achieving return on specialty investment

©2015 The Advisory Board Company • advisory.com

Achieving Return on Specialty Investment Enhancing Post-Acute Providers' Core Value Proposition Through Specialization

Post-Acute Care Collaborative

©2015 The Advisory Board Company 30389 advisory.com 2

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Project Director

Contributing Consultant

Post-Acute Care Collaborative

Design Consultant

Practice Manager

Monica Westhead

Julia Burgdorf

Nini Jin

Jared Landis

Executive Director Brian Contos


Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Introduction: Sizing the Gap to Goal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Chapter 1: Maximize Volume-Driven Specialty Reimbursement. . . . . . . . . . . . . . . . . .. . . . . . . . . . . .13

Chapter 2: Strengthen the Specialty’s Value-Based Appeal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Chapter 3: Leverage Existing Specialty Expertise to Access New Revenue Streams. . .. . . . . . . . . . 35


Available Within Your Post-Acute Care Collaborative Membership

To Order Publications To order copies of these and other Post-Acute Care Collaborative presentations, please visit advisory.com or contact your Dedicated Advisor.

The Post-Acute Care Collaborative has developed numerous resources to assist program leaders in securing long-term growth and market share. The most relevant resources are outlined here to supplement this publication. All of these resources are available in unlimited quantities through the Post-Acute Care Collaborative membership.

Strategic Guidance for Securing Hospital Partnerships

Market-Specific Data and Analytics

Hardwiring Cross-Provider Collaboration • Understanding new demands acute

care providers are placing on post-acute partners

• Models for post-acute involvement in patient-centered medical homes

• Integrating with home and community-based services

Next-Generation Partnership Strategy • Honing outreach messaging and

organizational value proposition

• Improving clinical collaboration with acute care hospitals

• Serving as the care manager for at-risk populations

Care Transitions Mapping Tool The Care Transitions Mapping Tool provides insights on patient movement between acute and post-acute providers within 30 days of discharge from the acute care setting. Providers can use this data to better understand relationships between acute and post-acute care partners, and understand opportunities to forge new partnerships that improve outcomes and reduce cost of care.

SNF Benchmark Generator The Skilled Nursing Facility Benchmark Generator provides Medicare benchmarks so you can compare your performance to your peers across an array of financial and utilization benchmarks. Providers can customize a cohort to compare their own performance to others in the same market or to SNFs with similar characteristics in other markets.

To Access Data and Analytic Tools To access these and other Post-Acute Care Collaborative tools, please visit advisory.com.


Executive Summary

Source: Post-Acute Care Collaborative interviews and analysis.

Recent market developments—such as growing inter-sector competition, the possibility of site-neutral payments, and increasingly narrowed networks—encourage post-acute care (PAC) providers to better define and promote their value proposition as a means of differentiation. These developments simultaneously offer new and exciting chances for PAC organizations to expand their roles in the care continuum and serve new patient groups.

One strategy to both guard against current threats and take advantage of future opportunities created by a marketplace in transition is clinical specialization. Because of the unique nature of their patient populations, many PAC providers already consider themselves specialists. However, there is still significant space for PAC providers to move further into creating well-defined, high-quality clinical service lines. Embracing specialization allows providers to present a clear value proposition that can safeguard volumes by capitalizing on emerging health system needs and preferences.

In order to achieve success, a specialty must represent a cohesive business venture, rather than simply a marketing endeavor. It requires significant investment and organizational commitment. Building and sustaining a strong specialty over time means allocating dedicated resources to treating a specific patient population and driving to a high level of clinical quality, ensuring the specialty is different from and clearly, unquestionably better than competitors’ offerings.

There are many benefits to a well-run specialty line. A strong clinical specialty can:

• Drive volumes to a provider by generating interest in the market among a wide variety of stakeholders—including case managers and patients.

• Solidify partnerships with referrers and payers taking on risk by achieving a high level of clinical quality and operational efficiency.

• Enable a provider to access new revenue streams by leveraging knowledge gained through practicing the specialty to form new business relationships.

This book offers 10 tactics to help providers build and support specialty lines that deliver those benefits—enabling them to achieve full return on specialty investment, and successfully position themselves within the market.


Sizing the Gap to Goal

Introduction


The post-acute industry has increasingly turned to specialization as a solution to the commoditization of post-acute services by referrers and payers.

Specialties are overwhelmingly common with 94% of providers offering at least one specialty. However, only 56% of providers are satisfied with the ROI they have seen from their specialty—a disappointing figure.

One critical reason for that dissatisfaction is a lack of organizational commitment to true specialization. Despite claiming to have added a new specialty line, over 60% of providers reported no operational changes to support the program.

Post-Acute Care Collaborative interviews confirm this lack of investment and highlight the truth that specialty development is commonly a marketing initiative, rather than a clinical enhancement.

Specialties Ubiquitous, but Not Living Up to Expectations

Source: Post-Acute Care Collaborative interviews and analysis. 1) All data on this page is from a survey of Post-Acute Care

Collaborative members conducted in the summer of 2014.

Specialties Prevalent Across the Post-Acute Care Industry1

Post-acute providers with at least one specialty

94% Post-acute providers with four or more specialties

33% Post-acute providers planning to add more specialties in the coming year

78%

100%

56%

Potential Satisfaction

Opinions of Specialty ROI Lukewarm… …With Programmatic Investments Lacking

Percentage of Organizations That Made No Organizational Structure Changes in Support of Their Specialty n=127

n=59

Percentage of Organizations Satisfied or Very Satisfied with Their Specialty’s ROI

Actual Satisfaction

Gap to full satisfaction with specialty

62% Made No Changes


Organizations commonly promote specialization not worthy of the term. The website shown to the right is fictional, but representative of many post-acute and long-term care providers’ home pages. The specialties are commonly offered services, while the accolades are unsubstantiated. The fictional organization shown, like many real providers, believes that marketing materials can sufficiently differentiate themselves from their competitors.

However, as nearly all post-acute organizations claim specialized services, such proclamations have limited impact in the market. If everyone is special, no one is; when all organizations claim specialization, these offerings become commoditized.

Referrers increasingly recognize the gap between a post-acute providers’ marketing efforts and their clinical capabilities. To achieve competitive differentiation and increase referrals through specialization PAC organizations must ensure their specialties are truly special.

A Marketing Tool, Not a Clinical Model

Source: Post-Acute Care Collaborative interviews and analysis. 1) Composite.

Krupke House Nursing Center’s1 Homepage

Meaningless, unsubstantiated “Center of Excellence” designation

Sector definition misrepresented as a specialty

Listed “specialties” are simply the services offered by the facility

IMAG

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“I’m skeptical of providers who come to us saying they have this great heart failure program or great program XYZ… it seems to me more of a marketing ploy rather than a true clinical model.”

Director of Post-Acute Integration Large Acute Care Health System


To derive value from specialization, it must represent a cohesive, comprehensive clinical strategy with significant support behind it. A complete definition of true specialization is shown to the right.

The concept of specialization is based on specialties, or clinical programs. Each of those programs must have all four of the components shown.

A true specialty is a program the organization supports at all levels with necessary resources committed. It is highly distinct from other offerings in the market, both because it is unique and because it demonstrates excellent clinical care and outcomes.

Defining True Specialization


Key Components of a Specialty

What Is Specialization?

Specialization is a business philosophy wherein the organization makes conscious, principled decisions to focus on specific patient groups and creates dedicated, distinct clinical programs to serve those patients.

