The Intersection of Clinical Services & Revenue Cycle.
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Transcript of The Intersection of Clinical Services & Revenue Cycle.
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Quality/PI
Revenue Cycle
Customer Satisfaction
Survey Process
$urvivability
The Intersection of Clinical Services & Revenue Cycle
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Strategy to Reduce Readmissions
HomeTown Health
Spring Conference 2012
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Presentation Focus What is the problem?
Reduced reimbursement from Medicare, Medicaid, and commercial payers
Hospitals assuming more risk for discharged patients
What is the solution? Choosing a proven readmissions solution
model Choosing a solution team Choosing a solution tool
Where do we go from here? Next steps
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What is the Problem? Reduced reimbursements for avoidable
readmissions Medicare now Medicaid Commercial plans
Driven by employers to reduce costs
Hospitals assuming more risks for discharged patients. Examples: Medicare High Readmission Penalty Medicare Bundled Payments Medicare and Medicaid Accountable Care
programs
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Readmission Risks Over Time
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Medicare Readmission Penalty Penalty Amount
Adjustments up to 1% will be imposed on hospitals in FY2013 (Oct 2012), related to higher than expected readmission rates
Penalty Basis Based on high readmission rates for fee for
service Medicare enrollees age 65 or older discharged from an acute care hospital with a principle diagnosis of Acute Myocardial Infarction (AMI) Heart Failure Pneumonia
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Future Medicare Readmission Penalties
More significant reductions in future years up to 2% in FY 2014 (Oct 2013) and
up to 3% in FY 2015 (Oct 2014)
Additional principle diagnosis conditions could be added such as: COPD Cardiovascular surgical procedures Vascular conditions
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Penalty Impact on Hospitals Hospitals in the bottom quartile
Hospitals in the bottom quartile on readmissions will suffer penalties in the hundreds of thousands
The measurement period has already begun.
Four HTH hospitals in bottom quartile CMS link -
http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/CCTP_FourthQuartileHospsbyState.pdf
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What if you are not on the CMS list? You could be on the next CMS list
Hospitals in the bottom quartile will work quickly to get off the list
Your readmission rates will be published on a public website (Hospital Compare)
Employers are selecting hospitals to reduce costs Workers and their families will be steered to
hospitals that can prove they deliver quality care. Providers would earn part of their fees for keeping patients as healthy as possible, similar to the "accountable care organizations" in the health care law.
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Effective Care Transition Barriers Practitioner Level Barriers
Practitioners often have not practiced in settings where they transfer patients
Sending practitioners may not communicate critical information to receiving practitioners
Practitioners may not know the patient and his or her preferences for care
Practitioners have no accountability Hospitals
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Effective Care Transition Barriers Patient Level Barriers
Patients assume that someone is in charge of coordinating care
Patients (and caregivers) are often the only common thread weaving between care sites
Yet they navigate the system with few tools or training to manage in this role
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Critical Success Factors Clinical professionals and care
coordinators must prepare patients and their caregivers to receive care in the next setting and actively involve them in decisions related to the formulation and execution of the transitional care plan
Bidirectional communication between clinical professionals, care coordinators, and patients is essential to ensuring high quality transition care
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Case Study 1 During a patient’s monthly follow-up
appointment with the cardiologist, he informed the doctor that he was having trouble with one of his medications. The doctor asked which one. The patient said “The patch, the nurse told me to put on a new one every day and now I’m running out of places to put it!” The physician had him undress and discovered that the man had over a two dozen patches on his body.
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Case Study 2 An older man with atrial fibrillation
who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose and within two days he was re-hospitalized with uncontrollable bleeding.
