1.800.360.0603

GE Healthcare Camden Group Insights Blog

Cardiac Care Bundles and the Need for Post-Acute Partnerships

Posted by Matthew Smith on Sep 26, 2016 2:21:31 PM

By Erin Byrne, Consultant, GE Healthcare Camden Group

partnership-definition-1.jpgPost-acute care continues to be an increasingly important component of the care continuum, as evidenced by the recently proposed expansion of CMS’s Episode Payment Models (“EPM”) focused on 90-day cardiac care episodes. More than ever, post-acute care providers are playing a crucial role in the care of patients across care settings, which is especially relevant to the current 90-day mandate for Medicare patients undergoing hip and knee replacements, as well as the newly proposed 90-day mandate for cardiac episodes, such as AMI and CABG.

Under this new value-based paradigm, successful management of risk and increased accountability for patient outcomes requires healthcare organizations to expand their focus beyond their individual care settings. This is especially true as it relates to post-acute care where a considerable amount of the total 90-day episode cost may be incurred. Through the proposed cardiac mandate, CMS is requiring hospitals to better control costs and decrease variability in service utilization patterns, which often is attributable to the post-acute portion of the episode of care. Acute care providers must prepare for the continued expansion of value-based payment arrangements by actively pursuing purposeful partnerships, strengthening care coordination and communication, and managing patients as they transition across the care continuum during their recovery.

Creating Purposeful Partnerships: Who Is the Right Partner?

Selecting partners is no simple task, and post-acute providers are no longer just referral partners. Hospitals must pursue post-acute care providers whose patient outcomes andclinical service capabilities will support value-based care under CMS’s cardiac EPM. With the clinical and financial responsibility of the patient’s care extending beyond the four walls of the hospital, hospital-based clinicians and their support teams have a heightened accountability for the quality of care being delivered in the post-acute setting. As such, skilled nursing facilities, sub-acute rehab facilities, home health agencies, and outpatient physical therapy providers are being closely evaluated for their ability to collaborate as well as their overall performance, including:

  • Performance on star ratings
  • Geography for convenience of the community or patient population
  • Medical staff that aligns with patient needs, with staffing coverage including physicians and advanced practice clinicians
  • Length-of-stay compared to benchmarks, the largest cost driver of post-acute spend
  • Readmission rates

CMS provides a range of resources and information on nursing homes and home health agencies in the public domain. Hospitals can utilize tools like Nursing Home Compare in their partner selection process, which provides detailed information about every Medicare- and Medicaid-certified nursing home in the country. Throughout the evaluation of post-acute care providers, a hospital self-assessment is also recommended to determine where patients are being referred and discharge to when they leave the hospital. Specifically, this assessment should consider length of stay in various post-acute settings, readmission rates, and how historical performance on these metrics compare to industry benchmarks.

Collaboration Across the Care Continuum

Proactive post-acute care providers will seize this opportunity to seek out partners, present their value proposition to hospital leadership, and collaborate with at-risk hospitals in the new value-based arrangements. Partners must collaborate to devise a cross-continuum strategy and implement new care models to support cardiac episodes from the time of hospital discharge through the patient’s full recovery. Once partnerships and post-acute care relationships are established, data and information will need to be shared and reported by acute and post-acute care partners including:

  • Deployment and adherence to evidence-based clinical pathways
  • Best practice protocols
  • Cost and utilization data
  • Quality measures
  • Patient-reported outcomes

Acute and post-acute partners must create cross-functional work groups to drive accountability and ensure adoption of protocols and best practices. Work group members should seek input from all post-acute partners about how work processes will most appropriately link together across care settings, solve problems, share learnings, and continue to improve collaboration.

Coordinating Care and Communication

Creating new lines of communication between multi-functional cross-organization teams is necessary to coordinate patient care throughout the 90-day cardiac EPM. A methodology and supporting infrastructure for ongoing information flow and problem solving must be developed to foster smooth care transitions and care coordination to deliver patient-centered care. These teams must sort out how each partner will handle patient transfers seamlessly to include all pertinent information, monitor patient adherence to clinical pathways, exchange and report data. Partners must work together to enhance use of care managers, information system integration, handoff protocols, and discharge instructions. The outcomes of this collaboration and planning will help guide care coordination, stratify hospital discharges by risk of readmission, complication or care plan non-compliance.

Hospital and post-acute care partners should assess resource needs to coordinate cardiac patients throughout the continuum, creating a comprehensive view as to how current or additional resources will work together in a revised, multi-partner care pathway to coordinate care incorporating post-acute care managers, SNFists, cardiac rehab clinicians, inpatient case managers, and cardiac services line leaders. Communication is important not only between care teams, but more importantly to the patient. Setting realistic patient expectations on how their episode will progress, while keeping the patient informed and involved in any revisions needed to their care plan establishes the patient at the center of the process, and should help drive better outcomes reported by patients on their actual experience of care.

Start Building Post-Acute Partnerships Now

Full episode and recovery planning must occur early and thoroughly to give patients a complete understanding of expectations of care before their surgery, while they are in the hospital, post-discharge and post-acute. Patient education should focus on self-management and support resources available to the patient and their care-givers. Identifying best practices to monitor patients’ care is crucial to manage risk of patient complications and potential readmission.

In today's value-based world, tracking patients throughout a bundle should be informed by the care management model. Patient outcomes will improve with monitoring and management of patient care throughout the 90-day bundle. Now is the time to begin the pursuit of aligned post-acute care partnerships. Pursing purposeful partnerships with post-acute providers are necessary to improve care coordination and communication to monitor and manage risks of bundle patients through CMS’s expanding Episode Payment Models.

Cardiac Care Bundled Payments


Byrne.jpgMs. Byrne is a consultant with GE Healthcare Camden Group, specializing in planning, strategy, and analytics in the bundled payment practice. She works with organizations to plan and implement bundled payment programs within Medicare, Medicaid, Commercial, and Employer markets. She may be reached at erin.byrne@ge.com 

 

 

 

Topics: Bundled Payments, Post-Acute Care, Cardiac Episode Payment Model, Erin Byrne

Q&A: Selecting Post-Acute Organizations for Joint Replacement Bundles

Posted by Matthew Smith on Mar 21, 2016 1:27:08 PM

By Andy Edeburn, MA, Vice President, GE Healthcare Camden Group

Q&A, Bundled Payments, Post-Acute CareWith mandatory bundles for joint replacement looming, many hospitals have worked through their financial impact analyses and sorted out their physician relationships. But it sounds like many have yet to develop a strategy for post-acute partners, especially selection tied to quality outcomes and post-acute clinical skill.