Dedicated Resources

• Distinct staff, leadership, and/or equipment dedicated to the specialty

• Additional investments in staffing, training, and technology made as necessary

Organizational Commitment

• Executives, leadership, and clinicians visibly support specialty

• Specialty program is a key organizational strategic priority

Differentiated Offerings

• Specialty stands out and is sufficiently different from competitors’ offerings

• Specialty performance is demonstrably superior to competitors, or is unique in the market

Clinical Excellence

• Staff and leaders committed to delivering excellent clinical outcomes

• Ongoing staff education and protocol development supports quality


Although the requirements for true specialization are the same across all organizations, not all successful specialties look alike. A wide variety of specialty types exist—all of which can drive ROI for the organization when properly operated.

The most common option for specialization is to focus on one or more diagnoses, though it’s not the only option. Providers can also choose to specialize in treating select impairments or even patient groups, such as exceptionally high-acuity patients or patients of a narrow age group, depending on the post-acute provider’s sector and market needs.

The table on the right demonstrates how varying specialty types can demonstrate the four key requirements for specialty program development.

This book will feature a wide variety of specialties, all of which meet this benchmark.

Specialization Not One-Size-Fits-All


1) Traumatic brain injury. 2) National Institute on Disability and Rehabilitation Research, 2009-2013 discharges. 3) As measured at admission and discharge.

Range of Specialization Options

Generalist Exclusive Specialist Intensity of Specialization

DRG-Based

Non-Diagnostic

Focus of Specialization

Suite of high-acuity services

Traditional View DRG-specific service line

Impairment-based clinical programs

Exclusive focus on one diagnosis

Organizational Commitment

Dedicated Resources

Differentiated Offerings

Clinical Excellence

Craig Hospital (Exclusive Diagnostic)

Only accepts patients with traumatic brain or spinal cord injury

All resources solely dedicated to specialty

Nationally known for TBI1 and spinal cord injury care

95% of patients with complete paraplegia discharged directly home2

Sheltering Arms (Impairment-Based)

Heavily involved frontline therapists in specialty care protocol design, implementation

Large investment in specialty-specific equipment

Only IRF in region to focus on impairment, not condition

27% greater increase in FIM walk scores3 than regional average

Susquehanna Health Skilled Nursing and Rehabilitation Center (High-Acuity)

Partnered with external vendor to operate specialty program when in-system resources proved unavailable

12-bed unit just for ventilated patients

Only SNF in region capable of handling vent weaning

0% 30-day all cause readmission rate

Representative Specialty Programs in Brief


Specialization is not an end in itself; it is a means to enhance patient care and secure a critical place in the market. Program development should enable strong partnerships with referral sources, driving volume growth and inclusion in narrowing referral networks. Concurrently, a strong specialty enables the organization to explore new business opportunities amid continuing payment transformation.

This book provides 10 tactics to ensure successful return on specialty investment across three vectors. First, driving volumes and reimbursement in the current, fee-for-service environment. Second, making the organization attractive to referrers who are taking on downside risk, improving the likelihood of network inclusion. Finally, utilizing specialty program development to access new revenue streams—often beyond the traditional payment structures of each post-acute sector.

Achieving Return on Specialty Investment

Ten Tactics to Ensure Return on Specialty Investment


1. Solidify Volumes Through Program Co-Development

2. Harness Specialty Spillover Volumes

3. Capitalize on Unique Payment System Opportunities

1

Maximize Volume-Driven Specialty Reimbursement

4. Address Referrer Cost of Care Priorities

5. Implement Staff-Driven Care Protocols

6. Support Generalist Staff with Specialist Experts

2

Strengthen the Specialty’s Value-Based Appeal

7. Recapture Lost Volumes by Expansion into New Sectors

8. Fill Downstream Service Gaps

9. Productize Specialty Knowledge

10. Realign Traditional Competencies into Novel Programs

3

Leverage Existing Specialty Expertise to Access New Revenue Streams


Tactic #1. Solidify Volumes Through Program Co-Development

Tactic #2. Harness Specialty Spillover Volumes

Tactic #3. Capitalize on Unique Payment System Opportunities

Maximize Volume-Driven Specialty Reimbursement

Chapter 1


Organizations commonly pursue specialization to drive volumes and bolster reimbursement.

As such, specialty lines are often chosen based on referrer interest. However, choosing a specialty based on referrers’ expressed concerns does not guarantee an influx of volumes.

The referrer’s request for additional support with a patient type does not convey the full scope of the challenge they are attempting to solve with the specialty line.

For example, hospital referrers may request a specialty line for a specific type of hard-to-place patient not because those patients represent a consistent, long-term priority, but because the hospital has recently seen an unusual concentration of those patients.

As a result, post-acute providers must conduct their due diligence prior to investing in a new clinical specialty.

Hospital Interest No Guarantee of Specialty Success

Source: Post-Acute Care Collaborative interviews and analysis. 1) Left Ventricular Assist Device.

Specialty Development Missing Key Information

Hospital Request SNF that can accept LVAD1 patients

PAC Provider Response Invests in additional staff, training, equipment to build LVAD line

Result: volumes too low to recoup investment costs

Hospital Request LTACH able to handle complex behavioral health patients

PAC Provider Response Hires specialized RNs to offer behavioral health services

Result: low referrals; behavioral health nurses assigned to treat general LTACH patients, leading to turnover

Overall LVAD volumes are very low, hospital interest stemmed from just two cases

Competitor working with health system psychiatrist to offer behavioral health line

Example A:

Example B:


Therefore, referrers’ needs and preferences should be combined with a variety of inputs and considerations when analyzing potential investment opportunities. A rigorous and holistic process is the precursor to long-term specialty program sustainability.

Shown here are select questions post-acute providers should ask themselves when selecting a specialty for their organization.

Numerous Inputs to Selecting the Right Service Line


z 1

• What services do I currently offer?

• What resources do I have available to dedicate to a specialty?

• What is my sector’s regulatory environment?

Key Considerations for Specialty Selection

2 3

5 4

Current State • What is my organization’s

mission? • Am I committed to

serving specific patient groups (e.g., pediatrics, geriatrics)?

Mission and Values • What (if any) diagnoses

are especially prevalent in my market?

• What (if any) functional impairments do I see more than others?

Market Conditions

• What is my competitive landscape?

• What (if any) specific populations or comorbidities do my competitors struggle to handle?

Competition • Who are my primary

referrers?

• What (if any) are my referrers’ specialty priorities?

• Do I need to appeal directly to consumers?

Referrer Priorities

For More Information For additional guidance on weighing these questions in the context of a specific organization, see the Post-Acute Care Collaborative’s “Specialty Decision Aid,” which can be found on advisory.com.


Case in Brief: Lutheran Homes of South Carolina • 5-facility system including skilled nursing and senior living, headquartered in Irmo, South Carolina

• Specializes in high-acuity Medicaid patients

• With Palmetto Health, worked with South Carolina Medicaid authority to expand the definition of complex patients (and the higher reimbursement attached to this definition) to include high-acuity patients

• Engaged Palmetto to create a unit for these patients and requested training and staffing support from Palmetto

Lutheran Homes of South Carolina saw an opportunity to leverage specialization to strengthen partnership with and drive referrals from their primary referrer, Palmetto Health. During conversations with Lutheran Homes, the health system expressed that they struggled to place high-acuity Medicaid patients.

Instead of building a specialty to meet their referrer’s need independently, however, leaders at Lutheran Homes requested support from Palmetto to collaboratively build a high-acuity specialty line within Lutheran Homes. As part of the partnership, Palmetto provides ongoing training for Lutheran Homes staff, along with a medical director and nurse practitioner to staff the high-acuity unit.

