FLAACOs 2014 Conference - Reducing Fragmentation in Post-Acute Care: A Citra Health Solutions Case Study
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FLAACOs 2014 Fall Conference - Reducing Fragmentation in Post-Acute Care: A Citra Health Solutions Case Study Presented by Krista Sultan
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FLAACOs 2014 Conference - Reducing Fragmentation in Post-Acute Care: A Citra Health Solutions Case Study
- 1. Reducing Fragmentation in Post-Acute Care: A Citra Health Solutions Case Study Ken Van Cara VP New Products & Innovation MedSolutions Krista K. Sultan Program Development Manager Citra Health Solutions
- 2. Today’s Intent • The Current Environment of Post-Acute Care • Key Steps to Coordinating Care in the Post-Acute Care Setting • Exploring the Partnership Further: Aligning Post-Acute Care for Citra Health Solutions 2Confidential: Do Not Distribute
- 3. The Current Environment of Post-Acute Care
- 4. Acute Symptoms Inpatient Post-Op Longitudinal Experience of Health Care Cumulative Costs of Patient Health Care Experience 4Confidential: Do Not Distribute
- 5. Fragmentation Acute Symptoms Inpatient Post-Op The lack of coordination between acute and post- acute care facilities creates severe fragmentation, leading to higher costs, and over-treated, under- treated, and readmitted patients. Challenge is to align providers and post- acute care facilities to reduce waste and patient harm. 5Confidential: Do Not Distribute
- 6. Tremendous Waste “Over half of the residents who experienced harm went to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011” Department of Health & Human Services (2014). Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries 6Confidential: Do Not Distribute
- 7. Patient Harm “1 in 5 Medicare beneficiaries who had post-acute SNF stays that were 35 days or less experienced at least one adverse event during their stays” “79% of these events either extended the beneficiaries’ stays in the SNF or resulted in emergency department visits or inpatient readmissions”“59% of these adverse events and temporary harm were clearly or likely preventable” Department of Health & Human Services (2014). Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries 7Confidential: Do Not Distribute
- 8. Readmission Penalties “In 2013, the CMS began penalizing excess readmissions by trimming up to 1% from payments for heart attack, heart failure, and pneumonia.” “Maximum penalties reached 2% in 2014 and will rise to 3% in 2015, when they will also be assessed for COPD and hip and knee replacements” SG2 (2013). Performance Guide: Reducing 30-Day Readmission Rates 8Confidential: Do Not Distribute
- 9. Readmission Penalties 1/4 Of Medicare FFS patients discharged from a hospital are readmitted within 30 days. $227M Total readmission penalties for 2014. For 2015, the maximum penalty increases from 2% to 3%. < 40% Of hospitals have a process to alert physicians within 48 hours of a patient’s discharge or to inform patients about test results. ACO Providers share financial risk for avoidable readmissions. SG2 (2013). Performance Guide: Reducing 30-Day Readmission Rates 9Confidential: Do Not Distribute
- 10. What will it take? “True coordination of care – defined as the organization of services among the hospital, physicians, post-acute care provider, and patient to encourage the delivery of the highest-value services – is required to ensure the best possible outcomes.” Ackerly & Grabowski (2014). Post-Acute Care Reform – Beyond the ACA 10Confidential: Do Not Distribute
- 11. Improving Care Coordination: Keys to Success
- 12. Patient/Physician connectivity Creates transparency into the acute and post-acute care settings to improve continuity of care Nurse outreach supports primary care follow-up visits A Solution That Meets Multiple Needs Improved post-acute experiences for members and their loved ones Better clinical outcomes and medical cost reductions Post-acute care site of service management • Identifying facilities with the services and quality suited to the needs of each member • Supporting patient decision making and care site selection with evidence based guidelines Readmission reductions 12Confidential: Do Not Distribute
- 13. Individualized Plans of Care • One Clinical Point of Contact Coordinates a single, individualized plan of care throughout the entire post-acute treatment – ideally managed by a single point of contact. Applies clinical decisions based on evidence-based guidelines. • Appropriate Site Selection Support Builds on individual risk assessment with an understanding each patient’s clinical, environmental, and psycho-social resources and needs: • Caregiver • Transportation • Home Environment • Health Literacy and Cognitive Ability • Activities of Daily Living 13Confidential: Do Not Distribute
