how to establish an accountable post-acute preferred...

11/28/2016

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How to Establish an Accountable Post-Acute Preferred Provider NetworkMaura McQueeney, MPH, DNP, President, BaystateVNA & Hospice/ Post-Acute Care, Baystate HealthLissy Hu, MD, MBA, Chief Executive Officer, CarePortHealth

L22This presenter has

nothing to disclose

Sunday, December 4

#IHIFORUM

Session Objectives

BackgroundProblem discovery 2013 – Multiple vendor and provider relationships coming and going from the medical center and outlying hospitals

Strategic QuestionHow should we partner for results in BCPI and ACO when we do not OWN post acute facilities? Embed MDs($)? Embed Mid levels($)? Partner for quality results ?

DecisionDevelop clear, post - acute partner scorecard, be transparent with results, select a preferred network based upon quality BEYOND star ratings, define monitoring and sustainable outcomes, create written agreements

MethodsHow we created an accountable preferred post acute network

Results and Takeaways Sharing our success tips

P2

#IHIFORUM

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Shifting Payment Landscape3

MACRAReadmission

s

IMPACT

Act

Bundled

Payment

s

CJ

R

ACO

Baystate Health

o Largest health system in Western

Massachusetts

o One academic medical center, two

community hospitals, 973 beds

o Owns a health insurance company –

Health New England

o 250 Physician Practices

o Acquiring surrounding community

hospitals to secure competitive

boundaries

o Next Generation ACO

o Early entrant into MSSP TJR bundle

o Strategically not in the long-term care

“space”

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DME, Lab Services, Imaging Services

SNF Liaisons

HHA Liaisons

Hospital SNF HHA

Creating a Central Nervous System: SPACC

• Strategic Post-Acute Care Committee (SPACC)

• Complex web of relationships and potential for conflict of interest

• Need to organize relationships around quality in context of BPCI and ACO

Getting Started: SPACC

• SVP for Quality and Population Health

• President, VNA & Hospice

• Physician leader of ACO

• Geriatrician representing post-acute

medicine

• Director of Quality (oversees BPCI

program)

• Director for Post-Acute Integration

• Heart & Vascular service line director

• VP, Strategic Planning

• Director of Case Management

• Ad hoc members: Lab and Imaging,

Medical Director of Health New

England (insurance organization)

• Identified relevant post-acute

stakeholders (ACO, BPCI)

• Hired Director for Post-Acute

Integration

• Instituted monthly meetings for

group to discuss SNF selection

criteria, quality measurement, and

performance improvement

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Assessing Skilled Nursing Facilities

• Assessed 30 facilities with high-

volume of Baystate patients

• Collected facility staffing levels,

process expectations, outcome

reporting expectations through

site visits and interviews

• Major criteria included CMS star

rating (3 and above), 24-hour

nursing care, physician staffing

levels, readmission rates, ability

to take difficult patients, and

willingness to partner

Collaborative Partner Facility ProfileCollaborative Partner Facility Profile

Contact 1 Title

Ownership Type (private, profit, nonprofit, parent company)

What is your ability to manage pts with psychiatric

diagnoses

Individual Facility DemographicsIndividual Facility Demographics

Category Response Yes/No (Yes

= 1; No = 0)Comments/additional Information

License Types (please list all) LTC

Number of Sub Acute Beds Short Stay all private rooms

Number of LTC Beds

Number of LTACH Beds

Number of Specialty Services Beds (vent, rehab)

MDs Contracted-Internist, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)

1 Community PCP

MDs Contracted-Geriatrician, and days per week on unit

LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0

MDs Contracted-Specialty MD, and days per week on unit


MDs Contracted-Internist, and days per week on unit Sub

Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)1 Community PCP


Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0



Midlevel (RN/PA) Practitioner Contracted and days per

week on unit LTC (Enter 1 if once/week; 2 if 3-5 days; 3 if daily)1


week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)?? 1

24/hr day RN (Y/N)? 1 Staff: 50% RN

Nursing Model: Primary Nursing Model (Y/N)? 1

Nursing Model: Consistent Alignment (Y/N)? 1

RN Specialty Certification: Rehabilitation (Y/N)? 1 RN, Cardiac Specialist

RN Specialty Certification: Geriatrician (Y/N)? 0

Full time, licensed (RN, SW, OT, PT) Case Manager or

Navigator (Y/N)?1

Dietician available (Y/N)? 1

Special diet available: low sodium, ADA etc. (Y/N)? 1

Special diet available: TPN (Y/N)? 1

Certified Wound Care Nurse available (Y/N)? 1 Hospital CWOC NP

Palliative and Hospice Care (Y/N)? 1Palliative MD at to support;