Lutheran Homes now receives more patients from Palmetto both within the high-acuity specialty population and the general patient population. Further, other acute care hospitals are now more inclined to trust Lutheran Homes’ staff, given their strong clinical capabilities.

Tactic #1: Solidify Volumes Through Program Co-Development

Building a Mutually Beneficial Program

Palmetto Health and Lutheran Homes Partner for High-Acuity Patients

Source: Lutheran Homes of South Carolina, Irmo, SC; Palmetto Health, Columbia, SC; Post-Acute Care Collaborative interviews and analysis. 1) Reimbursement is approximately 2.5 times greater than for regular Medicaid patients.

Palmetto Health System Lutheran Homes of South Carolina

• Struggled to place high-acuity Medicaid patients, creating a bottleneck in the inpatient setting

• Few SNFs willing or able to care for these complicated patients

• Sought SNF partner to collaborate on complex care unit

• Saw chance to work closely with primary referrer and access clinical training and support for staff

• Higher complex-care rate available for high-acuity Medicaid patients1

• Expanded abilities attractive to other referral sources

Provided Staff, Space Provided Training, Referrals High-Acuity SNF Unit

“Most of the SNFs in our market don’t want to get pushed out of their comfort zone…the hunger just isn’t there.”

Judy Baskins, VP Clinical Integration Palmetto Health System

“We have a reputation now of being able to handle a more complex patient…to step up to the plate and try something new.”

Tom Brown, President Lutheran Homes of South Carolina


A specialty line which is built effectively, and well integrated with a hospital partner, has the potential to drive volumes to such extent that the facility or unit simply cannot accommodate all referrals. If the facility is unable to capture those volumes fully, they will not see the full benefit of their investment.

Alden Estates at Skokie, part of The Alden Network, has achieved that level of success with their specialty: simple hip and knee replacement.

The Skokie facility generates significant interest among physicians and patients, because it is an attractive option clinically with a full range of amenities. Due to limited capacity and strict clinical criteria, however, the facility cannot accept all interested patients.

To ensure Alden does not lose those volumes, Alden leaders have built a plan to redirect patients unable to go to Skokie to other skilled nursing facilities in the Alden system—they have optimized that facility’s volume spillover.

Tactic #2: Harness Specialty Spillover Volumes

Getting the Most from an Attractive Specialty

Source: Alden Estates of Skokie, Skokie, IL; Post-Acute Care Collaborative interviews and analysis 1) All-cause, 30-day readmission rate.

The quality and reputation [the Skokie] facility has, it’s the equivalent of having 10 marketers on the street.

Bob Molitor, COO Alden Management Services

11 day average length of stay

Less than 1% readmission rate1

Training from local orthopedic surgeons

Physician-specific clinical protocols

Estates of Skokie’s Quality-Based Appeal

Alden Estates of Skokie, Clinical Criteria

Simple hip or knee replacement

Zero or one co-morbid conditions

Patients must have:

Minimal or no memory impairment


Alden takes a two-pronged strategy for keeping patients in-network while maintaining patient choice.

First, Alden adopts each physicians’ preferred protocols and demonstrates clinical quality at all facilities to further strengthen relationships with referring physicians. When Skokie can not admit a patient, Alden leaders encourage him to go where his physician suggests— and due to the groundwork laid, the physician typically suggests an alternative Alden facility.

Second, Alden has honed the way they interact with patients unable to be treated at Skokie in the moment. Those patients are informed that all Alden facilities use the same therapy company and offer similar amenities. In addition, if the patient asks, leaders at Skokie will offer to connect the patient directly with administrators at another Alden facility and schedule a tour for the patient. This approach is patient-led, but has resulted in keeping an average of 75% of these referrals within the Alden network.

Keeping Volumes While Safeguarding Patient Choice

Source: Alden Estates of Skokie, Skokie, IL; Post-Acute Care Collaborative interviews and analysis.

Methods to Influence and Inform Patient Choice

Gain Physician Approval

Alden leadership reacts to patients’ tendency to follow physician suggestion by: Developing MD preference for Alden facilities beyond Skokie by proving high-quality outcomes and adopting physicians’ preferred protocols throughout the Alden network

Offer Greater Convenience

Skokie facility staff assist families when another Alden facility is needed by: Connecting patients with other Alden facilities by scheduling tours at other Alden settings and connecting patients with admissions staff

Highlight Facility Similarities

Skokie facility staff react to patient desire for a facility similar to Skokie by:Providing comparisons to other Alden facilities; other Alden settings use the same therapy company, offer high-end amenities, etc.

Ongoing Efforts In-the-Moment Reponses to Individual Patients

Case in Brief: The Alden Network • 45-facility system including skilled nursing, senior living, and memory care, headquartered in Chicago,

Illinois

• Opened 28-bed Alden Estates of Skokie in 2011; specializing in short-term rehab patients recovering from simple hip or knee replacement who meet clinical requirements, including having no major memory loss and one or fewer comorbidities; equipped with high-end amenities

• Due to limited capacity and strict clinical criteria, Skokie unable to accept many of the referrals received

• Skokie staff draw parallels for patients between Skokie and other Alden facilities, and Skokie staff connect patients with admissions staff at other facilities, setting up tours and visits for the patient


To derive benefit from a specialty line’s spillover, an organization must successfully achieve four goals along two vectors.

First, the organization must obtain sufficient volumes to generate spillover. This requires both the specialty itself to be exceptionally attractive on its own, and the organization’s brand to be strong enough to maintain patients’ interest even if their preferred care site is unavailable.

Second, the organization must be correctly structured to accept any spillover that occurs. The system must have geographically proximate facilities; patients will not sacrifice convenience to stay within the system, especially when they have already been turned away from their first choice of care site. Finally, those nearby sites must have capacity to take on the additional volumes coming from the specialty.

Laying the Foundation for Spillover Benefits


Attractive Specialty

Selected specialty creates significant interest, draws patient and physician attention

Recognizable Brand

Clear organizational branding links other facilities to specialty line

Geographic Proximity

Alternate facilities as convenient for patients as their preferred location

Excess Capacity

Other facilities able to admit additional patients and accommodate greater volume

Factors Affecting Ability to Capture Overflow Volumes

Factors Determining Total Volumes Generated


While increased volumes typically unlock additional revenue, a carefully chosen specialty can also drives increased reimbursement by capitalizing on the idiosyncrasies of a provider’s payment structures.

For example, in Pennsylvania, a .01 increase in a skilled nursing facility’s case mix index (CMI) correlates with an increase of $1.38 per patient per day in reimbursement.

In an effort to leverage that payment opportunity, Susquehanna Health Skilled Nursing and Rehabilitation Center, opted to specialize in ventilator weaning. Vent weaning patients are measurably more complex than the generally skilled nursing population and an influx of that patient type increased the facility’s CMI from 1.10 to 1.18.

Tactic #3: Capitalize on Unique Payment System Opportunities

Intentionally Boosting CMI Through a Specialty

Source: Susquehanna Health Skilled Nursing and Rehabilitation Center, Muncy, PA; Post-Acute Care Collaborative interviews and analysis. 1) Case mix index..

