medicare

Home Health

(billable)

Hartford HealthCare at Home’s ACO Partnership


38

Source: Hartford HealthCare at Home; Post-Acute Care Collaborative interviews and analysis.

Solving ACO Care Managers’ Challenges

Case in Brief: Hartford HealthCare at Home

• Not-for-profit, post-acute provider located in the Northeast providing home

health, hospice, and community-based services; part of Hartford

HealthCare, a 6-hospital health system operating a Medicare accountable

care organization (ACO)

• Created the care transitions nurse program to assist ACO care managers in

helping patients who may need home support not identified in the hospital

• Hiring nurses individually as program scales, anticipating hiring four nurses

to staff the program for the health system’s 10 ACO care managers

• Anticipates 80-100 referrals per month to the program, identifying financial

breakeven if 25% of patients begin using Medicare home health services

after nurses identify needs during the home visit

• Initial estimates indicate 50%-60% of patients referred require Medicare

home health services; availability of home alternatives such as telemedicine

position agency as a solution rather than a service


39

Embedding Hospital Clinicians in Local SNFs

Source: Joshi D K et al, “The Successful Development of a Subacute

Care Service Associated with a Large Academic Health System,”

Journal of the American Medical Directors Association, July 2012;

Advisory Board research and analysis.

Elevate In-Setting Care

UMHS Subacute Care Service Staffing Structure

Subacute Care Service

Medical Director

4 Physicians and

5 Nurse Practitioners

SNF Partners

7 days/week

staffing coverage

• Fellowship training in

geriatric medicine

• Board certifications in

internal and geriatric

medicine

• Interest in managing

medically complex

patients post-hospital

discharge

• SNF and med-surg

unit experience

• Highly skilled in

managing wounds,

surgical drains,

IV lines, complex

medical care,

polypharmacy, and

geriatric syndromes

• Serves as visible

clinical director at

hospital for entire

subacute service

• Assures referring

physicians they can

discharge to SACS

SNF with confidence

Physician

Background

Nurse Practitioner

Background


40

Case in Brief: University of Michigan Health System

• Not-for-profit, 914-bed academic medical center located in Ann Arbor, MI

• Launched subacute care service in 2006 to enhance overall quality of

post-discharge care, decrease inpatient LOS, and reduce readmissions

• Patient care is provided in four privately owned SNFs within 20 miles of

the hospital

• Team of physicians and nurse practitioners manages all UMHS patients

discharged to SACS-affiliated SNFs

Embedding Hospital Clinicians in Local SNFs (cont.)

Source: Joshi D K et al, “The Successful Development of a Subacute

Care Service Associated with a Large Academic Health System,”

Journal of the American Medical Directors Association, July 2012;

Advisory Board research and analysis.


41

Partnership Yielding Positive Results

Despite Higher Acuity, LOS and Readmissions Reduced

Source: Joshi D K et al, “The Successful Development of a Subacute Care Service

Associated with a Large Academic Health System,” Journal of the American Medical

Directors Association, July 2012; Advisory Board research and analysis.

Case Mix Index

In Days

10.6

8.0

2006 2011

Average Length of Stay

1.98

2.03

2006 2011 2006 2011

15-Day Readmissions Rate

53% Increase in discharges

from UMHS to Subacute

Care Service SNFs

20.0%

17.4%


42

Establish Infrastructure to Fill Niche Service Gaps

Training to Address Medically Complex Behavioral Health Patients


HealthEast – Cerenity Senior Care Partnership

Collaborative Hospital-SNF Training Real-Time Clinical Support

Outpatient Clinic

Patient seen at hospital

physician clinic to avoid

unnecessary readmission

Physician Support Line

Hospital team available

over the phone for

on-demand consults

Clinical Training for Medication Management

Solution: Hospital

provides input on

patient stimulation

and socialization

Problem: SNF inexperienced

assessing capacity for patient

decision-making and

determining decision-maker

Solution: Hospital

shares ethical principles

for substituted judgment

and beneficence

Problem: Mandated dose

reduction in SNF raises

concerns about return of

symptoms

Solution: Hospital and

SNF physicians discuss

procedures for safely

tapering medications

Problem: Younger

population requires

activities atypical of

average SNF patient

Guidance for Addressing Population Needs

Protocols Around Patient Mental Capacity

Develop Cross-Continuum Specialty Programs


43

Case in Brief: HealthEast Care System

• Not-for-profit, four-hospital health system located in St. Paul, MN

• Medically complex behavioral health patients lingering in acute care

hospitals as post-acute providers reluctant to admit

• Established collaborative partnership with Cerenity Senior Care comprised

of formal clinical training and ongoing support to manage specific patient

population

• Training addressed key SNF challenges for managing complex medical and

behavioral health needs

• Patients discharged from HealthEast to Cerenity Senior Care with robust

support system in place

Establish Infrastructure to Fill Niche Service Gaps

(cont.)



