Hospitals, Clinics, Health Systems and Home Care
Cathy Barr CEO Bethesda Hospital
Vice President Community Based Services HealthEast Care System
New England Home Care Conference
May 31st,2012
Background ◦ Who is HealthEast Care System ◦ Health Care Reform and Market Landscape Government Payers Health Systems
◦ Health East Care System-Positioning for the Future Art of the Middle Game The Critical Few How Community Vitality plays into our Roadmap
◦ Home Health Care Opportunities Market Pressures Consideration of Labor Needs Alignment with Payers, Health Systems, Hospitals and Clinics
HealthEast Care System - St. Paul, Minnesota
HealthEast Care System
• 3 STAC, 1 LTAC Hospitals • 14 Primary Care Clinics • More than 35 specialty services • Home Care & Hospice • Medical Transportation
Some Statistics
Licensed Beds 925 Employees 7,300 Volunteers 1,200 Credentialed Physicians 1,400
Woodwinds
Health Campus
St. Joseph’s Hospital St. John’s Hospital Bethesda Hospital
Visits: 65,000
AVG LOS: 41 days
Patients Served:
7,000 +
Employees: 100+
Disciplines
• Skilled Nursing
• Rehab (PT, PTA, OT, SP)
• Home Health Aide
• Nutrition Services
• Medical Social Work
• Chaplain
Specialty Programs
• Ortho Team
• Perinatal
• Palliative Care
• Wound Management
• Infusion Therapy Nursing & Pharmacy
• Health Alert Personal Response
• Cardiac Care Team
The Pressures Hospitals and
Health Systems are Under!
ACA
ACO
HITECH
VBP
PMPM
Bend the Cost Curve
Value or
Volume
Medical Home
Doc Fix
Primary Care Attribution
Insurance Exchanges
Gang of Six Doughnut Holes
Co-ops
Care Transitions Total
Cost of Care
PMPM
?
Planning & Positioning
2010 – 2013 2014 – 2017
The Prelude Market Expansion
Regulation and Restructuring
2018 – 2020
Constitutionality challenge? Insurance expansion rollbacks? State insurance exchanges? Presidential Election!
Significant increase in insured population
Addressing the realities of affordability
Key Issues:
• Arguments before the Court lasted for three days.
March 26, 2012 thru March 28th The Courts decision is likely at the end of June.
• Court is divided along ideological lines
4 justices – record of conservative opinions (Scalia, Alito, Roberts, Thomas)
4 justices – record of liberal opinions (Sotomayor, Ginsberg, Kagan, Breyer)
1 swing vote - Kennedy
• The outcome of the case is unpredictable, and predictions are largely guess-work.
Moving to Population Health Management
Moving to Total Cost of Care Models
Piloting Risk Sharing/Gain Sharing reimbursement programs
Looking for Innovation
◦ Home Health Falls Prevention Programs
◦ Palliative Care
◦ Diabetes Management
◦ Cognitive Disorders
Dual Eligible Care Management
BCBS-Mass,
Boston, MA:
Alternative quality
contract
CaroMont,
Gastonia, NC:
Bundled payment
for knee
arthroplasty
Source: Sg2 Interviews, 2011.
HealthEast,
Saint Paul, MN:
Incentives tied to
total cost of care
target.