The comprehensive care for joint replacement ("CJR") initiative involves a 90-day episode of care, and the hospital component will typically involve only three or four of those days. Depending on the market, hospitals will likely need to consider both home health agencies and skilled nursing facilities as important players in their post-hospital continuum.

Hospitals often have a range of questions about picking post-acute providers. Here are some of the common questions that have crossed our inbox in the last few weeks.

Q: My hospital has reviewed our recent discharge data and determined that a lot of our post-acute discharges go to five providers. Can we just keep it simple and say these five are our partner group and leave it at that?

A: You could, but historical volume doesn’t always equal quality. In a lot of instances, it equals convenience. As you explore potential partners, there are three key things to consider:

  • Quality performance
  • Geography
  • Medical staff

There are ample options for learning about post-acute provider quality via state and federal resources – a fuller discussion is presented in the following question. Your hospital should look for providers in at least the top quartile of quality and seek out those who perform better than state and national averages. Second, consider the geographic distribution of post-acute providers in your service area. Discharging patients will want an option that is close to home or covers their community. Thus, balancing quality and geography is an important equation. Finally, you’ll want to make sure that your post-acute partners have consistent medical staff coverage that aligns with your patient needs. Skilled nursing facilities and home health agencies are required to have a physician as a medical director, but that physician oftentimes not directly involved in patient care nor following patients on a regular basis. Post-acute organizations can employ a range of physician models, some with open or closed staff models, or some using a “SNFist” – similar to a hospitalist but in a skilled nursing facility. You’re looking for post-acute partners with at least 30 hours per week of coverage, involving some combination of physicians and advance practice clinicians.

Q: What sort of resources can I access and what kinds of data should I review when it comes to selecting post-acute providers?

A: There are a number of resources readily available with information about post-acute organizations, especially skilled nursing facilities and home health agencies. Medicare’s beneficiary-facing website (www.medicare.gov) offers a range of information via its nursing home and home health compare tools. While much of this data is retrospective in nature, it can provide a good baseline around historical quality. It’s important to note, however, that a lot of the data regarding skilled nursing facilities is focused on aspects of long-term care and not on short-term, post hospital care. Other data that may be more pertinent to bundled payment is available via commercial data vendors or actuaries. If you’ve already completed any analysis about your organization’s costs and opportunity related to CJR, it’s likely that you should have some sense about who the high volume post-acute providers are, how long they keep patients with respect to benchmarks and how often they readmit patients. When considering post-acute providers for your discharges, post-acute length-of-stay is often the largest determinant of cost and should be an important data point for you. Readmission rates are also important.

Q: We’ve figured out which providers will be our network partners. Now we want them to follow our clinical protocols and perform. What’s the best way to get them on board?

A: While it’s probably easiest to just dictate terms and expectations, you’ll catch more flies with honey than with vinegar. One of the best ways to engage with post-acute providers is to acknowledge that they’re an essential part of your episode. Treating them like a true partner will get you halfway there. Beyond that, you should build the right infrastructure for ongoing dialog, education and problem solving. A dedicated workgroup or committee involving acute, post-acute and physician participants is essential. If you want post-acute providers to follow your protocols, sit down and work through the protocols together. Seek input from the post-acute organization about how their work meshes most appropriately with yours. Sort out how you will handle patient transfers, exchange data and report data. Meet regularly to address issues, share learnings and maintain the dialog. Most importantly, designate a resource in your organization to lead this effort. You’ll be happier for clearly-defined accountability, and the post-acute providers will always know who to call when they have questions.

Q: We obviously want to keep track of these patients after they’ve left post-acute. What’s the best way to do that?

A: For providers already down a value-based or population health road, keeping track of patients should flow automatically to your care management model. Absent this resource, you’ll want to create some kind of ad hoc approach that defines clear accountability and process for post-hospital/post post-acute follow through. You should consider some of the models around phone-based care management as a potential resource. Patient activation will play a key role – educating the patient about self-management or how to access support as needed. Post-acute providers can take on some of these function or assist, if you can create the right incentive for them take it on. One important requirement of CJR involves patient-reported outcomes. From an infrastructure perspective, your effort to gather this quality data from patients should ideally integrate with your patient monitoring efforts.

Q: We’re thinking about moving past a contractual arrangement with post-acute providers and are interested in exploring direct ownership or operation of post-acute. What do we need to know?

A: First and foremost, owning and operating post-acute carries as many challenges and pitfalls as any other healthcare business. How complicated can it be? Fairly complicated. Each post-acute setting currently retains its own unique payment system and regulatory framework. In some states, there are barriers to developing new post-acute settings; in other states, there are limitations about how you can move an existing provider from one geography to another. That said, there is a general spectrum of how hospitals and health systems can approach post-acute relationships, ranging from joint operating arrangements and networks through joint ventures and sole ownership. Each invites various pros and cons, and the right answer can be very organization and market-specific.


Andy_Edeburn.pngMr. Edeburn is a vice president with GE Healthcare Camden Group, with more than 20 years of healthcare consulting experience, specializing in acute, primary, post-acute, and senior care services. He is a nationally recognized expert on post-acute care. His areas of expertise include strategic planning, acute/post-acute integration, provider network development, and managed care. Mr. Edeburn is a frequent speaker on a range of topics including healthcare reform readiness, strategic planning, acute and post-acute integration, and change management. He may be reached at andrew.edeburn@ge.com.

 

Topics: Bundled Payments, Post-Acute Care, Andy Edeburn, Skilled Nursing Facility, CJR, SNF, SNFist

Post-Acute Care: The Original Outside-the-Box Tool for Acute Throughput Challenges

Posted by Matthew Smith on Mar 10, 2016 1:28:27 PM

By Andy Edeburn, MA, Vice President, and Geoffrey Martin, MBA, Executive Vice President, GE Healthcare Camden Group

Post Acute Care, Think Outside the BoxLet’s face it—hospital throughput represents a daunting challenge for providers throughout the country. As the population ages and more individuals find themselves with health insurance, hospital use—particularly emergency department utilization—has exploded.