Facility Case-Mix Index

Reimbursement Rate

A .01 increase in CMI leads to an additional $1.38 per patient per day

Effect of Facility CMI1 on Pennsylvania Medicaid Rates

Susquehanna Health Skilled Nursing and Rehabilitation Center’s Vent-Weaning Specialty Line Development

Identify Opportunity CMI driven by number of complex patients

Calculate ROI Models demonstrate likely costs are outweighed by potential revenue

Create Service Line Facility works with external vendor to offer specialty vent-weaning unit

Choose Patient Type Vent-weaning best option to raise CMI, due to prevailing market demand

Case in Brief: Susquehanna Health Skilled Nursing and Rehabilitation Center

• 138-bed skilled nursing facility, located on the campus of Muncy Valley Hospital in Muncy, Pennsylvania, part of Susquehanna Health

• Specializes in ventilator weaning

• Opened 28-bed vent weaning unit in 2011, staffed in part by external respiratory services vendor

• After opening vent weaning unit facility CMI increased from 1.10 to 1.18, leading to additional $472,000 per year in Medicaid reimbursement


As a result of a higher CMI, Susquehanna earned an additional $472,000 across a single year. They are also eligible for a $35,000 bonus payment if the facility has at least 10 ventilated Medicaid patients on each of Medicaid’s randomly chosen audit days.

Roughly two-thirds of the facility’s ventilator-weaning patients are Medicaid beneficiaries, but the ventilator weaning program’s results are not limited to Medicaid patients. Susquehanna has successfully negotiated with other payers, including Medicare Advantage and commercial insurers for higher carve-out rates for ventilator-weaning patients.

The opportunity to drive reimbursement by increasing a facility’s acuity level is not limited to Pennsylvania. The majority of states have variations on similar payment structures; each post-acute provider should uncover and understand the reimbursement opportunities available in their local market and evaluate their programs to take advantage of these payment rules.

The Proof Is in the Numbers

Source: Susquehanna Health Skilled Nursing and Rehabilitation Center, Muncy, PA; Post-Acute Care Collaborative interviews and analysis.

1) Medical Assistance; Pennsylvania Medicaid program. 2) If ventilator patients comprise at least 10% of facility’s total Medicaid

occupancy; payment based on one review day per quarter.

“This ventilator-weaning program has allowed us to have greater reimbursement for all of our Medicaid residents in the whole building.”

Anne Holladay, Administrator Susquehanna Health Skilled

Nursing and Rehabilitation Center

Representative Private Insurance per Diem Rates Additional Non-Medicaid Reimbursement

Additional yearly reimbursement resulting from .08 increase in CMI

$472K One-time incentive payment for serving 10 MA1 ventilator patients2

$35K

Additional Medicaid Reimbursement

$300

$568

LTC Ventilator


Tactic #4. Address Referrer Cost of Care Priorities

Tactic #5. Implement Staff-Driven Care Protocols

Tactic #6. Support Generalist Staff with Specialist Experts

Strengthen the Specialty’s Value-Based Appeal

Chapter 2


Driving volumes and census is a primary consideration for a post-acute provider’s financial viability. However, as the health care market transitions away from fee-for-service and toward value-based reimbursement, post-acute providers must ensure their selected specialties are attractive to referrers taking on risk.

In the context of value-based care, value is generally comprised of three elements: cost of care, quality of care, and cross-continuum patient management. A strong specialty can and should drive all three.

Three Major Considerations on Referrers’ Minds


Quality of Care

Cross-Continuum Patient Management

Cost of Care Tactic #4: Address Referrer

Cost of Care Priorities

Tactic #5: Implement Staff-Driven Care Protocols

Tactic #6: Support Generalist Staff with Specialist Experts

The ideal specialty will address all three concerns, securing a place in narrowing networks.


A primary consideration for referrers and payers taking on risk is cost. The elements comprising cost in the new market environment go far beyond the traditional costs post-acute providers have managed and monitored.

Traditionally, a low-cost provider was one with low day-to-day operational expenses. While operational expenses are still critical, referrers taking on risk consider cost to be a far broader metric, encompassing the total cost of caring for a patient across an episode. As such, cost includes readmissions, avoidable downstream utilization, and other challenges associated with inefficient patient management during the post-acute stay and beyond.

In order to be a valuable partner, PAC providers must demonstrate to referrers that they can deliver cost-efficient care across a patient’s entire episode.

Cost of Care

Considering Total Cost of Care, Not Just Day-to-Day Expenses

Source: Post-Acute Care Collaborative interviews and analysis. 1) Hours per patient day.

Traditional Post-Acute Provider Cost Considerations

Cost Considerations for Providers Carrying Longitudinal Risk

• Supply costs

• Nursing HPPD1

• Therapy costs

• Operational expenses

• In-sector efficiency

• Readmissions

• Avoidable utilization of health care services

• Level of downstream support needed post-discharge

• Acute and post-acute care lengths of stay


However, demonstrating their status as a low-cost provider is challenging for high-acuity, therapy-intensive providers such as LTACHs, IRFs, and select SNFs. Many referrers evaluate a patient episode on a 30-, 60-, or 90-day time frame post-hospital discharge. Viewed narrowly, high-intensity providers are quite costly during that time period. Yet, in many cases, the interventions provided can reduce costs in the long term, via functional gains and reductions in supportive care. However, those benefits are not easily seen within the episodic window, rendering an uphill battle for those providers to prove value.

All providers must position themselves to effectively address their referrers’ cost of care priorities. High-intensity providers may find their ideal strategy is to frame their appeal to referrers whose focus is on a longer episode.

Workers’ compensation is one such referrer. Because workers’ compensation carriers are responsible for a patient’s care until the patient returns to work, they are likely to support more expensive care upfront to achieve proven cost reductions in the long term.

Tactic #4: Address Referrer Cost of Care Priorities

Longer View Reveals Full Financial Benefit

Workers’ Compensation Understands Long-Term Cost Management


Workers’ Compensation in Brief

• Category of payers contracted by employers to cover health care costs and other compensation for employees injured on the job

• Generally responsible for all health care costs until the patient is fully recovered and returns to work

• As a result, workers’ compensation carriers may be willing to pay higher sums initially in exchange for improved long-term return to function

• Coverage is required in select states and optional in others

Functional Benefits

Cost

30 Days

Long-Term Value of Intensive Post-Acute Services

Workers’ Comp payers see that long-term benefits outweigh higher initial cost


Craig Hospital, an LTACH, has successfully built a strong relationship with workers’ compensation carriers. Craig’s chosen specialties are traumatic brain injury and spinal cord injury, both injury types common among workers’ compensation cases.

Selecting a specialty that matches the needs of workers’ compensation carriers was the first step in building a relationship with those carriers. The second step was to appeal to the carriers’ cost of care priorities: reduce patients’ long-term medical costs and return them to work as quickly as possible.

Craig Hospital’s outcomes demonstrate to workers’ compensation carriers that they are able to return patients to function more completely than their competitors, setting the carriers up for reduced long-term supportive costs despite a higher up-front investment.

Appealing to Workers’ Compensation

Source: Craig Hospital, Denver, CO; Post-Acute Care Collaborative interviews and analysis.1) National Institute on Disability and Rehabilitation Research, 2009-2013 discharges. 2) UDS-PRO, 2013.

Primary Priorities of Workers’ Compensation Carriers

Ways in Which Craig Hospital Meets Workers’ Compensation Needs

Specializes exclusively in traumatic brain injury (TBI) and spinal cord injury

Percentage of patients with TBI who return to work or school one year post-discharge1

59%

Percentage of patients with complete paraplegia discharged directly home1

95%

Average gain in FIM scores at discharge for patients with TBI2

42 points

Proven Ability to Deliver Functional Gains

Achieve recovery from common workplace injuries

1

Return patients to complete function 2

Minimize need for long-term medical support 3

“When someone gets hurt on the work site, that employer or that insurance carrier has the responsibility for a lifetime of care. Like us, their primary focus is on long-term functional outcomes, not short-term costs.”