10 Sole Community
Providers in
Maryland:
Prospective annual
budget—total patient
revenue
Aligning Hospitals, Health System, Physicians, and, Post Acute Care Services ◦ Developing Infa-structure-ACO, Care Management ◦ Focusing on Clinical Integration-Standardization of Care
Improve Care Transitions ◦ Improve Patient Outcomes Across the Care Continuum
Reduce the Total Cost of Care
Today’s Market
Disease-Centered System of CARE Production-Model Health System
Patient Training/Education may take more of a front seat for home health with reform
Retail Pharmacy
Wellness and Fitness Center
Diagnostic/ Imaging Center
Urgent Care Center
Home
Physician Clinics
Ambulatory Procedure Center
IP Rehab
Hospital
Home Care
Acuity
Community-Based Care Acute Care
Recovery & Rehab Care
SNF
OP Rehab
ACO Formation –clinical integration
Value Based Improvement with focus on: ◦ Care Transitions (Home Care is a key stakeholder)
◦ Superior Patient Care Experience
◦ Elimination of unnecessary waste
◦ Highly engaged staff and physicians
Electronic Health Record ◦ Engage patients thru medical record
◦ Analytics
Future Focus on primary and post-acute care partnerships
Home Care is integral in providing best care, best value
5%–10%
10%–15%
15%–20%
Incremental Change Incremental ideas that do not significantly disrupt the organization
Operational Improvement Departmental improvement ideas that reorganize activities; moderate impact on other departments Redesign Care Delivery Model Cross-departmental functioning and program elimination ideas; greatest potential to be disruptive Not silo redesign but redesign across the full continuum
% C
ost
Red
ucti
on
Consolidate roles and responsibilities
Invest in productivity
Leverage technology
Care transitions
Great opportunity for home care to be involved.
Lean process design
Six Sigma
Vendor and supply consolidation
Clinical Quality Patient Experience +
Cost Effectiveness
TCU/IRF/SNF
Health Alert
HOME CARE
Acu
ity/C
ost
Primary and
Specialty
Clinics Self
Community-Based Care
POST ACUTE CARE
Acute Care
Primary
Clinics
Specialty
Clinics
Based upon SG2 2010
Community Health
Worker, Parish Nursing,
Pathways for Better
Health
The Continuum of Care
LTACH
STACH
TRANSITION COACH
Self
Home Care
Do you have the clinical programs and personnel to serve the institutions patients?
Quality
Cost
Efficiency
Hospital/Health System Concerns
◦ Your programs and results
Readmission rate
Medication reconciliation
Functional Improvement
Pain Management
◦ Hospital Benchmarks and your agency’s performance = improved results and focus.
◦ Clinic Community Measures and your agency’s performance = improved results and focus.
Emergency Room-Hospital at Home Programs
quality
cost
efficiency
Hospital/Health System Concerns – Reduce Length of Stay
• Hospital national and regional benchmarks
–Value Based Purchasing Implications
• Reduce Readmission Costs and Future Penalties
• Core Measures
– Reduce Primary Care Cost after Acute Care Event and Maintain Patient in Community Longer
• Signs/symptoms
• Follow-up within 7 days
• Make it easy for Primary Care to use home health!
cost
Hospital/Health System Concerns
◦ Ease to Do Business With?
◦ Proactively Support Care Transition Processes
History and physical
Communication patterns and protocols
Hand-off’s smooth
Care paths or standards
◦ Focus on “ongoing” communication across the continuum.
efficiency
FY 2012 Year-To-Date Opportunity
Benchmark* STACH
Patients
STACH Patients Discharged to Home
Health Care % to Home
Health
2011 % To Home Health
Additional Cases Discharge to Home Health Care at
benchmark
Hosp A 14% 4,938 843 19.4% 16.8%
Hosp B 14% 9,427 820 9.9% 7.7%
11% 158
12% 300
13% 442
14% 585
Hosp C 14% 8,482 570 7.6% 6.6%
9% 181
10% 309
11% 438
12% 566
13% 695
14% 824
•Source: Fazzi Associates, Inc. Benchmark to Home Health Care is 14% •**home health projected growth rate – 3-5 % per year •***home health’s annual spend is expected to increase 10 percent per year
Collaboration with Acute Care Hospitals
Metric Hospital A Hospital B Hospital C
# Cases FY11 Annualized 240 203 690
Average Age of Patients 64.8 66.4 63.3
Patient Satisfaction – Overall Hospital Rating
65.7% 75% 76.6%
Patient Satisfaction - Pain Score Composite
65.6% 59.4% 74.4%
Inpatient LOS 3.1 3.3 2.8
Implant Cost $3,308 $3,375 $3,277
SCIP – ABX All or None 94.8 95.9 97.1
Discharged to SNF/TCU 40% 36% 18%
Readmission Rate 3.5% 5.7% 2.5%
Infection Rate 0.81% 0.84% 0.81%
Home Health Referrals 50.0% 48 % 72 %
Improve Care Transitions
HealthEast Care Navigation
• Help me through my care experience.