- 14. Individualized Plans of Care • Length of Stay Management at Every Site Work directly with patients and post-acute care clinicians to review patient progress and ensure appropriate utilization of facilities • Readmission Reduction Reconnect individual with primary care physician Provide Transition Coaching / Medication Reconciliation Deliver Patient Engagement Materials 14Confidential: Do Not Distribute
- 15. Robust Transition Support Transition to the Appropriate Site of Care Assessment and engagement with members on acute admission Continuous monitoring of patient progression along the care continuum Transition coaching based on member’s needs and readmission risk level Transition Home as Soon as Appropriate Transition Coaching to Reduce Poor Outcomes & Readmissions 15Confidential: Do Not Distribute
- 16. Technology-Enablement One of the keys to Citra Healthcare's success was their use of MedSolutions' post-acute care management system, which: Tracks members over time across sites of care Ensures appropriate utilization of facilities Performs medication reconciliation Accesses evidence-based guidelines Develops and delivers care plans and member education materials 16Confidential: Do Not Distribute
- 17. Exploring the Partnership Further: Citra Health Solutions & MedSolutions Krista K. Sultan RN, BSN, MS Program Development Manager Citra Health Solutions
- 18. Partnership Citra Health Solutions partnered with MedSolutions due to a lack of care coordination for their Medicare ACO patients. Medicare Shared Savings ACO Lack of Post-Acute Care Coordination Financial and Quality ConcernsCommunication Gap Little Visibility Into Hospital PCP Only 19Confidential: Do Not Distribute
- 19. Post-Acute Care Process MedSolutions was hired to create a coordinated approach that included all five elements of Citra Health Solutions as part of the solution We partnered to create and launch a collaborative approach that brought the hospital, Citra, and hospitalist stakeholders together, without making any large-scale changes to the processes already in place Using the MedSolutions approach, which incorporates the keys to care coordination success, Citra Health Solutions has realized a 43% reduction in utilization of Skilled Nursing Facilities (SNFs) and a 25% reduction in Inpatient Rehab Facilities (IRFs) 20Confidential: Do Not Distribute
- 20. Program Results Discharges To Initial Discharge Recommendation Actual Discharge w/ MedSolutions Recommendation % Increase/ decrease Estimated Saved (PMPM) Discharges % Discharges % Home 22 32.4% 27 39.7% 23% -- Home Health 19 27.9% 21 30.9% 11% $1.08 SNF 16 23.5% 10 14.7% -38% ($18.54) IRF 4 5.9% 3 4.4% -25% ($6.17) Other 7 10.3% 7 10.3% 0% -- Totals 68 100.0 % 68 100.0% -- ($23.62) Program Effectiveness 20% of patients were discharged to a more appropriate post-acute setting Significant reduction in SNF and IRF over-utilization and corresponding increase in use of Home Health and Home settings (Important note: Medicare FFS setting – we could only recommend) 21Confidential: Do Not Distribute
- 21. Patient Scenario The Discharge Planner took MedSolutions’ recommendation and sent patient “A” home. 22Confidential: Do Not Distribute
- 22. Quotes of Success “In a previously unmanaged patient environment, Citra and MedSolutions partnered to develop a unique solution for managing post-acute spend. Citra’s management of the patient-physician relationship and patient profile coupled with MedSolutions’ expert staff and clinical guidelines resulted in positive behavior change that out- performed traditional methodologies. The success utilizing influential techniques rather than denial truly embodies the transformation of healthcare today.” Nicole Bradberry - President and COO of Citra Health Solutions 23Confidential: Do Not Distribute
- 23. Quotes of Success “At [St. Vincent’s] Southside, the pilot has been a successful one. The MedSolutions team have been very supportive and responsive to the needs of the CM department and the patients they have serviced. The implementation was very seamless for all, while initially there were a few bumps in the road with communication, there now appears to be a solid/open line of communication established, which I think has been a huge factor to the success we have had this far. We look forward to continuing the partnership.” LaRhonda Brown – Case Management, St. Vincent’s Healthcare - Southside Confidential: Do Not Distribute 24
- 24. Reach Us Ken Van Cara MedSolutions 615-468-4266 Kenneth.VanCara@MedSolutions.c om http://www.MedSolutions.com Krista K. Sultan RN, BSN, MS Citra Health Solutions KSultan@CitraHealth.com Q&A
Editor's Notes
- Ken present – with partnership with Krista.
