preparing for health care reform: an opportunity for cp rehab professionals
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Preparing for Health Care Reform: An Opportunity for CP Rehab Professionals. Zack Klint, MS, CES Coordinator, Cardiopulmonary Rehabilitation Vanderbilt University Medical Center. Disclosure Information. I have no conflict of interest. Acknowledgements. Jay Groves, EdD , MMHC - PowerPoint PPT PresentationTRANSCRIPT
Preparing for Health Care Reform: An Opportunity for
CP Rehab Professionals
Zack Klint, MS, CESCoordinator, Cardiopulmonary
RehabilitationVanderbilt University Medical Center
Disclosure InformationI have no conflict of interest.
AcknowledgementsJay Groves, EdD, MMHC
EB Jackson, MBAAllison Jagoda, MS, CES
The US Health Care Spend
Per Capita Health Care Spend
Care Quality; How do we Compare?
Health Spending and Longevity
“The cost of sickness in America is a threat
to the country’s economic security”
D.W. Edington, PhD University of Michigan, HMRC
HC Reform and Family income
“The Health Care Reform Crossroads”
Health Care Reform; It is all About the Change
“Ultimately, all change efforts boil down to the same mission; Can you get people to start behaving in a new way?”
Chip Heath, Dan Heath, “Switch: How to Change Things When Change is Hard” 2010.
The “New Way” of Health Care
For Health Care reform, the “New Way” must include changes from:
– Government– Payers– Providers– Employers– Individuals
The Business of Health
“We are in the sickness business. We need to get into the health business”.
Dr. Delos Cosgrove, Chief Executive OfficerCleveland Clinic, Time Magazine, June, 2009
Health Care Shift
Treating Disease
Passive Participant
Health Care Cost
Cost-Shifting
Managing Health
Informed Decision Maker
Realigning Cost-Share
Integrated / ConnectedFragmented
Health Care Investment
Core Elements of Health Care Reform
• Accountable Care Organizations
• Bundled Payments
A Model for ACO’s
Proposed Benefits of ACO’s
Potential Impact of ACO’s on the Delivery of CP Rehabilitation Services
• Premium on care coordination. • Expanded and new care coordination teams.• Consistent outcome measures across the
continuum of care.• Must expand your reach and impact.• “The right care, for the right patient, at the right
time”.• Outcomes! Outcomes! Outcomes!
Bundled Payments for Care
Bundled vs Fee-for-Service Payments
What is Included in the Bundle?
• In-patient costs• Out-patient costs (0-180 days)• Diagnostics• Prescriptions • Bonus payments for achieving cost and quality
standards
Value-based Metrics
The Importance of Wellness in Health Care Reform
The Causes and Costs of Avoidable Chronic Illnesses
• The combined cost of the top 7 modifiable chronic diseases (cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions and mental disorders) exceeds $270B annually in direct costs and reaches over $1T annually with lost productivity.
• It is estimated that 70% of avoidable health care costs could be mitigated by behavior changes that involve healthy lifestyle development, wellness enhancement and early detection for the conditions listed above.
(Source: “A Wellness Initiative for the Nation”, February 6th, 2009, The Samueli Institute)
The Causes and Costs cont….Five behavioral risk factors have been shown to contribute the most to mitigating these costs;
1) Reducing toxic substance exposure- smoking, alcohol, drugs and pollution
2) Sufficient exercise and physical activity3) Healthy diet4) Psychosocial integration and stress management 5) Early detection and intervention
It is estimated that even modest gains in smoking and obesity control would reduce illness in the top seven modifiable chronic health conditions by 24-30 million, save up to $100B in treatment costs.
Potential Impact of Bundled Payments on the Delivery of CP Rehab Services
• A chance to “re-invent the wheel”.• Must contribute to the “value proposition”.• Renewed emphasis on sustainable, behavior
change (patient engagement).• Must have “real time” data to drive care
decisions.• May need a different skill set.• May need to do more with less.
Opportunity is here
Value
(BETTER) QUALITY•Safe, Evidence-Based Best Practices•Coordinate Care Across Continuum•Patient Service Experience
(LOWER) COST•Eliminate Unneeded Care•Efficient Workflows•Practice at Top of License
• How do we give patients “everything they need and nothing they don’t?”– Standardize care according to evidence-based care pathways– Improve the “tools” our teams rely on to deliver the best care for
every patient, every time– Facilitate personalized medicine by building in appropriate flexibility
and customization based on clinical presentation, patient history
Patient Arrival
Diagnostic Cardiac Cath
Non-Invasive Diagnostic
Testing
Medically Mgd. Pathway
Interventional Pathway
Surgical Pathway
High Risk of Another Ischemic Event
Low / Moderate Risk of Another Ischemic Event
Not Applicable (SNF, Hospice, etc.)