For hospital operators, historic approaches to acute throughput are coming up short, and a typical focus on inside-the-walls solutions, while important, are short-sighted. When it comes to literally thinking “outside the box,” hospitals need to look closer at post-acute care (“PAC”), especially skilled nursing facilities and home health agencies.

It’s true that PAC has received considerable attention over the last few months, given PAC’s role in bundled payment, especially for the CJR joint bundle mandate. But post-acute also represents an essential component of any acute throughput improvement plan and broader patient flow strategies across the continuum. As a “pressure relief valve,” PAC can help address acute bed length-of-stay issues, limit unwanted admits passing through the ED, and accelerate hospital thinking around continuum solutions.

Here are some key applications where PAC might be able to foster acute throughput redesign.

PAC Oriented Discharge Planning

While PAC is a destination for many acute discharges, it is often considered too late in the discharge-planning process. As a result, patients often stay longer than necessary in the acute bed while case management “looks for a bed” or tries to “find someone who will take this patient.” New requirements around discharge planning may be exactly the lever needed to start thinking (and talking) about PAC destinations immediately after admission. Patient assessment efforts within the first 24 hours should incorporate appropriate screening efforts that not only identify PAC as an option but also point to a specific PAC setting. This data, in turn, should guide case managers and discharge planners to more effectively apprise PAC about pending transfers and should also inform hospital-wide analytics about pending PAC needs.

Acute Admit Avoidance

Identifying patients who might be served outside the hospital is an often overlooked but essential step in both reducing wait times and avoiding unnecessary admissions. Emergency Department (“ED”) triage efforts must consider PAC as a viable alternative for appropriate patients, either via clinical assessment efforts or expanded case management. In many instances, community-based settings (like a skilled nursing facility) are capable of managing patients who present with non-urgent, non-surgical issues, like pneumonia or UTIs. In-depth evaluation of historical ED use should clarify the potential for acute avoidance opportunities and characterize specific patient types appropriate for PAC.

Real-Time Patient Management  

As more organizations consider adoption of advanced transfer centers, command centers, and similar efforts to better manage hospital performance in real time, PAC must be an omnipresent option for appropriate use. Bed managers, transfer leaders, and others making decision around the flow of patients must understand resources available to them outside the hospital and drive the use of these resources. While many PAC HIT systems have not reached a high degree of interoperability with acute systems, alternative approaches to identifying resources “on-call” or available, reinforcing PAC as an option, and directing patients to these options can be a powerful component in the command center information flow.

Integrating PAC into improved throughput efforts is likely easier said than done. To build strong ties with post-acute entities, many hospitals will first need to engage directly with these providers and identify quality- and capacity-oriented organizations who can serve in a hospital’s narrow network or collaborative. The use of data to clearly articulate how PAC fits into your overall patient flow strategy and to establish expectations with PAC providers is critically important. Once identified, hospitals and PAC providers will need to build strong and reliable infrastructure to support quick and efficient transfer of patients. Linking PAC network strategies related to population health management or bundled payment initiatives to the care redesign effort will reinforce the impact. In some instances, financial incentives (with clearly defined ties to quality) may serve as both carrot and stick on both sides.


Andy_Edeburn.pngMr. Edeburn is a vice president with GE Healthcare Camden Group, with more than 20 years of healthcare consulting experience, specializing in acute, primary, post-acute, and senior care services. He is a nationally recognized expert on post-acute care. His areas of expertise include strategic planning, acute/post-acute integration, provider network development, and managed care. Mr. Edeburn is a frequent speaker on a range of topics including healthcare reform readiness, strategic planning, acute and post-acute integration, and change management. He may be reached at andrew.edeburn@ge.com.

Geoff_Martin.pngMr. Martin is an executive vice president with GE Healthcare Camden Group and leader of the Care Design and Delivery Practice. Mr. Martin specializes in the areas of hospital operations, process improvement, and the use of advanced analytics to develop innovative solutions. He also has extensive experience in strategy development, care design, population health development, value management, and large scale technology implementations. Mr. Martin has worked with leading academic medical centers and large integrated delivery networks across the country to improve clinical, financial, and operational performance. He may be reached at geoffrey.martin@ge.com.

Topics: Acute Care Hospitals, Post-Acute Care, Andy Edeburn, Patient Throughput, Acute Care Efficiency, Geoffrey Martin, Throughput

Top Predicted Healthcare Trends of 2016

Posted by Matthew Smith on Jan 20, 2016 10:48:00 AM

Trends.pngThe nation's healthcare system will undergo tremendous changes in 2016. While macro factors are at play, some of the greatest challenges will be finding ways to respond to new payment models, consumer expectations, as well as changing organizational operations, facilities, and culture to respond to population health strategies. Here's a look at the trends and factors that will have the greatest impact during 2016:

Macro Issues: A Changing Industry

  • The World is Shrinking. Consolidation is one of the biggest phenomena occurring in every arena of healthcare. While we can expect the regulatory approvals for the major payer transactions to be resolved during 2016, keep an ear to the ground for additional mergers. As the number of players shrinks, this will impact both payer and provider strategies, particularly in markets where the payer mix is already highly concentrated. In the provider realm, there will be additional eyes focused on these actions as the Federal Trade Commission will continue scrutiny of provider consolidations, including hospital and medical group acquisitions. "It will be essential to demonstrate direct consumer benefit related to efficiency, access and quality, both pre- and post-merger," said Laura Jacobs, president, GE Healthcare Camden Group. Watch for consolidation to take many forms -- not just asset mergers but many other types of affiliations and integrated relationships.
  • Innovation Will Rock the Boat. From technology, to new models of care, to new approaches to patient experiences, innovation will cause ongoing marketplace disruption. Private equity dollars will continue to flow into mobile technology, while new primary care delivery models and telehealth will offer different ways to engage consumers. In addition, retail giants like CVS and Walgreens/Rite-Aid will push further into care delivery, pressuring traditional providers to enhance access, change delivery models, and/ or forge partnerships to address this issue. At the same time, healthcare organizations will be required to enhance efforts to improve the patient experience far beyond measuring patient satisfaction -- the experience must be exceptional at every encounter -- from electronic to face-to-face visits.
  • Expansion and Redefinition of Health Systems. Health systems will continue to expand their physician enterprise, although many will be challenged by the financial strain of operating large employed models. Compensation redesign to move away from strictly productivity-driven models will be a priority. Expansion and merging of clinically integrated networks will continue, as a vehicle to align incentives in population health and value-based payment models, as well as minimize the need for "owning and controlling" the continuum. Expect ongoing development or expansion of provider-owned health plans as either a counterweight to the highly concentrated payer market or a means of taking global risk with payers or employers. Meanwhile, payers will extend their reach into the care delivery space, acquiring physician practices and clinical networks.

