defining and driving value: provider and payer perspectives · patient-family centered care...
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Defining and Driving Value: Provider and Payer Perspectives
NAHC Financial Managers MeetingJune 2013
Serving theMidcoast of
M iMainein
KnoxWaldo
Li lLincolnCounties
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Who we are...
• Medicare Certified & State of Maine Licensed (Medicaid) Home Health Provider
• Medicare Certified & State of Maine Licensed (Medicaid) Hospice Provider
• State of Maine Licensed Private Duty Provider
Characteristics That Make Homecare Indispensible 1. Decades Old Traditional Characteristics
– Care delivery is comprehensive and multi-disciplinary
– Care is available twenty-fours each day
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Characteristics That Make Homecare Indispensible 2. Care in the home that reinforces, in an
i t f ili t th ti tenvironment familiar to the patient, teaching that began in the physician’s office or hospital which enhances the patient’s ability to embrace learning.
Characteristics That Make Homecare Indispensible 3. The integration of community health
i i lprinciples– A focus on health promotion and teaching on
environmental, psychosocial, economic, cultural, and personal health factors affecting individual and family health status.
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Characteristics That Make Homecare Indispensible 4. In-home assessments that provide a
h li ti i f ti t th i bilitiholistic view of patients, their capabilities, and the in-home support available for the patient to succeed.
Characteristics That Make Homecare Indispensible 5. Medication reconciliation which goes
h d i h d ith t hi dhand-in-hand with teaching and management in the home setting.
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Characteristics That Make Homecare Indispensible
6. A focus on the improvement of the ti t’ f ti l t tpatient’s functional status.
– Emphasizing fall prevention, aides in the restoration of independence, and greatly reduces emergency department visits and hospitalizations.
Characteristics That Make Homecare Indispensible 7. Agencies began stratifying the risk of re-
h it li ti d t hi ti thospitalization and teaching patients about “red flags” in December 2005 as part of the National Eight Scope of Work of the Quality Improvement Organizations.
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Characteristics That Make Homecare Indispensible 8. Agencies have reduced re-
h it li ti b d i i k th hhospitalizations by reducing risk through telemonitoring.– Re-admission rate for heart failure patients is
considerably lower than that of an agency’s general patient population.
Characteristics That Make Homecare Indispensible 9. Standardized practices and tools across
th ti fthe continuum of care.
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Characteristics That Make Homecare Indispensible
P lli ti C10. Nationally certified Staff• OASIS• Home Health Coding • Wound, Ostomy and
Continence Care • Diabetes Education
• Palliative Care• Hospice• Cardiovascular • Geriatric• Psychiatric
• Pediatrics• Lymphedema
Psychiatric • Infusion • Vestibular Rehabilitation
• Chronic Care Management
Characteristics That Make Homecare Indispensible 11. Agencies have been using an electronic
ti t d f d dpatient record for over a decade.
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Home care Competencies
• Community Health and Wellness –P l ti H lthPopulation Health
• Assessment beyond physical to social, emotional, and environmental
• Reinforcement of physician/hospital teachingteaching
• Hidden medications – vitamins, herbs, remedies influenced by financial, psycho-social, culture or religion
Core Competencies
• Patient and home assessments– Including ADLs and IADLs
• Rehabilitation– Fall Prevention
• Medication reconciliation and teachingCh i t• Chronic care management– Patient teaching – Patient self-management
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Transition Transition YearsYears
Mastering the Future
Medicare movement from a passive payer f l i t d t h fof claims to a prudent purchaser of
healthcare services.• Home Health Prospective Payment
– Episodic Care• OASIS• Home Health Compare• HHCAHPS• Value Based Purchasing
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Tracking and Trending
• Homecare Compare• Patient Experience• QAPI• Financial• Operational
– Percent of hospital discharges with a homecare referral
– Referral conversion rate
The importance of measuring
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Home Health Compare
• Overall rating of care given by HHA providerWilli t d th HHA t f i d• Willingness to recommend the HHA to friends and family
• How often home health patients had to be admitted to the hospital
• Multifactor Fall Risk Assessment conducted• Depression Risk Assessment conducted• Influenza Immunization received• Pneumococcal Vaccine ever received
QAPI
• Average Length of stay• Comfort 48 hours after admission• Willingness to recommend• Avoided unwanted hospitalization• Rating of weekend/evening
responsiveness – % of excellence
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Patient Experience
• HHCAHPS• Family Evaluation of Hospice Care• Discharge Phone Calls
Financial Benchmarks
• Revenue per Episode• Visits per Episode• Supply Costs• Hospice ADCL• Hospice Supply Costs• Private Duty Hours and Cost to Supply• Average Visits per Day
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Operational Benchmarks
• % of Hospital Discharges• Conversion Rate• % of TeleHealth Usage• Days to Submission RAP/EOE
Our Value Together
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Our Value TogetherReduction of Health Care Spending
• Cost cutting efforts short term– Lean Managementg– Supply costs
• Data sharing and Analytic Strategy to improve outcomes and reduce cost– ACH within 30 days, 60 days, 90 days
• Hospital Avoidance– Improved Chronic Disease Management
Care Coordination– Care Coordination– Clinical Tools and EHR – Quality Improvement and Quality Improvement
Techniques and Education including Board education• Improved physician relationships
Our Value TogetherReduction of Health Care Spending
• Partnerships/Value of homecare in the healthcare continuumcontinuum– Skilled Teaching continued– Patient Engagement continued– Chronic Care Management– Telemonitoring– Participation in bundled payment schemes– Shared pathways and protocols
• Stakeholder engagement—Shared Decision Making
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Moving in the Same Direction
Medicare movement from a passive payer of claims to a prudent purchaser of healthcare services.