- Ken present transition.
- Ken present.
- Ken present.
- Ken present. Examples of adverse events: “The term ‘adverse event’ describes harm to a patient or resident as a result of medical care. An adverse event indicates harm to the patient as a result of medical care, including the failure to provide needed care. Adverse events include medical errors but they may also include more general substandard care that results in patient or resident harm, such as infections caused by the use of contaminated equipment. However, adverse events do not always involve errors, negligence, or poor quality of care and are not always preventable. *See research for additional explanation. In February 2014, the Department of Health and Human Services conducted a study on the incidence of adverse events in skilled nursing facilities among Medicare patients. Their results showed the high instances of adverse events in skilled nursing facilities. Many of which were completely preventable. The study also found that along with this severe patient harm, came tremendous waste in the system. This waste could’ve been avoided in many cases by proper oversight into the post-acute facility. Preventing patient harm does not come at a cost – it saves costs.
- Ken present.
- Ken present.
- Ken present.
- Ken present. How do we address the growing problems in post-acute care, both in costs and patient harm? The New England Journal of Medicine and other well-known health institutions believe that the only solution is truly coordinated care between the hospital, physicians, patients, and the post-acute provider to ensure there are no gaps or breaks along the care continuum. There must be a bridge between the hospital or acute care facility and the post-acute facility for true care coordination and quality improvement.
- Ken present transition.
- Ken present.
- Ken present. Caregiver- Family or loved ones that are willing and able to help with recovery? Transportation - Can the individual get to an appointment with their PCP or physical therapy appointment? Home Environment - Does the home have the things a member needs to recuperate comfortably and safely? Can we setup a bed for them on the 1st floor, if their bedroom is currently on the 2nd floor? Are there lift chairs or wheelchair ramps needed? Health Literacy & Cognitive Ability - Does the member have the health literacy or cognitive ability to understand and follow their care plan? Activities of Daily Living - Does the member have the ability to prepare meals, bath, dress, use the telephone, use transportation?
- Ken present.
- Ken present.
- Ken present.
- Ken present. If he would like. Overall, not sure about this slide – that will be a Ken call. I have incorporated the notes from Mike that were used in an earlier slide – see them below in the notes section. I have “hid” the slide for now, until Ken decides whether or not to continue using it. Network Evaluation Score: Innovative tool to rate, score, and compare facilities & networks Care Management: Streamlined workflow to understand member’s condition and coordinate care Case Management: Focus on member’s unique clinical presentation and needs & see workload for the day and case statuses Utilization Management: View authorizations & benefits (HAVE RENAMED THIS ONE) Risk Stratification: Review members for specific readmission rates Evidence-Based Guidelines: Ensure most comprehensive guidelines are applied to decisions Provider Score Report: Search by city, state, zip, provider type to compare scores Medication Review: Perform automated review, indicating red flags Reporting: Gain transparency into population health & view health outcomes and impactive programs Expense Review: Expenses listed by site of care & opportunity for hard and soft savings Claims Management: Process and pay claims
- Marks transition to Krista’s portion of presentation.