Outpatient Pathway
Diagnosis & Pathway Selection
Diagnostic TestingCare by Risk LevelInpatient Pathways
Discharge
ACS Continuum(6 mos)
ACS Bundle
Acute Coronary Syndrome Bundle: Project Goals
Institutional Goals• Explore capabilities needed to deliver coordinated care and manage clinical and
financial risk under a bundled reimbursement model
Outcomes Goal• Reduce rate of non-value-added downstream encounters and downstream ischemic
events following an initial episode of Acute Coronary Syndrome
• Lower score for “9 Modifiable Cardiac Risk Factors” over the defined episode
Financial Goals• Create clinical capacity (inpatient, Dx and therapeutic)
• Limit healthcare spend over time for ACS patients, demonstrating value to payers & employers
– Reduce avoidable related readmissions
– Minimize repeat Dx tests, re-caths & downstream interventions
– Minimize avoidable complications 32
DEFINE STANDARD of CAREDesign Evidence-Based Continuum of Care Spanning 6-mo. Inpatient, Ambulatory + Ancillary
STUDY GAPSUnderstand Current State & Gaps Relative to Desired Future State
TEST CHANGESmall Tests of Change to Understand Implications
IDENTIFY HIGHEST-VALUE OPPORTUNITIESTransition Inpatient-to-Outpatient
Medications Across Continuum of CarePatient & Family Engagement Across Continuum of Care
LASTING CHANGEHardwire People, Processes and Technology to Deliver the Standard
ACS Demonstration Pilot Progress
Up Next!
33Crit Pathw Cardiol. 2011 Mar; 10(1):1-8
Clinical Success:Modifiable Cardiac Risk Factors
Circulation, 2007
ACS Cardiac Rehab Pilot
26 Week Comprehensive Risk Reduction Program
Cardiac Rehab – Fee For Service
Where does it fall short?– Missing eligible patients– Limited access due to finances– No reimbursement for medical management– Financial mechanism doesn’t incentivize value
• Quality – no premium on outcomes• VISITS = REVENUE
GLOVES ARE OFF– Improves flexibility for supervised exercise
• Visits ≠ Revenue• Risk Stratification
– Payment for LIFESTYLE MEDICINE• Supporting Change
– Opportunities to tap other disciplines expertise when appropriate
• Health Coaching, Health Psychology, RD, etc
Cardiac Rehab – Bundled Payment
“Everything they need, nothing they don’t”
Major Lifestyle DomainsWhat do we want to change?
CRPilot
TobaccoCessation
PsychoEmotional
Health
Exercise &
Physical Activity
Medication Adherence
Nutrition
Tools to address behavior by domain
Nutrition
Coaching
Mindfulness
RD
Shopping Demonstratio
n
Cooking Class
CHIP/Pritikin/Ornish
Exercise/PA
Coaching
Mindfulness
Exercise Testing
CHIP/Pritikin/Ornish
Movement classes (Yoga,
Tai Chi)
Pedometers
Medication Adherence
Coaching
Mindfulness
Medication Reconciliatio
n
Psycho Emotional
Health
Depression Screening
Mood Clinic
Coaching
Group Support
CHIP/Pritikin/Ornish
Smoking Cessation
Coaching
Smoking Cessation Specialist
Group Support
CHIP/Pritikin/Ornish
ACS Cardiac RehabKnown modifiable risk factors• Profile established by 7 day visit• OUTCOMES
• Evidence based measure of success
Coaching• Every participant – 12 phone coaching sessions
Coronary Health Improvement Project (CHIP)•Evidence based•Healthy nutrition•Moderate exercise•Group support
Clinical risk stratification•Cardiac Rehab Evaluation•Low – 8 monitored CR sessions (SES)•Moderate – 16 monitored CR sessions (SES)•High – 24 monitored CR sessions (SES)
Key Components
Vandy OCR
Low Risk
12 Coaching Sessions CHIP
Outcomes
8 SES
Moderate Risk
12 Coaching Sessions CHIP
Outcomes
16 SES
High Risk
12 Coaching Sessions CHIP
Outcomes
24 SES
ACS Cardiac Rehab Algorithm
Health Coaching – CR staff WellCoaches® Certification
– Strategic initiative at Vanderbilt Dayani Center and Vanderbilt Center for Integrative Health
– CR staff trained as Health Coaches• Outpatient - 3 of 4 staff certified (4 of 4
soon)• Inpatient - 1 of 3 staff certified
Clinical Success:
Circulation, 2007
Re-Define Care
Deliver Care Consistently
Evaluate Value (= outcomes / cost)
Iterative Small
Tests of Change
ACS 10 patient pilot Organization -Test the ACS pathway
(inpatient through 3 months + post-discharge)– Manually move 10 patients from admission
to 7 day visit and into outpatient management
Opportunity for CR– Pilot the Health Coaching model in
outpatient cardiac rehab
ACS 10 patient pilot Fee for service CR + 6 health
coach sessions 1 (60min) and 5 (30 min)
– Goals• Testing – Too many cooks in the
kitchen?• Test phone call model• Any influence on outcomes
Modifiable risk factor outcomes
Physic
al Act
ivity
Diabete
s Melli
tus
Weight
Manag
emen
t
Psycho
social
/ Dep
ressio
n
Tobacc
oLip
ids
Blood
Press
ure
Medica
tion A
dhere
nce0
10
20
30
40
50
60
70
80
% at goal - Baseline% at goal - 90 days
Improved Capture Rate?
VUMC CR Pilot0%
10%
20%
30%
40%
50%
60%
70%
80%
Improved Adherence?
Control Intervention Intervention participants0
5
10
15
20
25
30
35
Completed Visits
My Conclusions CPR programs/professionals are well
positioned to play essential roles as behavior change specialists in an era of health care reform– Health Coach– Health Navigator– Patient Engagement– Outcomes