Mike Fordyce CEO, Craig Hospital

Case in Brief: Craig Hospital

• 93-bed not-for-profit Magnet-Recognition® rehabilitation and research hospital located in Denver, Colorado, licensed as a general hospital and an LTACH

• Exclusively specializes in two diagnoses: spinal cord injury and traumatic brain injury; patients’ ages range from 15 to 65, with the average age being 38

• Strong relationships with workers’ compensation carriers; serves carriers by providing high-quality rehabilitation to their injured workers, education for staff, outcomes reports, collaboration, inclusion in patient team conferences


To ensure a mutually beneficial partnership, Craig Hospital has established an ongoing process for open communication with workers’ compensation carriers. The carriers are encouraged to attend care conferences and other ad-hoc meetings with workers’ compensation patients, but Craig also invites representatives to tour the facility and attend regular education sessions held by Craig leaders. They also share outcomes data frequently with their workers’ compensation partners, specifically tailored to the metrics most relevant to the carriers, such as long-term attendant care costs and return to work percentages.

These efforts have helped Craig to build a national referral base with more than 50% of Craig Hospital’s patients coming from outside of Colorado, and 16%-18% referred by workers’ compensation carriers.

Building an Ongoing Relationship

Source: Craig Hospital, Denver, CO; Post-Acute Care Collaborative interviews and analysis.

Modes of Communication Relevant Metrics to Share

Amount of necessary attendant care post-discharge

Percentage of patients discharged directly to home

Patient satisfaction scores

Percentage of patients who return to work or school

Patient/Family Care Conferences

In-Service Education

Facility Tours

Frequent Outcomes Reports

16%-18% 16%-18% of referrals to Craig Hospital now come from workers’ comp carriers

Results of Craig Hospital’s Workers’ Compensation Outreach


Not all providers will find that workers’ compensation carriers are the right partners for them; their cost of care priorities may not be well aligned. Regardless of the referral source, post-acute providers should take the broader lesson to heart: incorporate referrers’ specific cost priorities in the specialty selection process, and communicate in the referrer’s preferred cost-based terms.

A good specialty can be described by the way it impacts costs even beyond the organization’s setting, and therefore drives value for the referrer.

The graphic shown here provides a thought exercise to help post-acute providers consider the value of their individual specialty lines when thinking beyond in-setting care. The Post-Acute Care Collaborative encourages all providers to evaluate their own contributions to lowering total cost of care and use those contributions in partnership conversations with referrers who are taking on risk.

Framing Post-Acute Specialties in Terms of Cost

Translating Your Impact into Terms Payers, Referrers Understand


1) Average acute setting length of stay before post-acute facility can safely admit the patient.

2) Length of stay.

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

Percentage discharged to home


Demonstrating high quality of care is a priority in a value-based care system. In addition to delivering on their commitment to patients, post-acute providers must meet a growing array of outcome and performance measures scrutinized by referral sources.

Many post-acute providers, however, focus more acutely on scorecarding and communicating outcomes to referrers than they do on driving superior outcomes. This is a critical strategic error. To attract value-based referrers, the undeniable first step is to elevate clinical standards and implement processes that generate stellar outcomes.

One of the reasons specialization can drive quality is the repetitive nature of a specialized program, which allows staff practice and time to gain expertise with a specific patient type.

Offering one specialty exclusively is obviously one way to achieve that level of repetition. However, exclusive specialization is not necessarily an optimal strategy for all post-acute providers.

Organizations offering more than one specialty must take a more targeted approach to ensure clinical quality.

Quality of Care

Work to Drive Quality Should Precede Scorecards

1) Wound, ostomy, and continence nurse. 2) Certified rehabilitation registered nurse.

Three Components to Quality Messaging

Specialization Can Be a Boon to Quality

Pressure ulcer improvement in home health agencies with a WOCN1, as compared to agencies without

200%

Average IRF length of stay reduction for each 1% increase in CRRNs2

6%

Studies demonstrating specialist surgeons achieve better clinical outcomes than generalist surgeons

91%

Document Outcomes 2

Generate Outcomes 1

Market Outcomes 3

Traditional, limited focus of post-acute providers

Essential first step to generate referrer interest

Source: Westra B, et al., “Effectiveness of Wound, Ostomy, and Continence Nurses on Agency-Level Wound and Incontinence Outcomes in Home Care,” Journal of Wound, Ostomy and Continence Nursing, 2013, 40(1): 25-33; Nelson A, et al., “Nurse Staffing and Patient Outcomes in Inpatient Rehabilitation Settings,” Rehabilitation Nursing, Sep.-Oct. 2007, 32(5): 179-202; Chowdhury MM, et al., “A Systematic Review of the Impact of Volume of Surgery and Specialization on Patient Outcome,” British Journal of Surgery, Feb. 2007, 94(2): 145-61; Post-Acute Care Collaborative interviews and analysis.


Implementing care protocols, or care pathways, is foundational to improving clinical quality. Good protocols reflect evidence-based guidelines for care delivery, standardizing elements of care to ensure consistent outcomes. They also support staff in delivering excellent specialty care.

Many organizations make one critical mistake when designing and implementing protocols: they fail to obtain staff buy-in. Seeking staff input not only improves staff use of and compliance with the protocols, but also can improve the protocols themselves, based on staff members’ extensive on-the-ground knowledge.

Leaders at Sheltering Arms, an IRF, listened to therapist feedback that their protocols were overly focused on diagnosis. The leaders revised the protocols to target physical impairments common across their patient population instead, building the iWalk and iReach clinical programs specializing in patients with gait and upper limb mobility, respectively. Together, the protocols and associated programs have achieved strong functional gains and driven physician referrals to Sheltering Arms.

Tactic #5: Implement Staff-Driven Care Protocols

Staff Involvement Key to Successful Adoption

Source: Sheltering Arms Physical Rehabilitation Hospital, Richmond, VA; Post-Acute Care Collaborative interviews and analysis. 1) Controlled for age, length of stay.

Leaders at Sheltering Arms decided to specialize in stroke and brain injury care and developed care protocols

Therapists challenged by the clinical protocols; diagnosis-based guidelines were difficult to absorb into therapy practice

Leaders sought feedback from therapists and opted to shift to impairment-based protocols

iWalk, iReach, and iConnect programs fully implemented; outcomes data informs ongoing revisions

“Therapists don’t treat a diagnosis. They treat a functional impairment. iWalk and iReach work for a wide variety of patients because the disease might be different, but the impairment is the same.”

Jim Sok, CEO Sheltering Arms

Evolution of Sheltering Arms’ iWalk and iReach Protocols

Clinical leaders developed new guidelines with therapists’ input

Achieving Functional Gains

Additional FIM improvement for iWalk patients as compared to regional average1 20% Average additional improvement in iWalk patients’ in six minute walking distance, in feet, with clinical practice guidelines1

425

Case in Brief: Sheltering Arms Physical Rehabilitation Hospital • Rehabilitation system including two IRFs, several outpatient therapy locations, multiple physician clinics,

community-based transitional programs, and a home health agency, headquartered in Richmond, Virginia

• Specializes in gait and upper arm mobility; programs designated iWalk and iReach, respectively

• Restructured specialties to target functional impairment rather than diagnosis at therapists’ request

• Working with a local acute care hospital to expand iWalk and iReach protocols into the acute care setting


As referrers become increasingly accountable for care delivered beyond their setting, they are identifying post-acute partners who can impact results beyond their setting.

Comprehensive, cross-setting care is the motivation behind Sheltering Arms’ future evolution of the iWalk and iReach programs. While the protocols are currently used in Sheltering Arms’ inpatient and outpatient rehab services, leaders plan to implement the protocols in the acute care setting by partnering with their referral sources to establish a single, cohesive cross-continuum care plan for patients with gait and upper limb mobility impairments.