Hospice w/ Affiliate

Pharmacy Name Formulary available (Y/N)? 1

Contracted Payers and Plans (list)

Medicare (Y/N)? 1

Medicare Advantage (Y/N)? 1

Medicaid (Y/N)? 1

Medicaid Pending (Y/N)? 1

CCA (Y/N)? 1

HNE (Y/N)? 1

Fallon (Y/N)? 1

BC/BS (Y/N)? 1

AARP (Y/N)? 0

Others (% Agency on Short Stay Unit?) No agency

Sub$Total 23

nonprofit

Psych serivce in 2-3 x/week

Process Expectations: Pre-Admission to DischargeProcess Expectations: Pre-Admission to Discharge

DRAFT 7 (9/24/13)/



Preadmission Process: Liaison on site at BH (Y/N)? 1

Preadmission Process: Response Time for Decision (Enter

1 if ≤ 60 mins; 2 if ≤ 30 mins)2

Warm Hand-Off: Documented RN-to-RN Communication on

Admit (Y/N)?0

Warm Hand-Off: Documented RN-to-RN Communication

upon Discharge (Y/N)?1

Home Care Liasion at center for weekly

meetings

INTERACT** Tool Used or Alternative Tools (Enter # points

in Y/N column)5 INTERACT III

Electronic Medical Record (Y/N)? 0 Complete by 2014

Member of Data Exchange (Y/N) 0

Direct Admits from Home, MD Of fice, and other Community

Sites: 24/7 Clinical RN Supervisor (Y/N)?1

Direct Admits from Home, MD Office, and other Community

Sites: Med List (Y/N)?1


Sites: Payor Confirmation (Y/N)?1

List 24/7 Ancillary Contracted Services (lab, imaging,

pharmacy services) (Enter 1-3)3 Mobilex, O2 Solutions


pharmacy services) with 2 hour turnaround for reports

(Enter 1-3)

3

Rehab Services provided: frequency (Enter 1 for once per

week, up to 7 = daily)7 Contract w/

Rehab Services provided: coverage by all payors (Y/N)? 1

Physician or Mid-level Rounds: Describe (Enter 1 for once

per week, up to 7 = daily)1

IDT Rounds: MD involved (Y/N)? 0

IDT Rounds: Patients & Families involved (Y/N)? 0

IDT Rounds: RN involved (Y/N)? 1 MCR Meeting

IDT Rounds: Social Worker involved (Y/N)? 1

IDT Rounds: Done ≤ 48 hours after admit (Y/N)? 0 72 hr meeting

Sub$Total 29

Reporting Expectations: OutcomesReporting Expectations: Outcomes


= 1; No = 0)Comments/Additional Information

CMS Star rating (most recent) (Enter rating in Y/N) 3 AHCA:/ :/ /App/in;/JCAHO/

DPH (Date of last survey, status and deficiencies) 2013 DPH Score :

Flag on Admission to BMP: To PCP (Y/N)? 1

Flag on Admission to BMP: By Diagnosis (Y/N)? 1

Population reports available: List

D/C Dx, dispostion and HC provider ,

PCP, LOS, Referral info: adm, lost,

declined

ALOS – Sub Acute (Enter 1 if ≤ 15 days) 0 Ortho: 19; Cardiac: 18

30 Day Re-hospitalization Rates Subacute- average of last

3 months (Enter 1 if ≤ 20%; 2 if ≤ 15%; 3 if ≤ 10%)3 9%

Mortality Rate – Sub Acute TBD

Patient Satisfaction benchmarked with national database

(Y/N)? 1

If Yes, please record database Vendor and Quartile rank for

Overall Satisfaction MyInnerview: 98%

If No, please record how Patient Satisfaction is measured

AND last 6 months trend for Overall Satisfaction

Will you be able to schedule a Baystate Health Post Acute

Team site visit within the 4 weeks (Y/N)? 1

Sub$Total 10

For Internal Use OnlyFor Internal Use Only

Category Response Yes/ No Comments/Additional Information

STAAR Attendance 1

Baystate MD Affiliation/Presence 1 Cardiac:

Top 70% referral 2012 0

Citizenship (difficult patient placement) 0

Affiliation (ACO, PHO, other) 0

Total 62

**INTERACT- Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification,

assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal o f INTERACT

is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous

complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

Collaborative Partner Facility ProfileCollaborative Partner Facility Profile

Facility Name

Facility Address

City State Zip

Phone

Contact 1 name

Contact 1 Title

Contact 1 e-mail

Web Site

Ownership Type (private, profit, nonprofit, parent company)