Follow the Money

  • Transparency and the Pocketbook. Pressures related to price and cost -- along with the adjacent need for transparency -- will drive more transformation. Consumer scrutiny will play an increasing role in this dynamic as high deductible plans force them to pay closer attention to price. As a result, lower-cost alternatives will have a competitive advantage. Because payer rate increases will be in the low single digits (if at all), any upside will require participation in some value-based payment, such as shared savings or pay-for-performance. In addition, thanks to the new budget bill, new provider-based clinics will not be reimbursed any more than physician practices. These pressures will continue to force more efficiencies across the continuum related to patient throughput and require operating cost reductions, moving from cost-per-unit to cost-per-episode basis.
  • The Variety Show: Value-Based Payments. Value-based initiatives may radically change referral patterns and the need for effective population health management. For an example, consider the 2015 introduction of the Comprehensive Care for Joint Replacement (CJR) model for Medicare -- with a roll-out in 2016. There is no way to predict how quickly new similar initiatives could strike your market. In addition, as employers introduce narrow networks to better control costs, some markets will experience acceleration of employer direct contracting. Further, the "foot in two canoes" analogy will have to change to recognize the proliferation of payment models beyond a strict definition of fee-for-service vs. fee-for-value. The cacophony of models ranging from strictly fee-for-service to pay-for-performance, care management/patient-centered medical home, bundled payment, shared savings/ACO, full or partial risk/capitation, and beyond will continue to add administrative, strategic, operational, and financial complexity to most organizations. Trying to make sense of this blend of payment structures from both a financial and care model perspective will cause more confusion before the fog clears.
  • Increased Focus on Post-Acute Care. The spotlight will shine on post-acute care, thanks to population health management models and bundled payment. We'll see the emergence of "preferred" networks of providers providing these services, as well as repurposing acute care facilities to meet the needs of post-acute patients. More transactions involving post-acute providers -- home health, skilled nursing, rehabilitation, hospice ­-- will create increased upheaval in this realm of healthcare.

Inside the Walls

  • Patient Volume: The Seesaw Effect. Changing dynamics in the healthcare system will have a give-and-take impact on patient volume. While new payment models will decrease acute hospital utilization, the continued expansion of Medicaid and the insured population through the public exchanges will push additional patients through the doors. Additional factors feeding demand across the spectrum include an aging population and the ongoing rise of obesity and chronic disease. Although urgent care, better care management and redesigned primary care models will eventually deflect patients from the emergency department, the ultimate impact of these initiatives will take a while, requiring these areas of hospital to operate at (or over) capacity.
  • The People Factor. Change cannot occur without effective leadership, leading to an increased demand for clinical leaders who can help drive transformation. Participation in population health management will increase competition, as well as cost, for these capabilities. At the same time, there will be leadership turnover as mergers/consolidations occur and as systems evolve from "holding company" to "operating company" models (and sometimes back again). Finally, be on the lookout for union activity, which may be sparked in some regions due to cost pressures and reductions in force.
  • The Makeover. As administrators "rationalize" clinical service lines, they will strive to reduce variation in quality and cost across health systems. Physician alignment with these moves will be crucial. Simultaneously, consolidations and mergers will spawn a new wave of facility planning to repurpose or enhance the efficiency of existing structures.
  • The Rise of IT and Turf Wars. One area where capital will continue to flow: IT tools and resources. The need for new structures for data governance within health systems will be driven by the proliferation of population health tools and analytical systems. And in a related development, watch for a tug-of-war between CIOs and business unit leaders. Turf battles may ensue on selection of systems and data management.

Topics: Trends, Post-Acute Care, Value-Based Payments

Best of 2015: Leveraging Post-Acute Care to Address Acute Readmissions

Posted by Matthew Smith on Dec 30, 2015 9:57:22 AM

By Andy Edeburn, MA, Vice President, GE Healthcare Camden Group

hospital-readmissions-reduction-program.jpgLeading into the new year, GE Healthcare Camden Group will be re-publishing the most shared and popular blog posts of 2015.

For most hospitals impacted by readmission penalties, post-acute care represents a key bulwark in improving readmission performance and reducing penalties under CMS’ Hospital Readmissions Reduction Program. Two out of every five Medicare fee-for-service acute hospital patients are discharged to post-acute care, and most of these to either a skilled nursing facility or home health agency. As we shift from volume to value, our relationships with post-acute organizations become critically important. However, collaborating with post-acute providers is unsure ground for many.

If you are thinking about confronting your readmission challenges, here are some key thoughts about selecting and engaging more directly with post-acute partners.

Post-Acute Provider Capabilities

All post-acute providers are not the same, and the typical hospital will historically refer to 20 or 30 different providers with little regard for quality or outcomes. Winnowing this list down is an important first step. Start with the “choice list” you most likely give to patients headed to post-acute care. You’ll want to sort through this accumulated collection of nursing homes and home health agencies and start strategically downsizing. Using publicly-available quality data, surveys, or even direct visits to providers, identify which providers show measureable quality and are clinically prepared to address your readmission challenges. Understand what kind of physician coverage they have (or will need), and discuss the disconnects that currently exist between your organization and them. Combine your findings and rank providers based on your organization’s needs. If the process of selecting quality providers seems daunting, seek assistance from someone with post-acute knowledge and experience. At the end of this process, you should have identified a list of key organizations that have the right skill sets (or the ability to learn) and can partner with you to address readmissions. This is the beginning of your network.

