THE USE OF CLINICAL OUTCOMES TO PARTNER WITH ACCOUNTABLE CARE

ORGANIZATIONS

ALFA May 2014 Anne Ellett, N.P., M.S.N.

Sr. Clinical Specialist SILVERADO

#ALFA2014

Objectives Describe how Assisted Living communities can collaborate with ACO’s for common goals Discuss the value of tracking and measuring clinical outcomes in Assisted living How to identify which clinical outcomes will be most beneficial to your AL community and residents.

Accountable Care Organizations are intended to encourage voluntary networks

of providers to collaborate on care for Medicare beneficiaries with the aim of

improving outcomes and reducing costs.

Participating providers will be eligible to receive a portion of shared savings from bundled

payments

Translates to: ACO’s will seek out partners who have demonstrated quality and are able to

manage risk

Achieved by: • Measured outcomes by verifiable data • Excellent care management throughout the

progression of frailty • Aligned financial incentives

Post- acute is the Key to Managing Health Care Costs

Formation of ACO’s is in agreement with the ACA

Movement away from fee-for-service

(rewards for more care but not necessarily better outcomes/care)

towards quality based care

Moves the risk to the provider

Top 5 Needs of ACO’s

• Data management/technology • Network development • Case management • Patient engagement • Organizational realignment

Compare an ACO to Building a House

The ACO is the general contractor Wants to contract with other quality sub-contractors All of them share in the construction of the final product and are responsible for the final outcome

ACO’s - Strategic Change Involving Hospitals and Their Partners

• Focus on 3 key areas:

Clinical Efficiency throughout the care continuum – partnering with post-acute providers Clinical Quality Physician partnerships

Clinical Efficiency

More efficient, coordinated management of a growing census of complex and comorbid patients Reduced hospital readmissions Build an infrastructure for enhancing transition planning Accountability between the hospital and post-acute providers

Clinical Quality Hospital reimbursement will be reduced if quality

measures are not met Quality measures cover a wide range: Patient satisfaction Adverse events/patient safety – i.e., infections/falls/pressure ulcers Care coordination/transitions Post-acute follow-up – immunizations/screenings Management of chronic dx – diabetes, HTN, CHF, CAD, COPD, osteoporosis, anti-coagulant therapy

Emphasis on Collaboration and Coordinated Management

Electronic medical records Shared risk for poor outcomes Increased reimbursement for good quality measures

Where Can Assisted Living Fit into the ACO World?

AL can become an integral part of the post-acute continuum Data driven hospital relationships Continuum of services for frail elderly with multiple co-morbidities –SNF, outpatient rehab, AL’s, home health, physician private practices Assist to enhance transition planning by building relationships with nurse care managers

RESIDENT DEMOGRAPHICS

ALFA reports that the average age of AL resident is 86.9 years. Female residents (73.6%) outnumber male residents by almost 3 to 1. The average length of stay for assisted living resident is 28.3 months.

RESIDENTS HAVE MULTIPLE COMORBIDITIES

ASSISTED LIVING IS NOT PROVIDING HEALTH CARE, YET……LOOK WHO IS

LIVING UNDER YOUR ROOF…

ACO’s are Going to be Very Interested in Your Management of

Your Frail Elderly Residents

What are your differentiators?

What are the “Hot Buttons” for Hospitals and ACO’s now?

Rehospitalization within 30 days CHF, COPD, dehydration, pneumonia, sepsis, UTI’s Pressure ulcers Falls Management of chronic illnesses - HTN, CHF, CAD, COPD, DM, osteoporosis, anti-coagulant therapy

System for Tracking, Collecting and Improving Clinical Outcomes

These systems will be your differentiators Demonstrate your 30-day readmission rate by condition and your plan to decrease readmissions How are you doing on managing those “hot buttons?” (hospitalizations, P.U., falls, management of chronic diseases?)

AL is an Integral Part of the Continuum of Care

Partner with hospital on discharge plans for AL patients from first day of hospital admission Assist the hospital with decreasing in-hospital LOS by improved management of post-acute patients Effective use of your nursing resources Develop systems and show data of clinical outcomes Assist hospitals to decrease hospital readmission penalties

Partnerships are value-based. What can we bring?

What is Worthwhile to Track?

Falls/Fractures Hospitalizations and rehospitalizations Chronic disease management Pressure ulcers

Managing Transfers-out/ Rehospitalizations

Hospitals are penalized if they have patients rehospitalized for same diagnosis within 30 days AL can put together a program to demonstrate to hospitals their ability to care for their returning residents

Do you track hospitalizations? Do you know if you have a problem?