Hospitals Home Health CareProspective Payment System• DRGs
Prospective Payment System• OASIS
Case Mix WeightQuality Outcomes
Hospital Compare• Process Outcomes
Home Health Compare• Quality Outcomes
healthcare services.
Process Outcomes• HCAHPS
Quality Outcomes• Process Outcomes• HHCAHPS
Re-admissions Acute Care HospitalizationValue Based Purchasing (now) Value Based Purchasing
Moving in the Same DirectionHCAHPS HHCAHPS
C
SCR
IPTI
NG
Communication Patients who reported that their nurses “Always” communicated well.
How well did the home health team communicate with patients
MedicationManagement
Patients who reported that staff “Always”
Did the home health team discuss SManagement that staff Always
explained about medicines before giving it to them.
team discuss medicines, pain, and home safety with patients
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Moving in the Same DirectionFederal Value Based Purchasing
“Instead of payment that asks, How much did you do?, the Affordable Care Act clearly moves us toward payment th t k H ll did d ? d i t tlthat asks, How well did you do?, and more importantly,
How well did the patient do?” Don Berwick
FY2013 20 measures for VBP calculation • 12 Clinical Process of Care measures (70%)• 8 Patient Experience of Care dimensions (30%)
FY2014 24 measures for VBP calculation• 13 Clinical Process of Care measures (45%)• 8 Patient Experience of Care dimensions (30%)• 3 Outcome measures (25%)
FY2015 26 measures for VBP calculation
CMS Quality Based Initiatives Timeline2010 2011 2012 2013 2014 2015 2016 2017
Reporting hospital quality data for annual payment update 2%
1% 1.25% 1.5% 1.75% 2%
1% 2% 3% 3% 3%
Value‐based Purchasing 2%
Readmissions 3%
7%1% 2% 3% 3% 3%
Hospital Acquired Conditions 1%
Meaningful Use* 1%
7%At
Risk
*Medicare payments are reduced 1% starting in 2015 with an increasing percentage point each year thereafter up to 5% in 2018
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The Triple Aim
Population Health
• Flu clinics• Patient/family education• Pandemic preparedness• Blood pressure clinics• Foot care clinics
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Experience of Care
• Top 20 percentile nationally• Nationally measured and reported
Per Capita Cost
• Average daily costs• Acute care $1600/day• Skilled Nursing Facility - $357/day• Homecare - $2200/60 day episode of care• Hospice – routine $156/day
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OUR KEY VALUE• Acute Care
HospitalizationHospitalization • Improvement in
Medication Management• Improvement in
Ambulation• Treated Heart Failure
Patient’s SymptomsPatient’s Symptoms• Medication Teaching• Checked Patient’s Risk of
Falling
Our Value TogetherReduction of Health Care Spending
Back of the Envelop Calculations
COMPARED WITH 2008
• 2008 rate = 16.2%
COMPARED WITH 2011
• FY 2011 rate = 15.5%
MaineHealth
• FY 2012 rate = 15.2%• 215 fewer readmissions
• Savings of $2.1 M
• FY 2012 rate = 15.2%• 59 fewer readmissions
• Savings of $568,000
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“Patients can undo a month’s worth of expensive and intensive care just going home and going about their
normal routines.” John Charde, MD
Re-Admission Profile
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Our Value TogetherReduction of Health Care SpendingReducing Re-hospitalizations within the
Fi t S DFirst Seven Days• Close attention to medication management• Care coordination • Knowledge of red flags
“All Aimed at Reducing Acute Care Hospitalizations”
Risk Stratification for Re-Admission
• Uniform implementation of the Transitions f C B dlof Care Bundle
– Risk stratification– Discharge checklist– Medication reconciliation– Patient/family educationPatient/family education– Timely communication – Timely follow-up of patients after discharge
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Hospital AvoidanceInitiative
• Patient Centered Medical Home– Maine Medical Partners, Cape Elizabeth &
PrimeCare BiddefordProject aims
Improve care coordinationEnhance communication and health information exchangeinformation exchangeImprove access to home health benefitsImprove quality outcomesAvoid and reduce unnecessary hospitalization
Hospital AvoidanceInitiative
Hospital to Home• Standardized Teaching Tools• Patient education booklet with heart failure
zones• Free Scale Program• Telehealth Monitoring• Heart Failure Pathway
– Home Diuretic Protocol
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Hospital AvoidanceInitiative
• Community Paramedics– Falls in the adult/elderly population– Home Health Service Access
Hospital Avoidance Initiative
• CABG Bundling Initiative– Hospital to home pathway– Shared electronic patient record
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Hospital AvoidanceInitiative
• ADED (Aging Demographic Economic D l t I iti ti i Li l C t )Development Initiative in Lincoln County)– Long-term care– Access to healthy food– Transportation– Job opportunities in the sector for seniors andJob opportunities in the sector for seniors and
other residents.