Redesigning Post-Acute Discharge and Transfer

With the beginning of a network in hand, you can get to the meat of leveraging post-acute to tackle readmissions. The bulk of post-acute discharged readmits typically bounce back in 48-72 hours or less, so re-thinking the acute to post-acute discharge and transfer process represents a key starting point for changing behavior. What happens just before acute discharge and right after post-acute admission often involves many steps, but here are three important areas that usually benefit from greater review and redesign:

  • Universal Transfer DocumentationThe volume of information transferred from acute to post-acute (whether via paper or electronic means) is oftentimes chaotic and inconsistent. Practices can vary a lot: there can be wide variation among acute discharge planners about “what to send” and post-acute provider preferences for “what they want.” Standardizing the transfer is an important step towards consistency. Working in collaboration with your network, evaluate the current range of behaviors and re-design a universal process that everyone will use. Eliminate all of the unnecessary forms and data to focus on essential information that supports and informs the transfer. A standardized checklist as a dedicated cover sheet is often helpful and provides a tangible reference for both sides.
  • Readmission Risk Assessment – Stratifying discharges for their risk of readmission has been a results-oriented solution for many organizations, and acute and post-acute organizations can draw from a handful of simple scoring tools to help. One excellent example is the LACE index scoring tool. LACE evaluates four aspects of patient condition or behavior, including acute length-of-stay, if the acute admission occurred via the emergency department (“ED”), patient comorbidities, and ED visits in the preceding six months. The combination of these four results in a score ranging from one to 20, with higher scores indicating increasing likelihood of readmission. Patients who score at high risk (commonly 10 or greater) are noted appropriately at transfer and the readmission risk score is shared with the admitting post-acute provider.
  • Warm Hand-Offs – Direct communication among caregivers in a defined setting can be challenging enough, but interaction across settings is sometimes entirely non-existent. Improving (or daresay requiring) communication via warm hand-offs among physicians, nurses, and case managers is absolutely critical – even with a foolproof integrated electronic health record solution. Within 24 hours of patient transfer (either prior to or soon thereafter), an acute hospitalist should confer with the post-acute attending (commonly called a “SNFist”) or attending physician to review hospital care, discharge orders, and priority areas of concern that might lead to a readmission. Absent physician interaction, an acute RN case manager should connect with the post-acute intake nurse or case manager. Establishing a specific protocol about what should be communicated during the hand-off is helpful in reinforcing a change in behavior.

Understanding post-acute provider capabilities and redesigning practices around discharge and transfer represent mere opening steps in a longer journey of utilizing post-acute care to leverage readmission issues. In a future post, we’ll take a closer look at the role of care management in post-acute settings, reinforcing multi-disciplinary thinking across the continuum, and the post-acute to home discharge process.

The Camden Group, Hospital Readmissions, Readmissions Reduction


Andy_Edeburn.png

Mr. Edeburn is a vice president with The Camden Group, with more than 20 years of healthcare consulting experience, specializing in acute, primary, post-acute, and senior care services. He is a nationally recognized expert on post-acute care. His areas of expertise include strategic planning, acute/post-acute integration, provider network development, and managed care. Mr. Edeburn is a frequent speaker on a range of topics including healthcare reform readiness, strategic planning, acute and post-acute integration, and change management. He may be reached at aedeburn@thecamdengroup.com or 312-753-7940.

Topics: Readmissions, Readmissions Reduction, Post-Acute Care, Andy Edeburn, Acute-Care Readmissions

Mandated Bundled Payments Compel Hospitals to Rethink Post-Acute Care

Posted by Matthew Smith on Oct 26, 2015 3:55:30 PM

By Deirdre Baggot, Ph.D., Senior Vice President, and Andy Edeburn, MA, Vice President,                       The Camden Group

Bundled Payments

Medicare's Comprehensive Care for Joint Replacement ("CCJR") program signals an evolution in payment that demands a strong strategic response from hospitals and health systems.To this end, hospitals should monitor the performance of their post-acute care partners using performance measures established with input from the partners. Measures such as complication rates, length of stay, and readmission rates (i.e., major drivers of cost) should be monitored and reported in as close to real time as possible. Additional measures such as patient experience of care, ancillary use, and physician utilizational so should be tracked, but with the understanding that they are secondary to the economics of the bundle.

Cross-continuum bundles succeed when there is concurrent information exchange through technology leveraged across settings and providers. A checklist can serve as an easy first-phase approach to ensure smart execution, especially when systems are not yet talking. Although systems to effectively track and monitor measures ideally will involve integration among health information platforms that capture actual utilization and cost data, most post-acute care measurement is likely to be manual or self-reported.

Click the button below to read this article in full at hfma.org

Bundled Payments, CCJR, The Camden Group, HFMA

(Introductory paragraphs courtesy of HFMA)

Topics: Bundled Payments, Deirdre Baggot, Post-Acute Care, Andy Edeburn, CCJR

What Hospitals, Health Systems, and ACOs Need to Understand about Post-Acute Care

Posted by Matthew Smith on May 26, 2015 2:26:00 PM

By Andy Edeburn, MA, Vice President, The Camden Group

lightbulb_blackboard.jpgWe spend a lot of money on post-acute care. Some pundits think we spend too much ($58.6 billion in 2012 according to Medicare Payment Advisory Commission’s [“MedPAC”] June 2014 Data Book), and they might be right. From a national perspective, 43 percent of Medicare discharges go to post-acute care, and given our fee-for-service traditions, there has been little call for hospitals and systems to understand, much less get to know, post-acute providers. A typical community hospital might refer patients to as many as 30 skilled nursing facilities (“SNFs”) and more than a dozen home health agencies with little regard for their capabilities or outcomes. In the shifting landscape of healthcare reform, post-acute plays a big role in shaping both outcomes and spending. To that end, here are three issues healthcare leaders should understand about post-acute care.

Post-Acute Spending is Highly Variable and Needs Better Control

In our fee-for-service mentality, we have never been really concerned about readmissions, nursing home length-of-stay (“LOS”), or patient perception of post-hospital care. By virtue of their reimbursement systems, post-acute has been left on its own with almost no controls around utilization or performance.

With the shift to fee-for-value, however, the impact of post-acute use and spending has come under newfound scrutiny. While long suspected, recent studies have established that post-acute care represents the single largest area of variability in Medicare spending. A 2011 MedPAC study confirmed post-acute spending can vary from $60 per member per month to nearly $450 per member per month, depending on geography. In 2013, the Institute of Medicine’s Committee on Geographic Variation found that 70 percent of variation in Medicare spending is attributed to post-acute use alone.