The ultimate goal is to utilize the protocols consistently across a patient’s full episode so that Sheltering Arms can capture reliable data on patients’ assessment at admission and functional outcomes at discharge. This comprehensive data set will enable Sheltering Arms to predict a patient’s likely length of stay, cost of care, and functional outcome at the point of acute care admission.

Cross-Continuum Patient Management

Protocol Benefits Not Limited to Source Setting

Source: Sheltering Arms Physical Rehabilitation Hospital, Richmond, VA; Post-Acute Care Collaborative interviews and analysis.

• Protocols as standardized as possible across all settings, while maintaining sector specificity

Present State

Inpatient and Outpatient Rehab

Acute Care Partners

• Protocols developed in IRF and used to treat Sheltering Arms patients

• Protocols developed in IRF but customized for hospital partners with physician and hospital input

Planned Future Uses of Sheltering Arms’ Specialty Care Protocols

Predictive Modeling

• Patients begin to receive specialized gait and upper limb mobility care immediately upon injury

• Leaders can predict patient LOS, cost, and ultimate functional outcomes on acute care admission via an algorithm based on prior cases

• Patient care is customized based on knowing patients’ likely clinical and functional outcomes

Future State


Care protocols set a foundation for high-quality care delivery but are not a substitute for clinical experience and expertise.

Specialty expertise can be especially challenging for home health providers, who are typically generalists out of necessity. Home health nurses typically manage geographic areas and must be prepared to care for all patient types nearby. This type of assignment improves efficiency by minimizing nurse travel time, but reduces nurses’ ability to deliver specialty care once a patient returns home.

MedStar Visiting Nurse Association, a home health provider associated with the MedStar health system, has solved this challenge by assigning each nurse manager to a clinical specialty area.

At MedStar, home health nurses themselves are still assigned to patients geographically, but they are matched with a different manager based on each patient’s clinical presentation. This allows the nurses easy access to a specialist in the patient’s primary condition, delivering specialty care without being specialists themselves.

Tactic #6: Support Generalist Staff with Specialist Experts

Achieving Generalist Efficiency with Specialist Quality

MedStar VNA Restructures Clinical Support System

Source: MedStar Visiting Nurse Association, Columbia, MD; Post-Acute Care Collaborative interviews and analysis.

Nurse B’s Service Area

Nurse A’s Service Area

Nurse C’s Service Area

Clinical Manager Assignments

Oversees CHF care

Oversees diabetes care

Oversees IV infusions

Case in Brief: MedStar Visiting Nurse Association • Home Health agency serving parts of Maryland, Virginia, and Washington, DC; part of MedStar Health

• Functions largely as a generalist provider. Services include at-home infusion, diabetes care, and orthopedic rehabilitation; staff nurses are generalists, expected to care for any patient in their assigned geographic area

• In order to ensure true specialty-level care, MedStar leaders shifted reporting structures in 2014 to assign nurse managers by diagnosis rather than geography


Two primary components ensure MedStar’s manager assignment structure results in excellent specialty care.

First, managers must be true specialty experts. They are assigned to specialties based on previous experience, certifications, and skills, making certain they can coach home health nurses through the complex challenges unique to the patient type.

Second, nurses must have real-time access to their assigned managers. At MedStar, the correct manager is assigned by the system’s EMR based on each patient’s most acute or circumstantially relevant condition. The assigned manager’s contact information is auto-populated, and the manager can view the nurse’s documentation in real time. All nurses carry work-issued secure cell phones to create a direct link to the manager, enabling the nurse to call the manager with any questions and even send photos as needed.

These connections ensure specialty care is seamlessly delivered across the entirety of the health system. Strengthening the relationship between the hospital system and VNA.

True Specialty Experts, Always on Call

Source: MedStar Visiting Nurse Association, Columbia, MD; Post-Acute Care Collaborative interviews and analysis. 1) Wound, ostomy, continence nurse.

Easy-to-Access Support Experience-Based Manager Assignment

Manager’s Background

Specialty Assignment

Certified WOCN1 Wound care/diabetes

Direct EMR Connection

On-Demand Phone Support

• Patients assigned to disease category and associated manager in the EMR

• Manager has real-time visibility into nurse’s documentation

• If any trouble spots seen in EMR, manager contacts nurse directly

Former inpatient neurology RN Stroke

Skilled at IV care IV team

• Patients with comorbidities assigned based on most acute or pertinent condition.

• If patient’s condition changes, manager assignment can be altered at any time.

S

• Nurses can securely send photos of wounds to managers as needed

• Nurses provided email-capable mobile phone for their workday

• Appropriate manager’s phone number auto populates in the EMR for questions


Tactic #7. Recapture Lost Volumes by Expansion into New Sectors

Tactic #8. Fill Downstream Service Gaps

Tactic #9. Productize Specialty Knowledge

Tactic #10. Realign Traditional Competencies into Novel Programs

Leverage Existing Specialty Expertise to Access New Revenue Streams

Chapter 3


The benefits of specialization can extend beyond volume generation and partnerships within the traditional bounds of an acute/post-acute relationship. A strong specialty can also open the door to new business opportunities.

These opportunities take a variety of forms and allow post-acute providers to access revenue streams they could not previously. A well operated specialty line can transition into a new care setting or adapt to reach new patient types. If providers are sufficiently flexible, they can even establish different-in-kind specialties to access funding beyond the guideposts of their traditional reimbursement structures.

Specialties as a Springboard to New Opportunities


Avenues to Reach Untapped Revenues by Elevating a Specialty

Existing Specialty Revenues Reimbursement for traditional setting, patient type, and business lines

New Specialty-Related Revenue Opportunities New revenues captured by using specialty expertise to reach new setting, patients, or business line

Expansion of Revenue Sources, Based on Specialty Care

New Care Setting

• Extend specialty into novel setting or sector

• Capture revenue not available in traditional sector

New Patient Types

• Serve new patient population via existing specialty

• Expand patient base, attract higher-margin groups

New Business Lines

• Offer new product based on specialty knowledge

• Move beyond traditional funding sources


Once a provider develops a successful specialty program, a logical next step is to extend that program to their other locations or care settings.

Armfeldt Rehabilitation1 successfully moved their specialty—rehabilitation following orthopedic surgery—from an IRF to a sub-acute unit to access their traditional patients in a new setting.

Armfeldt had developed significant specialty expertise in treating post-operative orthopedic patients, but changes in medical necessity requirements shifted such patients away from the IRF setting. In an effort to avoid losing that core patient group, as well as their institutional knowledge, Armfeldt partnered with a local hospital to operate a sub-acute unit specifically for post-operative joint replacement patients. The unit represents a joint venture between Armfeldt and the hospital in which it is located, but accepts patients from all local hospitals. Currently, 60% of the referrals to the unit come from other hospitals.

Tactic #7: Recapture Lost Volumes by Expansion into New Sectors

Following Traditional Patients to a New Setting

Source: Post-Acute Care Collaborative interviews and analysis. 1) Pseudonym.

Development of Sub-Acute Unit to Serve Specialty Population

• Armfeldt Rehabilitation1 developed specialty line for simple joint replacement patients

• Invested considerable resources in training, protocol development, etc.