What is your ability to manage pts with psychiatric

diagnoses

Individual Facility DemographicsIndividual Facility Demographics



License Types (please list all) LTC

Number of Sub Acute Beds Short Stay all private rooms

Number of LTC Beds

Number of LTACH Beds

Number of Specialty Services Beds (vent, rehab)

MDs Contracted-Internist, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)

1 Community PCP





MDs Contracted-Internist, and days per week on unit Sub

Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)1 Community PCP






week on unit LTC (Enter 1 if once/week; 2 if 3-5 days; 3 if daily)1


week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)?? 1

24/hr day RN (Y/N)? 1 Staff: 50% RN

Nursing Model: Primary Nursing Model (Y/N)? 1

Nursing Model: Consistent Alignment (Y/N)? 1

RN Specialty Certification: Rehabilitation (Y/N)? 1 RN, Cardiac Specialist

RN Specialty Certification: Geriatrician (Y/N)? 0

Full time, licensed (RN, SW, OT, PT) Case Manager or

Navigator (Y/N)?1

Dietician available (Y/N)? 1

Special diet available: low sodium, ADA etc. (Y/N)? 1

Special diet available: TPN (Y/N)? 1

Certified Wound Care Nurse available (Y/N)? 1 Hospital CWOC NP

Palliative and Hospice Care (Y/N)? 1Palliative MD at to support;

Hospice w/ Affiliate

Pharmacy Name Formulary available (Y/N)? 1

Contracted Payers and Plans (list)

Medicare (Y/N)? 1

Medicare Advantage (Y/N)? 1

Medicaid (Y/N)? 1

Medicaid Pending (Y/N)? 1

CCA (Y/N)? 1

HNE (Y/N)? 1

Fallon (Y/N)? 1

BC/BS (Y/N)? 1

AARP (Y/N)? 0

Others (% Agency on Short Stay Unit?) No agency

Sub$Total 23

nonprofit

Psych serivce in 2-3 x/week

Process Expectations: Pre-Admission to DischargeProcess Expectations: Pre-Admission to Discharge

DRAFT 7 (9/24/13)/

Process Expectations

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Preadmission Process: Liaison on site at BH (Y/N)? 1

Preadmission Process: Response Time for Decision (Enter

1 if ≤ 60 mins; 2 if ≤ 30 mins)2

Warm Hand-Off: Documented RN-to-RN Communication on

Admit (Y/N)?0

Warm Hand-Off: Documented RN-to-RN Communication

upon Discharge (Y/N)?1

Home Care Liasion at center for weekly

meetings

INTERACT** Tool Used or Alternative Tools (Enter # points

in Y/N column)5 INTERACT III

Electronic Medical Record (Y/N)? 0 Complete by 2014

Member of Data Exchange (Y/N) 0

Direct Admits from Home, MD Of fice, and other Community

Sites: 24/7 Clinical RN Supervisor (Y/N)?1


Sites: Med List (Y/N)?1


Sites: Payor Confirmation (Y/N)?1


pharmacy services) (Enter 1-3)3 Mobilex, O2 Solutions


pharmacy services) with 2 hour turnaround for reports

(Enter 1-3)

3

Rehab Services provided: frequency (Enter 1 for once per

week, up to 7 = daily)7 Contract w/

Rehab Services provided: coverage by all payors (Y/N)? 1

Physician or Mid-level Rounds: Describe (Enter 1 for once

per week, up to 7 = daily)1

IDT Rounds: MD involved (Y/N)? 0

IDT Rounds: Patients & Families involved (Y/N)? 0

IDT Rounds: RN involved (Y/N)? 1 MCR Meeting

IDT Rounds: Social Worker involved (Y/N)? 1

IDT Rounds: Done ≤ 48 hours after admit (Y/N)? 0 72 hr meeting

Sub$Total 29

Reporting Expectations: OutcomesReporting Expectations: Outcomes


= 1; No = 0)Comments/Additional Information

CMS Star rating (most recent) (Enter rating in Y/N) 3 AHCA:/ :/ /App/in;/JCAHO/

DPH (Date of last survey, status and deficiencies) 2013 DPH Score :