For hospital and systems, particularly those participating in an ACO or working towards the value-based paradigm, this post-acute variability represents an enormous Achilles heel. SNFs that “optimize” LOS, or home health agencies that repeatedly readmit to achieve greater revenues, can unnecessarily drive up Medicare Part A spending, and as a result, the total cost of care for a given beneficiary. As a handful of early ACOs and fee-for-value adopters have learned, getting to know your post-acute providers and developing formal relationship or networks is central to addressing these variations in use, and ultimately, spending and outcomes.

Post-Acute is Inherently Schizophrenic and Competitive

Many presume that post-acute care is just another kind of “continuum” – an interconnected sequence of services or settings that support post-hospital care. While post-acute service typically occurs after an acute inpatient stay, and there is sometimes a referral from one post-acute setting to another (i.e., SNF to home health), post-acute is highly disconnected within itself and has considerable overlap.

SNFs and home health agencies (which account for about 80 percent of all post-acute services nationally) are an excellent example. Post-acute care in SNFs evolved to address medically-complex patients requiring rehabilitative therapies while home health historically took on less complex patients with fewer needs. In the last 10 years, the lines between these two providers have blurred dramatically. Home health has ramped up its clinical skill to address complex wounds, congestive heart failure, and other patients who might have historically gone to a SNF. Many post-orthopedic procedure patients are now serviced by home health. As a result, SNFs have worked to take on more complex patients – those who might have gone to an inpatient rehabilitation facility (“IRF”) or even a long-term acute care hospital (“LTACH”). All of this has created both tension and increasing competition among different kinds of post-acute providers. The Centers for Medicare & Medicaid Services has worked to address some of these issues by redefining criteria for some settings (IRF and LTACH in particular) and suggesting site-neutral payment as one means, challenging the industry to sort out its differences. Bundled payment will also challenge traditional thinking as it gains more traction and becomes the dominant form of payment for post-acute services.

For a hospital or system seeking the “right” setting for a post-acute bound discharge, the prospects can be daunting. There is no uniform patient assessment tool for post-acute, and it is not unusual for patients to be placed in the wrong setting – sometimes at significant financial cost (e.g., $26,000 for a typical SNF-based episode vs. $64,000 for an LTACH episode). Understanding the differences among post-acute settings and determining appropriate settings for post-acute bound patients are critical for those organizations focused on the Triple AimTM. Providers need to re-engineer discharge planning, know how to pick the right partners, and improve communication both with and among post-acute providers.

Post-Acute is Eager to Partner and Adapt to the New World

Hospitals, health systems, and ACOs looking for the right post-acute organizations are often surprised by what they find. Most post-acute providers are willing and eager to engage. They understand the importance of a clinically integrated future, desire preferred relationships, and are facing their own value-based program expectations around quality reporting, readmissions, and payment.

Building the right kind of partnership, however, won’t just happen because you say so. Hospitals, health systems, and ACOs need to engage post-acute providers as active partners and treat them as equals in creating systems, tools, and networks to successfully treat and manage post-acute bound patients. There has been a lot of buzz about post-acute network development over the last 12-to-18 months, but much of that work has involved simply picking providers. Little of it has focused on actually engaging partners to fix the real problems – redesigning care, improving transitions, expanding physician coverage in post-acute settings, enhancing post-acute clinical skills, and creating measures of quality and performance that can drive long-term improvement. It is important to recognize that the hard work of change inside organizations must extend outside the walls or the historical view of the business.

The post-acute partnering pioneers of the past few years have seen tremendous results for their efforts – 20 to 50 percent drops in readmissions, impressive reductions in post-acute LOS, and dramatic shifts away from high-cost post-acute settings in favor of lower cost, comparably effective options. At the same time, patient satisfaction with improved acute/post-acute relationships hit an all-time high. For some, the approaches to post-acute partnering have even served as templates for partnership models addressing renal and behavioral health populations.

As we think about the next few years and the continued push towards greater integration and the goal of true population health management, post-acute care cannot be an afterthought or a minor footnote in any organization’s planning or thinking process. As post-acute continues to evolve, it will take on an ever-increasing role – shortening acute LOS, taking on unnecessary inpatient admissions, and managing the bulk of post-hospital care and service in a given episode. Now is the best time for hospitals, systems,and ACOs to step deeper into post-acute care, engage the right partners, and take the first steps towards a value-based acute/post-acute future.


Andy_Edeburn.pngMr. Edeburn is a vice president with The Camden Group, with more than 20 years of healthcare consulting experience, specializing in acute, primary, post-acute, and senior care services. He is a nationally recognized expert on post-acute care. His areas of expertise include strategic planning, acute/post-acute integration, provider network development, and managed care. Mr. Edeburn is a frequent speaker on a range of topics including healthcare reform readiness, strategic planning, acute and post-acute integration, and change management. He may be reached at aedeburn@thecamdengroup.com or 312-753-7940.

Topics: ACO, Hospitals, Health Systems, Post-Acute Care, Andy Edeburn, Post-Acute Spending

Leveraging Post-Acute Care to Address Acute Readmissions

Posted by Matthew Smith on May 13, 2015 2:22:40 PM

By Andy Edeburn, MA, Vice President, and Tina Pike, MBA, MSN, HCM, RN, Senior Manager, The Camden Group

hospital-readmissions-reduction-program.jpgFor most hospitals impacted by readmission penalties, post-acute care represents a key bulwark in improving readmission performance and reducing penalties under CMS’ Hospital Readmissions Reduction Program. Two out of every five Medicare fee-for-service acute hospital patients are discharged to post-acute care, and most of these to either a skilled nursing facility or home health agency. As we shift from volume to value, our relationships with post-acute organizations become critically important. However, collaborating with post-acute providers is unsure ground for many.

If you are thinking about confronting your readmission challenges, here are some key thoughts about selecting and engaging more directly with post-acute partners.

