©AAHCM

Post Acute CareWilliam Mills, M.D.

©AAHCM

Dr. Mills is an employee and shareholder of Kindred Healthcare and has equity interests in HopeBridge Hospice, LLC and

chroniccaremanagement.com, LLC.

Disclosures

©AAHCM

Post acute care today

Care transitions

Post acute care tomorrow

How HBPC can partner with post acute care

Agenda

Post Acute Care Today

35% of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)

Intensity of Service LowerHigher

(1) Kaiser Family Foundation, 2011 statehealthfacts.org and AARP 2011 projections (2) Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System

Medicare Patients’ Use of Post-Acute Services Throughout an “Episode of Care”

47.6 million Medicare beneficiaries with an estimated 9,100 individuals added to the program each day.(1)

Patients’ first site of discharge after acute

care hospital stayPatients’ use of site

during a 90 day episode

SHORT-TERM ACUTE CARE

HOSPITALS

LONG-TERM ACUTE CARE

HOSPITALS

INPATIENT REHAB

SKILLED NURSING

FACILITIES

OUTPATIENT REHAB

HOMEHEALTHCARE

37%2% 10%

11%

41%

52%

9%

21%2% 61%

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Source: The Moran Company. Analysis of 2008 Medicare acute-care hospital data sorted by APR-DRG grouper.Note: SOI is measured by the 3M APR-DRG Grouper.

Short-term Acute-care Hospital (STACH) and PAC Severity of Illness (SOI), in Prior STACH Stay

Patient severity of illness varies by PAC setting

Clinical and non-clinical factors help determine the best PAC setting for a given patient

Provider• Relationships with local

PAC providers •Practice patterns

Clinical• Current health

status•Comorbidities•Prognosis

• Payer coverage rules PAC Facility

•Specialization•Proximity•Capacity

• Relationship with acute sitesReferring

Provider• Relationships

with local PAC providers •Practice patterns

Patient• Psychosocial

support• Ability/

willingness for self-care

• Treatment preferences

Intent: To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care, improved outcomes, and overall quality comparisons.

Requirements: ◦ LTACH, IRF, SNF, and HHA providers must submit

to CMS specified quality and resource utilization assessments.

IMPACT ACT 2014

Emerging Tactics in Post Acute Care

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1

• Physician Alignment and Access that assures immediate access to office-based primary care or house calls as well as primary care management in acute and post-acute venues

2

• Robust IT Platform and Just-in-Time Business Intelligence that provides cross continuum information in real time for pre-acute, acute, post-acute, and home-based encounters

3

• Risk-Adjusted Enterprise Care Management that includes stratifying population and tailoring care management as well as longitudinal management of beneficiaries

4

• Developing Network of Post-Acute Providers for standardized, evidence-based care across the acute/post-acute continuum and seamless, optimal patient experience

Characteristics of Today’s Most Effective Post-Acute Care Partnerships

• Physician integration – physician participation in care across settings

• Agreed-upon clinical protocols• Clearly defined expectations

Clinical Collaboration

• Regularly established forum for communication and performance improvement; for example, joint operating committee

Communication

• Hospital volume is concentrated in a small number of post-acute providers to allow for increased clinical collaboration

Concentration

• True partnership around improving patient outcomes and reducing utilization

• Process to review and improve care on an on-going basis

Partnership

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Care Transitions Program

Patient/ Caregiver

Engagement & Education Across the Continuum

Transition Plan of Care

Support & Collaboration

Communication with Patient’s Health Care

Provider

Medication Management

Support of Follow-Up

Plan of Care

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Reducing Gaps in Patient Care through:

Program Goals:

Reduce readmissions Increased engagement with

patient’s primary care provider Improve outcomes, key quality

metrics, and the patient’s experience

Provide greater continuity of care to and from different care settings

Promote patient engagement in care planning and goal setting

Reduce medication errors

Care Managers are paired with patients most at risk for

rehospitalization to improve provider coordination with

transition to home

Care Transition Managers to Smooth Transitions, Connect Patients with Primary Care Physicians, and Reduce Rehospitalizations

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Joint quality committees to promote data sharing and communication, improved outcomes, and consistent quality measures across settings of care

Health Information Exchange – Connecting electronic medical records to support care management across settings, streamlined reporting of clinical/utilization metrics

Condition-specific clinical programs, care pathways and outcome measures to support episode care management, decision making and learning

Patient-centered care management capabilities that extend across post-acute sites of care and into home to improve quality and reduce costs

Post Acute Care TomorrowEnhanced Physician

Collaboration

CareManagers to Smooth Transitions

IT Linkages and

Information Sharing

Targeted Clinical

Programs & Pathways

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Physician Communication EMR Linkage

Joint Operating Committee (JOC)

Performance Improvement

Staff/affiliate physicians provide coverage at Kindred Post-Acute Sites

Medical leadership is actively engaged in JQCs and guide performance improvement initiatives

Setup medical record access to the STACH EMR

Automating movement of H&Ps, progress notes, and discharge summaries

Monthly meeting composed of administrators, physicians, quality and case management staff

Operates under charter defining objectives of committee, parameters of the relationship, and establishment of a mission

JOC uses performance dashboard including LOS, readmission rates, patient satisfaction, quality metrics (e.g., falls, wounds, infections, wean rates, mortality)

Post Acute Care Tomorrow: Bundled Payment Collaborative Elements

Multiple Communication Elements Drive Success

Operationalization of “The Triple Aim” Post Acute Medicine

Improve Health

Improve Patient

Experience

Cost effective care

Home-Based Primary Care

Risk Stratification

Acute/Post Acute Alignment

Care Transitions Programs

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Patient Facing Tactics• Health risk assessments and patient

stratification

• Care plan development and tracking; care team

• Advanced care planning, including placement

• Care transition management, medication reconciliation

• Technology usage/tools in caregiving, monitoring

• Expanded “HH of the Future”:

• Chronic care, disease management

• Ongoing monitoring

• Intervention algorithms/processes, resources

• Other services, including hospice, palliative

• Patient education, engagement, data mechanisms

• Patient satisfaction surveys and feedback

Provider Facing Tactics• Provider support and education: disease

pathways, care plans, care team, placement, protocols

• Resources of HBPC network

• Network development, including specialists, DME, lab services, radiology, etc.

• Support/coordination in patient management

• Provider feedback mechanisms

• Provider training on tools, IT system, data/analytics

• Reporting on cost/utilization and quality/outcomes:

• Dashboards

• Real-time notifications of hospitalizations, care transitions, alerts/interventions needed, etc.

• Capabilities to spot/manage “frequent flyers”

Health Information Technology Tactics• Integrated and complete EHRs for Health Info Exchange across network

• Analytics to identify and manage “frequent flyers”: risk pools, placement, care plans, tracking

• Real-time reporting on cost, quality/outcomes, patient satisfaction

PATIENT

HOME-BASEDPRIMARY CARE

HBPC-driven care management provides most immediate, impactful care model for high risk PAC users

HBPC as Fulcrum of Care Coordination for High Risk Patients

Home health and

home therapy

Acute care hospital

LTACH

Subacute

Nursing home

Assisted living

Lab

DME

Outpatient clinics

Private duty home

care

Social work

Visiting hospice

and palliative

care services 15

Home Based

Primary Care

Conclusions

The aging and chronically ill population will continue to use increasing amounts of post acute care.

Enhanced focus on reporting of clinical quality and resource utilization can promote increased alignment between acute and PAC sites as well as improved outcomes.

HBPC can be a valuable partner to high PAC users, by providing improved care access, coordination and management.

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