44

Partnership Boosting Referrals and Admissions


Behavioral Health

Admissions

141

215

Nov. '10 -Apr. '11

Nov. '11-Jan. '12

62 76

Nov. '10 -Apr. '11

Nov. '11-Jan. '12

Total

Referrals

Monthly Average of HealthEast – Cerenity Patient Transfers

A True Partnership

Medical Director,

Post-Acute and Community Health

HealthEast Care System

”

“In order to seamlessly serve our

complex patients across the entire

continuum, it is critical that the staff

working at the various sites of care

(hospital, post-acute etc.) act as a

cohesive team. This has been

transformational adaptive change for

us and the rewards for our patients

have been truly amazing.”

Before partnership

After partnership


45

Home Health, Hospice Spending Associated with Lower Total Costs

Bolstering Downstream Support

Source: De Jonge, Erik K, et al., “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,”

Journal of the American Geriatrics Society, 2014, http://onlinelibrary.wiley.com/doi/10.1111/jgs.12974/pdf; Post-

Acute Care Collaborative interviews and analysis.

1) Diagnostic testing, transportation, Medicare Part B drugs, nonphysician

practitioners, durable medical equipment, outpatient facility.

Enhancing Traditional Home Health Episodes

Service Category Intervention Control Change

Hospice $3,144 $1,505 109%

Home Health $6,579 $4,170 58%

Physician $4,143 $5,718 (28%)

Skilled nursing $4,821 $6,098 (20%)

Other1 $7,962 $11,392 (30%)

Hospitalization $17,805 $22,096 (19%)

Total Medicare $44,455 $50,978 (13%)

Financial Impact of Medstar’s Medicare Home-Based Primary Care Demonstration

Mean 2-year spending per patient

• Primary care team of

geriatricians, NPs,

social workers, LPNs,

office coordinators

• Physicians visit every

3-4 months and provide

24/7 call, NPs visit

regularly as needed

• Team conducts weekly

care conferences with

home health, mental

health, pharmacy

HBPC Model


46

Source: De Jonge, Erik K, et al., “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,”

Journal of the American Geriatrics Society, 2014, http://onlinelibrary.wiley.com/doi/10.1111/jgs.12974/pdf; Post-

Acute Care Collaborative interviews and analysis.

Enhancing Traditional Home Health Episodes

Case in Brief: Medstar Health

• Not-for-profit, 10-hospital health system located in the Mid-Atlantic region

• Piloted a home-based primary care demonstration for the fee-for-service Medicare

population based off of the Department of Veteran’s Affairs’ home-based primary care

model

• 2-year results yielded significant cost savings, primarily from reduced hospitalizations

• Despite initially segmenting their patient population to high-risk patients, upon

retrospectively segmenting their patient population by the most frail patients (JEN Frailty

Index score of 7 or more), researchers found that if the middle and low risk patients had

not received the intervention, savings would have been the same

• JEN Frailty Index measures the presence or absence of 13 characteristics with a point

on the 13-point scale given for the presence of each characteristic; characteristics

measured are minor or major ambulatory impairment, mental health diagnosis, mental

retardation, dementia, impairment in sensory function or self-care, presence of general

symptoms, diagnosis of cancer, presence of major chronic diseases, pneumonia, renal

disease, and other medical risks.

• Program highlights opportunity for providers to better segment patients for intensive

health interventions to maximize the financial impact of the program and potentially

improve pricing from managed care payers


47

Source: De Jonge, Erik K, et al., “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,” Journal of the American

Geriatrics Society, 2014, http://onlinelibrary.wiley.com/doi/10.1111/jgs.12974/pdf; Post-Acute Care Collaborative interviews and analysis.

Shrink Volumes to Maximize Per-Patient Impact

Frailty

Category

(JEN Index)

Proportion

of Sample Intervention Control Change

Statistically

Significant?

Low (0-3) 20% $22,611 $19,146 18% No

Medium (4-6) 43% $42,223 $43,383 -3% No

High (7+) 37% $58,689 $76,827 -24% Yes

(p < 0.001)

With Proper Risk Stratification, Less Can Be More

Patients included in the intervention cohort who could

have been served with routine care to achieve similar

spend reduction results at a lower program cost

63%

Medicare Spending for Home-Based Primary Care by Patient Frailty

Stratification by Patient Frailty Intensifies Program Results


48

2

3

4

1

Road Map






49

Care Management

Care Management the Catch-All for Emerging Risk

Source: Post-Acute Care Collaborative Interviews and analysis.