ED Over Utilization
• Patients with frequent re-admissions not li ibl f h h ltheligible for home health care
– Home Health Referral– Skilled Care as appropriate– Telehealth– Safety Net patientsSafety Net patients
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Our Greatest Value Care in the Home
Patient/Family Centered Care...
Total agency involvement in creating a culture of quality patient/family centered care
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Patient-Family Centered Care
Patient/Family Centered Care Involves Every Component of the Agency:Every Component of the Agency: • Front Loaded Nursing Visits • Chronic Care Management• Evidence-based Pathways and Protocols• Physical Therapy Falls Program• Occupational Therapy Cognitive Function Assessment• Occupational Therapy Cognitive Function Assessment
and Plan• Social Service working Flex Hours to Meet Family Needs• Private Duty care available for Patient/Family Needs
• Too much focus on acute illness• “an acquired, transient period of
vulnerability” • “…risks in the critical 30-day period after
discharge might derive as much from the allopathic and physiological stress thatallopathic and physiological stress that patients experience in the hospital as they do from the lingering effects of the original acute illness”
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Contributing Factors
• Sleep disturbance • Pain & other di f t• Nutritional issues
• Cognitive factors
discomforts• Medications• Deconditioning
Our Greatest Value Care in the Home
High Risk Clinical Indicators Impacting H it li ti R tHospitalization Rate• Diminished Cognition• Dehydration• Nutrition• History of a fall in last 6 months• History of a fall in last 6 months• Arrhythmias• Uncontrolled Blood Sugars• Co-Morbid Conditions
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Our Greatest Value Care in the Home
FALLS PROGRAM• HomeSafe Program• Fall Risk Assessment at Start of Care• Physical Therapy Intervention• Cognitive Assessment as Indicated• Environmental Assessment • Fall Risk Assessment at Discharge• Community Paramedicine
Medication Management
59% of our patients are on 10 medications or more…– 15% of those patients are on 15 or more
medications– High utilization of Beers List medications
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KEY PATIENT EXPERIENCE MEASURES
Scripting • Talk About Medicines• Ask to See Medicines • Talk About New Medicine
Purpose • When to Take Medicines• Side Effects of Medicines
What Do We Have
• How to best align goals and strategies
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We need to connect...
Physicians Hospitals
Connectivity
Home Care Other Providers
Shift the Paradigm
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Capitalize on a changing workforce…
• Today 65% of nursing working are in acute care.
• In ten years that number will flip
Selling…
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Tools that Enhance our Value
• Point of CareT l h• Telephony
• Polycom• Telehealth• PT/INR• Mobile Access• Smart Phones• Oxygen Saturation Machines• VPN
Demonstrating Value to:Hospitals
• Safety Net Patients• Home Diuretic Protocol• CREST Patients• Bundling CABG patients• Transitions of CHF patients
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Demonstrate Value To:ACOs/Managed Care Organizations• Patient Centered Medical Homes• Community Care Teams• Population Health
ACO Initiative:Value Oversight Committe
• Launch an “awareness campaign” for facilities and
• Monitor use of hospice, referral patterns and patient and family
organizations so that providers are educated about available hospice services;
• Develop a resource listing of regional hospice resources;
• Launch an “awareness campaign” for the general public
satisfaction with the intent to give feedback to referring physicians;
• Evaluate and increase use of hospice services in underserved areas;
• Promote current hospice about hospice services available to them;
• Develop tools to help doctors determine when patients’ life expectancy would be appropriate for hospice referral;
bereavement services to support programs to families and staff.
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Demonstrate Value To:Direct Consumers• Patient/Family Education• Private Duty• 24/7 Availability• Electronic Medical Record• Telehealth• Nationally certified clinicians
Home Care is at the Hub of the Health Care Continuum
Acute
Chronic
Long Term CareHOME
CARE
Preventive Hospice
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Reflecting
Com m ents?
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Contact Information
Donna DeBlois, Executive DirectorK W l Li H d H iKno-Wal-Lin Homecare and Hospice
Rockland, [email protected]
Amy Warrington, Director of Business OperationsKno-Wal-Lin Homecare and Hospicep
Rockland, [email protected]