• Generated high-quality outcomes, saw strong volumes for specialty

• Change in medical necessity definition restricts volumes for simple orthopedic patients

• Most joint replacement patients sent to lower-acuity, non-specialty providers

• Armfeldt’s specialty expertise no longer useful in traditional setting

Strategic Response: Orthopedic Sub-Acute Unit

Treats post-op joint replacement patients

Occupies dedicated unit with 35 beds

Receives 60% of referrals from outside partner hospital’s system

Specialty Expertise Market Pressure

Joint venture between Armfeldt and local hospital

Case in Brief: Armfeldt Rehabilitation

• IRF, headquartered in the Northeast

• Specializes in pediatrics, spinal cord injury, brain injury, stroke, and orthopedics

• Developed strong specialty programming to provide post-operative rehab therapy to single joint replacement patients; however, definition of medical necessity for IRF care changed, limiting number of single joint replacement patients Armfeldt could accept

• Collaborated on a joint venture with local hospital to create inpatient sub-acute rehabilitation unit focusing on unilateral joint replacement surgery patients


When transitioning a specialty to a new care setting it is imperative to ensure the strength of the specialty is not diluted. While care processes must adjust to meet the needs of the new setting, the same dedication to high-level specialty care must remain consistent.

To do so, Armfeldt maintained the same level of care for the patients in the sub-acute unit that they had offered in their IRF, including delivering frequent, intense therapy not commonly offered in a sub-acute setting and following the same clinical pathways they had initially designed for IRF patients. Patients ambulate early and often, resulting in faster and more complete recovery than at similar sub-acute offerings.

The sub-acute unit breaks even financially, but provides benefits by generating consumer interest in downstream Armfeldt services, such as home health or outpatient rehab. Simultaneously, the program strengthens referring relationships with orthopedists, while enabling Armfeldt to continue to serve simple orthopedic patients.

New Setting, Same Approach to Treatment

Maintaining a Tried and True Clinical Process


Care at Orthopedic Sub-Acute Unit

Specialty Experience Yields Strong Outcomes in New Setting

Average length of stay, in days

8.4 All-cause 30-day readmission rate

5.6% Rate of discharge back to the community

96%

“When you have a homogeneous patient group and staff all trained in the same way, you’re really able to be efficient.”

Medical Director, Sub-Acute Unit

Patients ambulate first day post-op

Evidence-based clinical protocols

Staff trained at Armfeldt main campus

No relaxation in commitment to program quality

At least 2 hours of therapy daily


In select cases, the opportunity to extend a specialty is not limited to a new sector or care setting, but also includes an opportunity to reach new patient types.

Transitional Learning Center (TLC) is a rehabilitation provider specializing exclusively in traumatic brain injury. Upon initial assessment, patients are segmented into one of four care pathways: two aimed at return to the community and the other two intended to help more severely injured patients achieve basic physical skills.

Following discharge, the more severely injured patients frequently sought additional support from TLC, as they were unable to find specialized long-term care. TLC, however, offered only short-term rehabilitation—failing to meet some patient needs and capitalize on an opportunity for programmatic growth.

Tactic #8: Fill Downstream Service Gaps

Identifying a Downstream Opportunity

TLC1 Responds to Patients’ Needs for Long-Term Support

Source: Transitional Learning Center, Lubbock, TX; Post-Acute Care Collaborative interviews and analysis.1) Transitional Learning Center. 2) Average Length of Stay.

Patient Pathways at TLC Typical Discharge Destination

Return to Work

Neurorehabilitation LTC Facility, Group Home

Community, LTC Facility, Group Home

Community

Community

Opportunity to serve specialty population at new acuity level

High level of function, potential to live independently, ALOS of 4 months

Return to School High level of function, potential to live independently, ALOS of 4 months

Functional Independence Intermediate level of function, potential to live in supervised environment, ALOS of 7 months

Low level of function, no potential to live independently, ALOS2 of 7 months

Case in Brief: Transitional Learning Center • 3-facility system including inpatient rehabilitation and assisted living, headquartered in Lubbock, Texas

• Specializes exclusively in Traumatic Brain Injury (TBI)

• Realized higher-acuity patients in facilities providing intensive inpatient rehabilitation were either discharged to the community but readmitted for additional care due to lacking community supports, or were discharged directly to LTC facilities

• Identified TBI patient population’s need for long-term care, saw this demand as a business opportunity and opted to build a third facility offering long-term assisted living, not short-term rehabilitation


Following a due diligence process, TLC expanded their specialty into a new care type: assisted living. They opened the Tideway facility specifically for the patients who, even after rehabilitation, would never live independently again.

In addition to moving into the long-term care space, Tideway allowed TLC to access patients they previously would not have seen—patients with traumatic brain injuries dependent on support for ADLs, but who were not in need of intensive rehabilitation. Although many of Tideway’s residents previously received rehabilitation services from TLC, Tideway also receives residents from other rehabilitation facilities.

TLC maintained not just their specialized staffing but also their community-focused care model at Tideway. While residents at Tideway are expected to live out the remainder of their lives within the facility, TLC provides many opportunities for residents to participate as fully as possible with activities in the community.

Expanding Beyond Short-Term Rehab

Source: Transitional Learning Center, Lubbock, TX; Post-Acute Care Collaborative interviews and analysis. 1) Activities of Daily Living. 2) Instrumental Activities of Daily Living.

Tideway Assisted Living Facility

Many, but not all, residents previously received rehab therapy at main TLC facilities

Primary resident needs require long-term support, not rehabilitation

Residents must have TBI, require assistance with ADLs1, IADLs2

IMAG

E C

RE

DIT

: TR

ANS

ITIO

NAL

LE

ARN

ING

CE

NTE

R.

Profile of Tideway’s Target Patient Population

Case in Brief: Transitional Learning Center’s Tideway Facility • 12-bed Tideway facility, located in Galveston, was constructed in 1998; has now grown to 32 beds

• Requirements for admission to Tideway similar to those for admission at other TLC facilities, but those at Tideway have also reached the maximum potential benefits from rehabilitation and are unable to live independently

• Tideway facility allows TLC to care for patients within their specialty diagnosis but at a new level of acuity

• Texas law allows TLC’s two original facilities, both ALFs, to receive reimbursement for short-term, inpatient TBI rehabilitation despite their licensure


Extending a specialty to access new patients or new care settings can effectively achieve program growth. Another less common approach to growth is to think beyond care delivery and productize hard-earned specialty knowledge.

Leaders at Oncology Care Home Health had developed extensive training materials and clinical guidelines for staff over 16 years of specialized clinical practice.

Recognizing the value of their intellectual property, they began offering training modules, clinical protocols, operational guidance, and marketing strategy (along with as-needed consulting services) to other home health providers wishing to develop a specialty oncology line.

Tactic #9: Productize Specialty Expertise

A New Use for Specialty Training Materials

Oncology Care Home Health Brings Internal Training Modules to Market

Source: Oncology Care Home Health, Wilmington, DE; Post-Acute Care Collaborative interviews and analysis.

Oncology Care Training Collateral

Parenteral Opiate Therapy

Purpose: To ensure safe administration of parenteral opiates administered in the home General Information: 1. Parenteral opiates can be administrated

either intravenously or subcutaneously

2. A subcutaneous site for opiate delivery must be changed every 3 to 7 days; a subcutaneous site is best maintained when the hourly volume of the opiate infused does not exceed 2 mL/hour

Operational Support System

Experienced Clinicians Specialized nurses and physicians with significant experience in the field available for consultation

Unlimited Duration Extensive support provided during implementation with continued resources available on an ongoing basis as needed

Accessible by Phone Majority of communication is telephonic; one-off calls and standing phone appointments

Case in Brief: Oncology Care Home Health • Consulting and educational materials provider to home health agencies looking to add an oncology

specialty line; headquartered in Wilmington, DE

• Originally founded by a home health nurse with an oncology background as a home health agency exclusively specializing in at-home oncology care

• Oncology Care Home Health staff are entirely focused on oncology—including the phone receptionists and aides—which better equips them to understand the needs of cancer patients


The product offered by Oncology Home Health meets a traditional delivery system need. However, understanding specialty lines in terms of non-traditional collections of services is a newer idea and a strength of companies such as Walgreens, who have been successful assembling sets of otherwise unconnected services into products aimed at meeting a specific market need.