Post-Acute Provider Capabilities

All post-acute providers are not the same, and the typical hospital will historically refer to 20 or 30 different providers with little regard for quality or outcomes. Winnowing this list down is an important first step. Start with the “choice list” you most likely give to patients headed to post-acute care. You’ll want to sort through this accumulated collection of nursing homes and home health agencies and start strategically downsizing. Using publicly-available quality data, surveys, or even direct visits to providers, identify which providers show measureable quality and are clinically prepared to address your readmission challenges. Understand what kind of physician coverage they have (or will need), and discuss the disconnects that currently exist between your organization and them. Combine your findings and rank providers based on your organization’s needs. If the process of selecting quality providers seems daunting, seek assistance from someone with post-acute knowledge and experience. At the end of this process, you should have identified a list of key organizations that have the right skill sets (or the ability to learn) and can partner with you to address readmissions. This is the beginning of your network.

Redesigning Post-Acute Discharge and Transfer

With the beginning of a network in hand, you can get to the meat of leveraging post-acute to tackle readmissions. The bulk of post-acute discharged readmits typically bounce back in 48-72 hours or less, so re-thinking the acute to post-acute discharge and transfer process represents a key starting point for changing behavior. What happens just before acute discharge and right after post-acute admission often involves many steps, but here are three important areas that usually benefit from greater review and redesign:

  • Universal Transfer Documentation – The volume of information transferred from acute to post-acute (whether via paper or electronic means) is oftentimes chaotic and inconsistent. Practices can vary a lot: there can be wide variation among acute discharge planners about “what to send” and post-acute provider preferences for “what they want.” Standardizing the transfer is an important step towards consistency. Working in collaboration with your network, evaluate the current range of behaviors and re-design a universal process that everyone will use. Eliminate all of the unnecessary forms and data to focus on essential information that supports and informs the transfer. A standardized checklist as a dedicated cover sheet is often helpful and provides a tangible reference for both sides.
  • Readmission Risk Assessment – Stratifying discharges for their risk of readmission has been a results-oriented solution for many organizations, and acute and post-acute organizations can draw from a handful of simple scoring tools to help. One excellent example is the LACE index scoring tool. LACE evaluates four aspects of patient condition or behavior, including acute length-of-stay, if the acute admission occurred via the emergency department (“ED”), patient comorbidities, and ED visits in the preceding six months. The combination of these four results in a score ranging from one to 20, with higher scores indicating increasing likelihood of readmission. Patients who score at high risk (commonly 10 or greater) are noted appropriately at transfer and the readmission risk score is shared with the admitting post-acute provider.
  • Warm Hand-Offs – Direct communication among caregivers in a defined setting can be challenging enough, but interaction across settings is sometimes entirely non-existent. Improving (or daresay requiring) communication via warm hand-offs among physicians, nurses, and case managers is absolutely critical – even with a foolproof integrated electronic health record solution. Within 24 hours of patient transfer (either prior to or soon thereafter), an acute hospitalist should confer with the post-acute attending (commonly called a “SNFist”) or attending physician to review hospital care, discharge orders, and priority areas of concern that might lead to a readmission. Absent physician interaction, an acute RN case manager should connect with the post-acute intake nurse or case manager. Establishing a specific protocol about what should be communicated during the hand-off is helpful in reinforcing a change in behavior.

Understanding post-acute provider capabilities and redesigning practices around discharge and transfer represent mere opening steps in a longer journey of utilizing post-acute care to leverage readmission issues. In a future post, we’ll take a closer look at the role of care management in post-acute settings, reinforcing multi-disciplinary thinking across the continuum, and the post-acute to home discharge process.

The Camden Group, Hospital Readmissions, Readmissions Reduction


Andy_Edeburn.pngMr. Edeburn is a vice president with The Camden Group, with more than 20 years of healthcare consulting experience, specializing in acute, primary, post-acute, and senior care services. He is a nationally recognized expert on post-acute care. His areas of expertise include strategic planning, acute/post-acute integration, provider network development, and managed care. Mr. Edeburn is a frequent speaker on a range of topics including healthcare reform readiness, strategic planning, acute and post-acute integration, and change management. He may be reached at aedeburn@thecamdengroup.com or 312-753-7940.

 

pike_headshot.pngMs. Pike is a senior manager with The Camden Group with over 25 years of clinical, business, and management experience in the healthcare industry. Her areas of expertise include business development, strategic planning, operations management, Lean strategies, and performance and process improvement. She has a strong clinical background and has assisted organizations with patient throughput, physician and patient engagement strategies, transformational culture change, as well as, the development of care models which span across the continuum of care to help healthcare organizations transition to value-based care and population health. She may be reached at tpike@thecamdengroup.com or 585-512-3900.

 

Topics: Readmissions, Readmissions Reduction, Tina Pike, Hospital Readmissions Reduction Program, Post-Acute Care, Andy Edeburn, Acute-Care Readmissions

Hospital Readmissions Reduction Strategies: The Impact of the Hospitalist

Posted by Matthew Smith on Apr 22, 2015 10:24:03 AM

By: Tawnya Bosko, MHA, MSHL, MS, Senior Manager, and Vinnie Sharma, MBA, MPH, Manager, The Camden Group

RA-thumb5As penalties associated with avoidable readmissions continue, hospitals across the country are attempting to identify the most effective approaches to tackle this challenge in order to limit monetary as well as reputational losses. While the solutions required will likely be as multi-faceted as the problem itself, one specific group that can play a pivotal role in reducing readmissions are the hospitalists.

Hospitalists play a central role in process improvement within hospitals, which gives them a head start in tackling the readmissions challenge. However, in certain cases, over-emphasis on length-of-stay (LOS) reduction may contribute to the problem, which can lead to higher readmissions, patient dissatisfaction, and increased liability for the physicians and the hospital. Thus, the hospitalists and the hospital leadership need to develop a proactive, coordinated set of strategies to achieve the desired results of efficient care as well as reduced readmissions. Use the following ten tips to support your organization’s coordinated strategy.

1. Promote a Team Approach

Reducing readmissions requires a team effort with other physicians, nurses, care coordinators, case managers, family members, and post-acute providers. Hospitalists typically work in a team-based environment and are used to playing “quarterback” to a multidisciplinary team of healthcare professionals to improve inpatient processes and quality, and thus are best qualified to lead efforts to reduce readmissions. Because many of the areas that can impact readmissions are outside the immediate purview of the hospitalists (e.g., case management or post-acute care), some organizations utilize a dyad approach where the hospitalist co-chairs the taskforce with an administrative leader.

