integrating acute rehabilitation within a regional comprehensive health care system matthew n....
TRANSCRIPT
Integrating Acute Rehabilitation Within a Regional Comprehensive
Health Care System
Matthew N. Bartels, MD, MPH
Professor and ChairmanDepartment of Rehabilitation Medicine
Montefiore Medical CenterAlbert Einstein College of Medicine
Bronx, NY
Disclosures
• None related to this talk unfortunately, but working on it………
Why Care About IRF in Regional Comprehensive Health Care
System?• IRF Growth has stalled, potentially
reversed• Insurance trends are not in IRF favor
– Favoring cheaper over better– 60% (or whatever) rule– Bundling
• Low return on high capital expenses• Intense manpower requirements• Small specialty/presence with powerful
competitors
IRF in the US
Numbers of IRF in US
• Progressive decline in IRF since 2004• A few more self standing IRF, less Hospital Based
IRF
Use of IRF ServicesDecline in volumes, but increased cost per patient
Discharges by Diagnosis• Orthopedic cases fading• Joints will be essentially gone in 2016
IRF Patient Mix• Brain injury, spinal cord, and stroke stable. • Debility mild increase
Top 10 Diagnoses in Free Standing IRF
• Diagnoses tend to neurological
• Do not take into account changing patient populations and needs
• Transplant, debility, ICU survivors not included
• Short term costs primary consideration
Medicare FFS vs. M’Advantage
• Worrisome trend for IRF in Medicare Managed Care
• Reduced use of IRF in favor of SNF
Medicare FFS vs. M’Advantage• Case weight is higher for MA, with lower use• MA is more selective in using IRF
IRF Quality/Efficiency Measures• IRF FIM efficiency has improved• Discharge to community stable
IRF Costs per Discharge• Interesting trends• Lower costs with:
– Freestanding– For profit– Urban– 60 or more beds
• Information helpful for assessing plans for your health network
Where is the Growth/Shrinkage?
How to Preserve Acute Rehab in this New Era of
Managed Care• This is in some ways an existential
moment!• Need to prove our worth• Establish that value is more than just in
dollars spent• Look to create new ways of providing
inpatient acute rehabilitation• Need to incorporate rehabilitation
specialists in the leadership of Post Acute Care (PAC)
Where Are the Opportunities?
• Coordination of care• Need to create pathways for appropriate
diagnoses• Need to look to the care of “non-classical”
diagnoses• Need to have the ability to move patients
between models of PAC• Need new models of home care and
subacute care
How Do You Make These Changes?
• Obstacles: – Medicare and its rules
• 60% rule• Classical Diagnoses• Managed care approvals• Bundles
– Private insurance• Approvals• Bundles• Coverage/contracting
Dream Solutions
• Be able to take all patients that need acute rehabilitation, regardless of diagnoses, insurance approvals, bundles and so on.
• Provide a flexible coverage that would allow individuals to move from level to level of care as needed and appropriate
• Spend more time on care and less on insurance and administration
An Approach to the Solution
• Incorporation of acute rehab as a part of the continuum of PAC
• Rehab central to all patients and discharge thought processes
• Need to have a health network willing to work with rehab and providers
• Need to be able to create innovative care models in conjunction with other providers
Creating the Ideal Solution at Montefiore Health System
• Montefiore Health System is the umbrella for a comprehensive medical network in the Lower Hudson Valley in New York State
• Montefiore has been a leader in managed care through the Care Management Organization (CMO), has worked to assume risk sharing with most payors, Pioneer ACO (savings for three years)
• Over 80% government payors creates both an opportunity and a challenge => risk sharing is the answer
• Allows for innovative care models
What is Montefiore?• Children’s Hospital at Montefiore• Montefiore Einstein Center for Cancer Care• Montefiore Einstein Center for Heart and Vascular
Care• Montefiore Einstein Center for Transplantation
• Clinical• Translational• Health
Services
• ~1,323 Residents & Fellows• ~420 Allied Health Students• ~1,552 Graduate &
Undergraduate Nursing• ~200 Home Health Aides• ~100 Social Workers
ResearchTeaching
• Home Health Programs
• Primary Care• House Call
Program
• 7 Campuses• 7 Hospitals• 2,200 Beds• 150 Skilled