Flag on Admission to BMP: To PCP (Y/N)? 1

Flag on Admission to BMP: By Diagnosis (Y/N)? 1

Population reports available: List

D/C Dx, dispostion and HC provider ,

PCP, LOS, Referral info: adm, lost,

declined

ALOS – Sub Acute (Enter 1 if ≤ 15 days) 0 Ortho: 19; Cardiac: 18

30 Day Re-hospitalization Rates Subacute- average of last

3 months (Enter 1 if ≤ 20%; 2 if ≤ 15%; 3 if ≤ 10%)3 9%

Mortality Rate – Sub Acute TBD

Patient Satisfaction benchmarked with national database

(Y/N)? 1

If Yes, please record database Vendor and Quartile rank for

Overall Satisfaction MyInnerview: 98%

If No, please record how Patient Satisfaction is measured

AND last 6 months trend for Overall Satisfaction

Will you be able to schedule a Baystate Health Post Acute

Team site visit within the 4 weeks (Y/N)? 1

Sub$Total 10

For Internal Use OnlyFor Internal Use Only

Category Response Yes/ No Comments/Additional Information

STAAR Attendance 1

Baystate MD Affiliation/Presence 1 Cardiac:

Top 70% referral 2012 0

Citizenship (difficult patient placement) 0

Affiliation (ACO, PHO, other) 0

Total 62

**INTERACT- Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification,

assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal o f INTERACT

is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous

complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

Outcomes Reporting Expectations

Facility Score Card

Scoring Post Acute Providers

• Developed scorecards with point system, reviewed with SNFs

• Chose 14 facilities as preferred providers

• Meet with preferred providers regularly, provide blinded scores

and engage in other quality improvement activities

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Balancing Transparency and Privacy

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K

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2

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lace

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Quality of Care (based on 30-Day Readmits & CMS Star Rating)

Baystate Health Post-Acute Care Partner Prioritization Matrix

A B C D E F G H I J K L M N O P Q R S T U V W

Implementation Challenges

Aligning with case managers who had concerns about patient

choice

Communicating preferred providers to patients

Encouraging patients to select post-acute providers based on quality

vs. geography

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Changing the Discharge Discourse

Standardized communication, developed by SPAC committee, case

management leadership and legal:

“The Baystate preferred skilled nursing facility network is a select

group of nursing facilities around the Pioneer Valley that meet

quality and safety standards set for by Medicare and endorsed by

Baystate Health

Engaging Patients in Post-Acute Decision-

Making

Baystate adopted an interactive tool for discharge planners and patients to

choose post-acute care

Preferred providers are highlighted and communicated to patients and

families

Integrates with case management workflow tools and available on a tablet;

search results can be emailed to family members and other decision-

makers

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Post Acute Search Tool Benefits Case Managers,

Patients & Supports Baystate’s PAC Strategy

Compliance with Impact Act and proposed

changes to conditions of discharge planning

Proposed rule “require[s] that hospitals assist patients…in

selecting a PAC provider by using and sharing data that

includes but is not limited to HHA, SNF, IRF, or LTCH data on

quality measures and data on resource use measures.”

With CarePort, Baystate has provided its patients with ' first-of-its kind' technology that helps them decide

where to go for post-acute care—a critical decision, as numerous studies show that post-acute providers

vary on quality and their ability to car e for different types of patients,” said Joel Vengco, VP/CIO,

Baystate Health . “In other words, it ’s not an easy decision for patients and families to make. Until now."

Tracking Baystate Patients Post-Discharge

Integration with regional HIE

(PVIX) and six post-acute

providers

Understanding post-acute

outcomes for all Baystate patients

Skilled nursing facility readmission

rates and length of stay by patient

population

Leakage vs. Keepage

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Sustaining the Network

Quarterly Quality Meetings:

Sharing best practices

“Preferred” Subset for BPCI

Exiting SNF partners

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Outcomes

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Outcomes

Outcomes

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Success Factors

Personal Touch

RFPs vs. personal touch because of high turnover of SNF staff

For example tenure of nursing staff, will nursing staff know to call hospital?

TeamIntegration work led by “SNF insider”

Innovation in the communityHealth New England – SNFs can take care of patients with medical needs such as IV antibiotics, TPN to avoid readmission. HNE takes care of cost of IV Abx and TPN

On the Horizon

Deciding to create a Tier 2

Physician Incentive for SNFist from Next Gen ACO

Embedded ACO Physician in the ED

Building care coordination teams

Navigators vs. liaisons

How to make it scalable and cost-effective?

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How Well Do You Know Your Post-Acute Providers?

Break-out session

• Complete a Quick Environmental Scan (Handout)

• What did your assessment tell you?

• Where are your strengths?

• Where do you need help?

BREAK OUT SESSION

How Well Do You Know Your Local Post Acute Providers?

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Next Steps: Road Map

Who are your Executive Sponsors?

Who would possess the attributes of a Post Acute

Integration Leader in your organization?

Where are your internal and external obstacles?

(measurement systems, competing priorities, human resources)

Group Report Out

Q & A

how to establish an accountable post-acute preferred...

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