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What’s the Solution? Key Goals
Identify issues and barriers to transitions across the continuum of care
Evaluate appropriate referral criteria between levels of care
Assess available technology, evidence based guidelines, medication reconciliation, and adherence gaps
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What’s the Solution cont’d? Focus on the root cause of readmissions
Patient non compliance With medications With physician follow-up With nutrition (meals) With physical therapy
Barriers to patient compliance Lack of transportation Lack of help at home Home environmental barriers
Heating and cooling Changing bed sheets Reducing fall related risks
Cultural, mental, and language barriers16
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Solution Components Select a proven care transitions model
National models include Eric Coleman CTI model Mary Naylor model Project RED Boost Guided Care
Select care coordinators – options include: Hospital staff (legal review required) Local area agency on aging Home health agency FQHC Outsource to case management company
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Solution Components cont’d Engage patients and caregivers
Obtaining consent for participation Orientation and education
Engage care transition team members Patient Physicians Patient Pharmacists Skilled Nursing Facilities Home health care agencies Community resources
Area agency on aging United Way agencies Churches
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Solution Components cont’d Select Care Transitions Tool for:
Collecting hospital discharge data Conducting risk assessments Building transitions care plan Selecting and scheduling referrals
Medical Non medical
Tracking care plan compliance Capturing and analyzing results
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Care Transition System
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Non Clinical Components
Support network engagement
Clinical Components
Disease Management
Mental/Dental/Specialty Care
Medication Management
Immunization Schedule
Transportation
Home environment
Food and Nutrition
Patient Management Action Plans
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Real Healthcare Reform
Hospitals
Local government agencies
Safety Net Clinics
Health Departments
ChurchesUnited Way
Agencies
Area Agency On Aging
Home HealthAgencies
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My patient’s most pressing health issue was a broken carburetor
“Months later, before a pending well-child visit, I called the school to get an update on his development. I was shocked to learn that it had been weeks since he had last attended. When he and his mother came in for their appointment, I learned her car had broken down. She was saving money for a fix, but had no one to rely on for her son’s transportation and hadn’t known where to turn for help. . . .
This was a crystallizing moment for me. The long-term health and well being of a developmentally delayed child whom I had helped coax through recovery from prolonged hospitalizations and multiple complicated surgeries hinged not on the quality of my medical care but on a taxi voucher and a broken carburetor.”
Dr. Douglas Jutte, MD, UC Berkeley Medical Program - 12/7/2011
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Gaps with EMR Technology “Today’s EMR technology was not developed to support role-based access to information for team care. Instead, it was developed to support a traditional fee-for-service, visit-based reimbursement model, with the focus on documentation requirements to support a billing function.
That technology is inadequate to the transformationalactivities required for new health care models. Anchoring the electronic health record (EMR) in the traditional visit-based care delivery model limits the potential of the medical home togenerate paradigm-shifting care delivery transformationand the positive outcomes it promises.”
Source: Cyberinfrastructure Patient-Centered Medical Home: Current andFuture Landscape - Zayas-Caban, Finkelstein ,Kothari, Quinn, Nace, 2011
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Where do we go from here? The clock is ticking
Oct 2012 will be here soon Hospital Compare site already up
Act now to manage “forced” risk Engage with Home Town Health
E.g., CMS Community Care Transitions Grant Engage Home Town Health Partners
CivicHealth - Care Transitions Tool Other HTH partners as appropriate
Consultants Personal telemonitoring
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Questions and Answers
Richard Taylor CivicHealth [email protected] 615 482 3600
Lou Semrad HomeTown Health [email protected] 706 474 0434
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Additional Slides
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Hospital (Discharge
Plan)
Care Coordinators
PatientPhysician
Family
Health advisors
and coaches
Provider and Social Services Network
Care Transitions Team Interactions
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Patient community Database
Eligibility and Community Resources
Referral Coordination
Case Management/Disease
Management
Process Function Uses/Data
Outcomes Reporting/ Analytics
Patient Intake
Patient Eligibility
Patient Referrals
Patient Management
A Comprehensive Patient Management Solution
Patient assessments and demographics,medical history
Eligibility Rules (e.g.,CHIP,Medicaid); community resources database
Set up and schedule Referrals – social and Clinical (transportationmeals, home services)
Manage patientCompliance (goals, alertsFollow-up interventions)
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Patient Management Applications Care Transitions
Managing patients after discharge ER Room Redirection
Reducing uncompensated care by redirecting uninsured patients to safety net clinics
Accountable Care Programs E.g., chronic Disease management
Community Health Improvement programs E.g., reducing community obesity
Prenatal and Maternal/Child health programs Coordinating care for pregnant mothers
Senior Citizen Health Management Coordinating programs for seniors
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