- Krista present. See Krista’s original notes below. Little Visibility Into Hospital: There was a time with primary care physicians always followed their patients when they were admitted to the hospital. Unfortunately, that is no longer the most common practice. Most patients are cared for by hospital-based internists during their inpatient stay. Often a patient’s primary care physician will not be aware until some time after discharge that their patient has been hospitalized at all. This makes follow-up care after an inpatient stay in the hospital difficult to coordinate in a timely manner. Communication Gap: There are a number of different parties involved in coordinating care in the inpatient setting. Hospitalists, specialists, case managers, nurses, physical and occupational therapists all work together inside the hospital to create and manage the plan of care once a patient is admitted to the hospital. What happens, however once the patient is discharged from the hospital? Whose responsibility is it to coordinate care once the patient leaves the hospital? The natural answer to this question is of course – the primary care physician. The PCP historically plays the role of being the first and central point of care in the patient’s journey throughout the healthcare system. However, if the PCP does not have clear visibility to when the patient is admitted to and discharged from the hospital, then how can they effectively coordinate care? Financial and Quality Concerns: Since the Affordable Care Act was signed in March 2010 there has been a steady increase on the emphasis of quality in health care. This legislation has gradually increased the number of financial incentives for hospitals and providers delivering high quality care, as well as financial penalties for those who do not meet quality standards. Patients have more visibility into quality ratings than ever before and are encouraged to factor these ratings into how they select where and when to receive healthcare. Medicare Shared Savings ACO: 2012 marked the beginning of the Medicare Shared Savings Program, where providers participating in accountable care organizations (ACOs) could potentially take home a portion of their Medicare Savings each year. One of the largest expenses for any ACO is inpatient hospitalization making this a target expense for any ACO serious about saving. Hospital readmission is a notable area of focus because it is easy to see that patients are most vulnerable for admission to the hospital within 30 days of discharge. This new structure for delivering healthcare placed an increased emphasis on creating a smooth transition between healthcare services. Lack of Post-Acute Care Coordination: When patients are discharged from an inpatient setting it is imperative that they follow-up with their primary care physician so that their PCP can monitor their transition between healthcare settings. The large majority of inpatient stays lead to changes in medication regimes that if not executed properly can lead to hospital readmissions. It is also important that patients understand the signs and symptoms of disease progression and exacerbation so that they can seek help early if their condition should worsen. In order for the PCP to take on this role of care coordinator they must first be aware of the patient’s stay in the hospital. Communication between acute care facilities and community based practitioners is poor which unfortunately leads to poor patient outcomes and avoidable readmissions.
- Krista present. See Krista’s original notes below. There are a number of different care transition programs that have been published advertising success in mediating patient transitions from an acute care setting. The single common denominator is having a dedicated clinical provider assuming the role of care navigator. In this role, the practitioner serves as a central liaison between hospital staff, patient, and community practitioners. In the current paradigm, the ACO model was used as the central theme in coordinating care. ACO patients were identified when entering the acute care setting and paired with a care navigator. Using this central practitioner as an anchor, the patient was effectively guided through the care transition while keeping all stakeholders informed of their progress. Thus by adding a central advocate for the patient the communication gap was bridged. Patient Hospital Providers Care Management Hospitalists
- Ken present.
- Krista present. Some of Krista’s original notes are below. In this case, when the nurse case manager intervened she not only allowed the patient to be discharged to a lower level of care, she also advocated for a safer and more cost effective method of treatment. In addition to saving money on the discharge setting she also reduced the hospital spend by having the patient transitioned to oral medication. Once the patient’s kidney function had been restored with intravenous fluid therapy there was no need to continue with IV treatment. The longer IV treatment is continued the more likely the patient is to experience a complication such as infection or thrombosis. Thus in this case the treatment recommendation was not only the most cost effective, but also the most conservative course of treatment.
- Krista present.
- Krista present.
- We will prepare some questions for you all to have as reference and to spur the conversation if questions come in slowly.