Nursing Beds• 1 Freestanding ED• 3 Urgent Care
Sites
HomeCareHospitals
• Clinical support
• Network applications
• Finance• Legal• Planning• Purchasing• Compliance• Marketing• Human Resources
• Care Management(>300K Covered Lives)
• Disease Management• Care Coordination• Telemedicine• Pharmacy Education
Information Technology
CorporateFunctions CMO
• Health Education• Community Advocacy• Wellness• Disease Mgmt.• Nutrition • Obesity Prevention• Physical Activity• Reduce Teen Pregnancy• Lead Poisoning Prevention
Population Health
• ~23,000 Employees• ~3,450 Integrated Provider
Association Physicians• ~1,800 Employed MDs• ~4,270 RN/LPN
• ~3,300 NYSNA RNs• ~10,280 SEIU/1199
Workforce
Community
Academic HealthSystem
Notable Centers of Excellence
Primary & Specialty
Care
• Advanced Primary Care
• Sub-specialty Care• Dental• School Based Health
Centers• Mobile Health
• Neuroscience• Orthopedic• Ophthalmology• OB/GYN
Integrated Delivery System
Integrated Delivery System• Montefiore Locations–Over 2,200 Beds Across 7 Hospitals
– Including 120 beds at CHAM– Including White Plains Hospital
–Over 170 Sites including:• 64 Primary Care Sites
– 21 Montefiore Medical Group Sites• 21 School Health Clinics• 9 Mental Health / Substance
Abuse Treatment Clinics• 49 Specialty Care Sites
– 2 Multi-Specialty Centers– 4 Pediatric Specialty Centers– 15 Women’s Health Centers
• 5 Dental Centers• 5 Imaging Centers• Freestanding Emergency
Department• 3 Urgent Care Sites
–Schaffer Extended Care Center–Home Care Agency–School of Nursing–Burke Rehabilitation just added
Role for Rehabilitation
• Help to define the issues for post acute care
• Create a comprehensive PAC strategy– Incorporate a strong Acute Rehab
Presence– Also partner with and help to manage
risk in subacute care facilities– Establish and own a home care provider
• With shared risk:– Take on some risk, gain some freedom– Allows “breaking” some of the rules
Post Acute Care Opportunities
• Pathways with unique opportunities– Patients with slow acute care progress
• Subacute for brief time, then acute, then home
• Have 7 day a week home care with therapy
– Most Total joints go home: >80% in about 2 days• 7 day home care, presurgical prep• For other 20%: protocols with subacute
providers, acute for the select few with need
– Partner with subacute for short stays => make them part of the risk equation.
Where does Rehabilitation Medicine Fit?
• Need to make the right alliances• Be present in the planning and the
financial portions of the medical center• Post acute care is very expensive, very
risky, and very complicated– Rehab has very important skills to offer– Need to be flexible in our approach– Offer innovative solutions– Potentially with more risk, more
innovation
Rehab Innovations
• Can we save acute?– Yes! Need is for new patient populations– Innovative pathways and flexible
services/bundles– Transplant, complex cardiac and pulmonary– Medically complex debilitated – ICU
survivors– Cancer patients
• Live longer, more complex issues• Often can benefit from short rehab stays
to consolidate functional needs– Neurologically complex patients
For Acute Rehab/IRF
• Integration into the large at risk medical center/health care system will be essential
• Allows for innovation and growth/evolution• Staying with current models will lead to
eventual death by attrition• Issues are: costly and regulation• Could be the renaissance for acute/IRF
– But we (Rehab) need to do it and no one else knows or cares as much as we do.
Potential Benefits
• Save costs and improve post acute care outcomes– Allow innovative models/pathways– More patients served– As part of the bundle/continuum => not
forgotten– Potentially less regulation
• In at risk environment, CMO is the (internal) care management for multiple plans
• Re-admission, d/c to home all now counted
• Potentially the end of the RAC?!?!– “RAC” is new model is being cost
ineffective for your health system => internally determined
Conclusions
• The current model of acute rehabilitation/IRF is not likely to be sustainable
• Trends are towards smaller IRF presence– Limitation of diagnoses admitted not
realistic– Cost driven, not necessarily outcome
driven• However, we can change this course for IRF
– Need to look at IRF in the continuum of PAC
– Need rehab physicians to get involved in PAC
– Must present new and innovative models of care