Traditional Risk

• Site-specific clinical capability

• Delivery alignment with

prospective payment system

Emerging Risk

Self-management

capability

Primary care,

continuing care

access

Home safety Care delivery

efficiency

Medication profile

consistency

Cost-appropriate

system navigation

Information

exchange

Addressing the comprehensive

patient and caregiver needs that

influence functional outcomes,

satisfaction, and long-term cost

Common Goals:

• Reduce unnecessary resource

utilization (hospital, ED visits)

• Improve patient and caregiver

satisfaction

• Raise clinical quality indicator

performance

• Foster information exchange

• Facilitate care access

Risk Assumption with Health Care Evolution

Support Required Beyond Care Setting Walls


50

Scoping the Ambition


Payer

Support

Availability

Episodic Care Management 1

Examples: Primary care integration, senior

wellness coaching, diabetes management,

behavioral health case management

Long-Term Care Management 2

Necessity

as a PAC

Responsibility

Value to

Referrers

Referrer Episodic Exposure Growing

All hospitals soon incented on PAC efficiency;

readmissions a national area of focus

Emerging as Primary Care Responsibility

Uncoordinated or overly ambitious approaches

may confuse patients, alienate PCPs;

however, post-acute expertise a highly

valuable input for primary care development

External PAC Management Risky

Poor hospital or third-party management of

PAC utilization can cause readmissions from

early discharge or cost overruns from

inappropriate setting placement

Slower Payment Alignment Progress

Commercial payers lacking contracting

sophistication for innovative long-term care

payment; however, private payment and

physician ACOs funding select innovations

Examples: 90-day longitudinal care pathing,

transitional care services, length of stay

management, PCP follow-up coordination

Medicare Incentives Most Aligned

Medicare FFS incentives, bundling, and

shared savings gains realized from short-

stay patients, quickest return on investment

potential for Medicare innovators

Limited value for non-integrated hospitals

However, highly relevant for integrated

systems, physician ACOs, payers


51

Information-Sharing Vital for Care Management


Two Critical Cross-Continuum Care Management Challenges

Hospital Care

Manager

HHA PCP Care

Manager

“I’m calling for your

post-discharge check-up…”

Tracking Patient Location Tracking Needed Services


52

Leveraging Data to Assess, Monitor Provider Quality


Harnessing Multiple Goals of Information-Sharing

Time, Amount of Collected Data

Deg

ree o

f S

yste

m

Inte

gra

tion

Health System Benefits of Information-Sharing

INDIVIDUAL PATIENT

INFORMATION TRANSFER

Share patient information

across providers to reduce

unnecessary utilization

EFFECTIVE CARE

MANAGEMENT

DEPLOYMENT

Ensure patients receive all

services needed without

unnecessary duplication

PROVIDER QUALITY

TRACKING

Review collected data

to target improvement

opportunities, inform

financial arrangements


53

Addressing Duplications, Gaps in Existing Roles

Commonalities in Hospital Roles Inform New Post-Acute Opportunities

Multidisciplinary Working Group Audits, Revises Care Management Functions

Care Management

Redesign Team

Care managers, social

workers, nurses

convened weekly over

period of nine months

Day-in-the-Life Summary

Overview of daily routine,

primary duties and activities

Job Descriptions

Outlined roles for inpatient

positions, transitions coaches

Staffing Resources Produced

• Job roles and

responsibilities

• Multidisciplinary rounding

process across system

• Use of technology,

resources

• IT-based peer-to-peer

communication

Functions Audited

Hospital Care Management Gap Audit Tool

• Catalogs job functions, common names, and duties for hospital care management staff

• Allows Post-Acute Care Collaborative Members to recognize service gaps, identify

common blind spots for hospital and physician group partners

• For complete opportunity audit tool, please see the appendix.



54


Addressing Duplications, Gaps in Existing Roles

(cont.)

Case in Brief: LifeBridge Health

• Health system including two acute care hospitals and a multi-service

post-acute care center located in Baltimore, Maryland

• System clarified, standardized care management functions to remove

duplication, gaps as part of Care Management Redesign Initiative

• Steering and Leadership Committees consisting of system senior

executives provided strategic direction, oversight to working groups


55

Case in Brief: Walgreen Co.

• Largest drug retail chain in the United

States, with 372 Take Care Clinics and

over 700 locations throughout the country

• In 2012, created WellTransitions™

program to help health systems reduce

readmissions by offering transitional

support for at-risk patients

• Strong initial results include 5 point lower

readmission rate over 6 months for

patients enrolled in the program versus

eligible patients who did not enroll

• Received American Hospital Association

endorsement for medication adherence

portion of WellTransitions™

WellTransitions™ Program Components

Medication

Reconciliation

Appointment

Reminders

Prescription

Delivery

Follow-Up

Phone Calls

“Solution” Sales on the Rise for Non-Providers

Source: “WellTransitions©,” Walgreen Co., http://healthcare.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions’;

Post-Acute Care Collaborative interviews and analysis.

Recognizing the Potential of Targeted Services

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