Walgreens’ WellTransitionsTM program is a set of services, such as medication reconciliation and follow-up phone calls, bundled together and marketed to health systems as a way to manage high-risk patients and reduce rehospitalizations and avoidable utilization. Response to the program has been strong so far.

Post-acute providers have a similar opportunity to bundle their existing tasks into new service lines, and in doing so access new patients and revenue streams.

That is the root of the final tactic of this book: understanding the value of the individual tasks an organization offers, and then realigning them into service lines that not only allow access to new patients, but also new reimbursement opportunities beyond the constraints of the post-acute sectors.

Recognizing the Potential of Targeted Services

“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.

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


Visiting Nurse Association of Ohio assembled their existing competencies to build a transitional coaching program for all high-risk patients, regardless of their eligibility for Medicare’s home health benefit, funded through partnership with a local ACO. This enables Visiting Nurse Association of Ohio to build new relationships and access an entirely new revenue stream.

The program provides support for patients transitioning from the hospital to home or from home health to routine care. It offers two in-person visits and six phone calls over the 60-day period following discharge.

Many patients enrolled in the program do not qualify for home health coverage under Medicare because they are not homebound. However, they are high-risk, and without dedicated support at home, they are at risk for a readmission. As such, when presented with the planned transitional coaching program, an ACO agreed to pay a $250 case rate for these services for the top 10% of their most expensive Medicare beneficiaries.

A New Model for Transitional Care

Source: Visiting Nurse Association of Ohio, Cleveland, OH; Post-Acute Care Collaborative interviews and analysis.

Designed for High-Risk Patients

• Serves 10% most costly Medicare patients

• Program created to reduce expensive hospital readmissions

Transition: Hospital to Home Health

Transition: Home Health to Living Independently

Visiting Nurse Association of Ohio’s Transitional Coaching Program

Based on Intensive Patient Interaction

• Nurses visit within 24 hours of discharge

• Nurses make two visits and six phone calls during first 60 days post-discharge

Reimbursed Directly by ACO

• ACO pays case rate of $250 for these services

• Many patients not eligible for Medicare coverage of home health services

Case in Brief: Visiting Nurse Association of Ohio • Home health provider, headquartered in Cleveland, Ohio

• Specializes in readmission reduction and behavioral health

• Saw demand in the market for a readmissions reduction solution and recognized that many of their core competencies could directly impact a patient’s likelihood of readmission

• Combined relevant tasks into a new transitional care service line, overlaying additional protocols and providing additional training for staff; resulting service line does not include many aspects of traditional home health care such as medical support or nursing care


The opportunity to assemble existing tasks into a new service line and use the resulting program to access new revenue streams is not limited to home health. FirstLight Home Care, a non-medical home care provider, took a similar path when developing their Readmissions Rescue program. The services FirstLight brought together, while not medical in nature, have a significant and proven impact on readmissions.

Understanding the impact of social determinants on health outcomes, local ACOs have funded the Readmission Rescue program for their Medicare patient populations—expanding FirstLight’s client base. Previously, FirstLight, as a non-medical provider, only served private pay clients.

Both Visiting Nurse Association of Ohio and FirstLight successfully leveraged a different-in-kind specialty type to access entirely new patient pools and revenue streams.

The flexibility demonstrated by these programs is increasingly important as referrers and payers experiment with care management program design and funding.

Impacting Clinical Outcomes with Non-Medical Care

FirstLight Develops “Readmissions Rescue” Program

Source: FirstLight Home Care, Cincinnati, OH; Post-Acute Care Collaborative interviews and analysis.

Potential of Non-Medical Home Care

Additional Investments to Create Separate Service Line

Targeted Protocols

Developed internally, guided by on-staff RN, to reduce readmissions

Dedicated Staffing

RN leads program nationwide with specialty care managers present at each branch

Technology Acquisition

Upgraded data systems for greater compatibility with hospitals and easier access for MDs

Factor Affecting Readmission

Non-Medical Home Care Interventions

Self-Care Capability

Follow-Up Appointment

Home Environment

Offer patient education, assist with medication administration and lead exercise regimen

Schedule follow-up appointments with physician and provide safe, timely transportation

Monitor vital signs remotely and offer personal emergency response system

Case in Brief: FirstLight Home Care • Non-medical home care provider, headquartered in Cincinnati, Ohio

• Specializes in readmission reduction

• Realized that although many of their traditional services reduce risk for readmissions, health systems did not consider non-medical home care a viable option in readmission reduction strategies

• Decided to highlight existing competencies via targeted service line with sole aim of preventing readmission for high-risk patients; created Readmission Rescue program in 2013


Both Visiting Nurse Association of Ohio and FirstLight have seen positive clinical results from their unique programs and focused their impact on readmission rates.

In order to be successful with a new service line built from traditional competencies, it is critical that the new line maintains the same level of dedication and focus as any other specialty, and continues to meet the hallmarks of a specialty seen on page 9 of this book.

Uncommon Offerings, Impressive Results

Source: Visiting Nurse Association of Ohio, Cleveland, OH; FirstLight Home Care, Cincinnati, OH; Post-Acute Care Collaborative interviews and analysis. 1) Emergency Department.

VNA Ohio Transitional Coaching FirstLight Readmission Rescue

Readmission Rate 30-Day, All-Cause

2%

Appeal to Physicians “Physicians are making referrals like crazy because they didn’t know these services were an option before.”

Dana Traxler, Regional Executive Director Visiting Nurse Association of Ohio

Building Volumes

Patients currently enrolled in Readmission Rescue

1,000

ED1 Visits Readmission Rate 30-Day, All-Cause

55% Reduction

58% Reduction

For More Information To learn more about how to access new revenue streams by building a specialty service line from an organization's existing skills, access the Post-Acute Care Collaborative’s workbook, “Leveraging Traditional Competencies to Meet New Market Needs,” available on advisory.com.


As the industry evolves to incentivize long-term population health, newer specialties focused on patient management continue to emerge. In addition, patients are becoming more complex, and specialties must maintain the clinical strength of a narrow focus, while providing care for a whole person, rather than just a specific diagnosis or impairment.

Post-acute providers who do not recognize this change will fail to achieve the initial partnership and growth goals that drove their desire for specialty program development.

Concurrently, new incentives provide opportunities for post-acute providers to offer services they would not have previously offered for financial reasons.

While the specific types of specialty offerings evolve, the importance of strong clinical programs remains critical for future growth amid industry change. Organizations must recognize these shifts, and ensure their specialties keep pace.

Taking a Broader View of Population Health


Shared Goals for Patient Management Across All Sites of Care

Integrate Care Plan High-Risk

Patients Top 5%

Rising-Risk Patients 15%-35%

Low-Risk Patients 60%-80%

Improve Outcomes

Teach Patients New Skills

Optimize Utilization Patterns

Coordinate Across Team Members

Improve Self-Management

Those with complex disease(s), comorbidities

Those whose conditions may not be under control

Those with minor, easily managed conditions

Sample Next-Generation Specialty Areas

Preventing Deterioration Following an Episode of Care

Maintaining Wellness Among Healthy Seniors

Improving Patient Self-Management of Chronic Conditions

Caring for Exceedingly Costly, High-Need Patients

achieving return on specialty investment

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