Every time a resident is “911’ed” , this is an opportunity for team review – what could have been done to avoid a 911 call? S/S of illness in elderly can be subtle

Emergency Send-outs

Prior known change of condition? Due to a fall? Exacerbation of chronic condition? Due to behavior changes ? Admitted/not admitted? # of 911 calls/month?

A Resident Returning from the Hospital is at High Risk

Elderly admitted to the hospital: At discharge, 31% deteriorated in ADLs At 3 months, 51% had either died or worsened in functional status Continued decline in function after hospitalization: 2 days post-hospitalization, 65% lost ability to walk At discharge, 2/3 had not improved in function 10% deteriorated further

Elderly Admitted to Hospital

Bed rest

pressure sores

pain

poor motivation

incontinence

weakness

weight loss

Urinary infection/sepsis delirium narcotics

urinary retention

IMMOBILITY

Your Plan for Decreasing Rehospitalizations

Keeping in touch with your resident and family during the hospitalization Meeting with your team to formulate a rehabilitation program for the specific resident/diagnosis (there are no surprises) when they return to your community What are the goals for post acute discharge? – hit the ground running – no surprises… Establish a pattern of good communication with all providers involved in the resident’s care- team approach

Staff Training

What are the most common reasons for hospitalizations in your community? (falls, CHF, DM, pneumonia, behaviors) Do they know how to recognize the subtle signs of worsening conditions? Empower/reward them to report status changes early (S/S of illness are subtle in the elderly)

Resources

You can’t provide good care for frail elderly by yourselves We’re not delivering health care but…

Build Partnerships Communication with discharge

planners/nurse case managers Partner with an excellent home health with PT/OT/ST Active pressure wound prevention program Build relationship with a good hospice, integrate them into your community

Internal Resources

Nursing – if you have a nurse, don’t expect 1 nurse to be able to provide good nursing care to 100 frail residents… Regional/Consulting Nurse – are you getting the most value from them? Vendors that will provide staff training: Home health, PT, Pharmacy, Hospice, DME, Professional organizations – Alz. Assoc., Am. Parkinson’s Disease Assoc (APDA), Heart Assoc.

Summary – How to Manage Emergency Transfers and Rehospitalizations

What type of assessment and care plans were in place? Reason/dx for the send-out Identification of trends in your community What type of system do you have in place to communicate with the acute care system about your residents AL is expected to manage – or facilitate management of – chronic illnesses of their residents

Benefits of Measuring Clinical Outcomes

ALLOWS YOU TO SHOW EXCELLENCE! You can’t improve something if you are not measuring it Measuring specific outcomes assists you to communicate clearly with your team and increases the efficiency of work – provides focus Measuring and sharing the outcomes with the team empowers them and builds a culture of transparency

Sharing Your Outcome Measures with Residents/ Families is a

Customer Satisfier

Proving that you are measuring clinical outcomes is a powerful testament to your quality of care. The eyes are on AL now…

Bad things can happen even to good operators – by establishing a system of measuring outcomes, you have the tools to enable you to quickly respond to formulate a plan to address a bad situation

Hospitals and the Nurse Case Managers will Remember Which AL’s

Can’t Manage their Residents with Chronic Disease

Hospitals will look at their own analysis of who comes back into their hospital – Where had they been discharged to and what was the diagnosis?

4.2%

4.4%

4.6%

4.8%

5.0%

5.2%

5.4%

5.6%

5.8%

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

5.1%

5.3%

4.8%

5.0%

5.3%

5.1%

5.4%

5.7%

4.9%

5.2%

SILVERADO AVERAGE RATE OF TEMPORARY DISCHARGE

Pulmonary 6%

Cardiac 8%

Lacerations/Wound repair 10%

Tx of Fx or rule out Fx 16%

Psych Eval or Tx 4%

Seizure/ Alt LOC 9%

Pneumonia 6%

UTI 7%

Infectious Process 7%

Dehydration 2%

GI 1%

Vascular 7%

Other 17%

Silverado - Temporary Discharges by Diagnosis

AL Providers who have an organized approach and can show

data that demonstrates quality, will be a preferred partner with the

ACO’s in their post-acute network

• What can AL’s do to partner with ACO’s? Communication What problem can you help them solve?

• Be proactive Do you know your physicians? Do they know your goals? Are your doctors affiliated with an ACO?

• Identify areas of improvement and fix it • Demonstrate quality with data that confirms it

www.SilveradoCare.com AEllett@Silveradocare.com www.SilveradoCare.com