2. Coordinate Discharge Planning

Hospitalists are often asked to balance hospital efficiency (e.g., through managing LOS and cost per case) while ensuring that the patient receives appropriate care in the most appropriate setting. Hospitalists can manage this balancing act by working with case managers and care coordinators to develop a plan of care starting on the first day of admission. The tasks of planning post-discharge care, coordination with the Primary Care Physician (“PCP”), specialists, and communication with family should be initiated as early as possible.

3. Improve Patient Education

The best preventers of readmissions are often the patients themselves. If properly educated on symptoms, medications, warning signs, and need for follow-up with PCPs, many of the most common problems that result in readmissions can be prevented. While it certainly depends on the ability of the patient to follow instructions, hospitalists can lead the effort by providing written as well as verbal instructions in an easy to understand way. Depending on the situation, it may be appropriate to engage family members. Additionally, deploying a patient education specialist or case manager to follow-up with the patient to make sure they understand the hospitalist’s recommendations and plan of care identifies areas where patients may be unclear and resolves those issues before discharge. This also serves as a vehicle to improve patient experience. Optimally, patients should be given a phone number to call should they have questions after their discharge. That number should be given by the hospital, hospitalist, case manager or in coordination with the PCP.

4. Strive for Smoother Hand-offs

Transition from the inpatient setting to post-acute or home setting is a critical step in preventing adverse outcomes and potential readmissions. Effective communication about the needs of the particular patient applies to not just the inpatient stay, but to the discharge process and post-discharge environment. Hospitalists need to pay particular attention to effective and timely communication with the PCPs or post-acute providers. While a letter or faxed copy of discharge notes is common practice, it is usually not sufficient; phone calls can be much more effective in relaying important information and developing a game plan, especially for complex patients. Additionally, electronic exchange of health information and shared viewing of the electronic patient record is optimal. This often remains a challenge due to lack of integration between inpatient and ambulatory records.

5. Schedule Follow-up Appointments

Patient follow-up appointments should be scheduled with the PCP before discharge, and an appropriate outreach and communication process should be structured so that patients who miss their follow-up appointments are identified. This requires a tightly coordinated effort between the hospitalists, the hospital and the patient’s PCP or other relevant specialty provider. Further, home health agencies can support the transition to home with home visits to assess the patient’s condition, home environment, and ensure compliance with medications. Hospitalists should drive the communication with the PCP and coordinate efforts with internal hospital departments to ensure appropriate post-discharge visits are arranged.

6. Improve Medication Reconciliation

Multiple studies have demonstrated that proper medication reconciliation can result in a significant decrease in readmissions and adverse events. Hospitalists can take a leading role in improving medication reconciliation through a coordinated effort with the pharmacist, pharmacy technicians, and nursing staff. Depending on the approach, the process may require additional staffing resources, and the hospitalists can spearhead the task of communicating the expected benefits to administrative leaders. Further, medication reconciliation doesn’t stop within the hospital walls. Ensuring that the PCP is updated regarding changes in medications while in the inpatient setting and the ambulatory record is updated are pertinent; as is coordination with post-acute care providers.

7. Utilize Post-Acute Care

As the healthcare system moves to an integrated delivery model, hospitalists can play an important role in the post-acute arena to improve care coordination. Several organizations now send hospitalists to round in skilled nursing facilities (“SNFs”) and nursing homes to ensure a safe transition and follow-up. Some organizations have dedicated physicians to the SNF setting, often referred to as “SNFists.” For less acute patients, several programs offer post-discharge clinics that are staffed either by hospitalists or through a partnership with the PCP. While utilizing hospitalists or advanced practice professionals with hospitalists’ oversight, outside of the inpatient setting, may require financial support from the organization, the benefits from reduced readmissions, lower costs, and higher patient satisfaction can be significant.

8. Identify Those at Greatest Risk for Readmissions

Hospitalists are in the best position to identify patients that are at greatest risk for readmissions. Using data analysis to provide a greater level of detail and feedback to hospitalists is important to overall success, as is instituting a feedback process to account for the hospitalist’s identification of high risk individuals, processes and conditions. Utilizing a risk stratification tool and arming hospitalists with information from that tool at the time of admission are recommended.

9. Encourage Communication Between Admitting and Discharging Physicians

Studies have shown that often there isn’t communication between the admitting and discharging hospitalists regarding patients that are readmitted. While basic information is often exchanged, there isn’t a tightly coordinated effort to discuss readmitted patients between the physicians that are involved in the care. Closing the communication loop between hospitalists could provide valuable information and lessons learned and ultimately reduce readmissions as well as improve quality and support a team-based environment.

10. Design Incentives Models that Matter

Having clear guidelines and processes that should be followed by the hospitalist program are important. Additionally, since the readmission penalty is structured to only impact the hospital at this time, and hospitalists are still compensated for seeing readmitted patients, creating an incentive model methodology that bonuses the hospitalists for improving or maintaining a given readmission rate may help align overall incentives in the program and engage hospitalists in the process. Hospitals should work collectively with the hospitalists group and other stakeholders to design effective incentive models.

Readmissions reduction requires a well-coordinated approach among many providers along the continuum of care as well as with the patient, family, and other participants. Hospitalists can play a critical role in the development of a culture of safety that improves patient outcomes, reduces penalties for the hospitals, and also minimizes the medical-legal risk exposure. Readmissions reduction is a clear first step in transitioning to a more value-based delivery system, and hospitalists can and should play a critical role in this process.

The Camden Group, Hospital Readmissions, Readmissions Reduction


 

bosko_headshotMs. Bosko is a senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization (“PHO”) and MSO development, managed care strategy, and physician alignment. She may be reached at tbosko@thecamdengroup.com or 310-320-3990.

 

 

 

Vinnie_Sharma_SquareMr. Sharma is a manager with The Camden Group with more than ten years of experience providing advisory services to physician organizations and health systems. Mr. Sharma has an extensive background in managing or consulting for medical groups, faculty practice plans, and health systems, with a focus on operational and financial improvement. He may be reached at vsharma@thecamdengroup.com or 310-320-3990.


 

Topics: Readmissions, Hospital Readmissions, Tawnya Bosko, Readmissions Reduction, Vinnie Sharma, Post-Acute Care, Patient Education

Subscribe to Email Updates

Value Model, Health Analytics

Posts by Topic

Follow Me