• Connect me to the right resources.
• Communicate with me in ways I understand.
• Patient Centered – patient/family partnership
• Effective - impact clinical quality measures.
• Safe - close care gaps, reduce complications
PATIENT CENTERED
GUIDING PRINCIPLES
Vision Promise: Care for patients within an integrated and patient centered model of care that leverages all components of the HealthEast Care System delivering a coordinated and positive care experience.
Excellent Patient Experience
Quality Outcomes
Effective Specialty Programs
Episodic Care
Longitudinal Care Relationship
Steering Team 5/29/08
• Timely - prevent care delays
• Equitable – culturally responsive
• Efficient – best use of resources across continuum
• Help me to manage across episodes.
• Coordinate my whole experience with HealthEast.
Financial Alignment
Right Care Right Time Right Place
0
1
2
3
4
5
6
Jan Feb Mar Apr May Jun July Aug Sep Nov Dec
Ac
uit
y L
eve
l
InPt Visits Outpt Visits Cardiac Rehab Office Visits Home
Meet Bouncing Bob!
Four Pillars
• Medication Management
• Personal Health Record
• Follow-up with PCP
• Education regarding
Red Flags
Prescriptive
Interventions
• Hospital meeting
• Post-Discharge
Home Visit
• Post-Discharge
3 phone calls
Diagnoses:
CHF, CAD, Arrhythmia, PVD, COPD, CVA, Diabetes, Hip Fracture & Joint Replacement
21.5% Medication Discrepancy Addressed
Percent of patients that found program to be helpful/very helpful with
Managing Medications 85%
Better understanding on when to call PCP 89%
Better prepared to work with PCP 85%
Follow-up appointments 69%
Patient using the PHR 70%
Would recommend to family and friends 95% 9.7 % readmission rate 30 days post discharge
(for any level of intervention)
Compared to national average 20-25%
Quality
Patient
Satisfaction Cost
March 2011 - March 2012
1114 persons enrolled
Services Provided per
Episode of Care
Average Visits
per Episode Interventions
Nursing 15 Med Rec, Disease Management/Education
Physical Therapy 3 Gait, Exercises, Strengthening
Occupational Therapy 3 Adaptive Equipment, Energy Conservation
Dietician 1 Nutrition Consult & Education
Medical Social Worker 1-2 Community & Financial Resources
Home Health Aide 6 Bathing & Personal Cares
Patient Data:
75 year old female lives with 80 year old
husband with dementia
Patient Diagnoses:
CHF, HTN, CAD, OA, DM, CRF,
Depression.
• Coordination of Care with the PCP • Case Management • Enhance Patient Experience • Improve Quality
Average Episode cost for CHF= $2,730
Medical
floor
Transition Coach
Pulmonary Navigator
PCP Navigator
P C P
Navigator
Pulmonary
Navigator
Inpatient Navigators
(redesign of roles)
D/C plans care progression flag others
Connect with Hospitalist Coordinator
D/C
Post Acute Care
Palliative Care
Home Care
Transitional Care
0%
5%
10%
15%
20%
25%
Baseline Pilot
22%
10%
30-Day Readmission Rate
0%
1%
2%
3%
4%
5%
Baseline Pilot
5%
0%
7-Day Readmission Rate
31 5 # Readmissions 7 0
24 4 # Patients
Readmitted
6 0
Baseline Pilot
Total Inpt Encounters 143 49
Chronically ill, unstable patient
Desire to stay at home
Services include: physician, nursing, HHA and therapy as needed
Frequency of visits in 24 hour period is dependant upon patient condition
Grant applications?
Escalating costs, require health care systems, acute care hospitals and payers to find alternatives that successfully accommodate the complex needs of acutely ill patients.
Home Health and other Post Acute Care Options can provide a service that is comparable to acute care facilities and allows for a critical mass of patients needed for optimal and cost effective outcomes.
• Focus on primary care clinics
• Focus on wellness/case mgt and community care management in the home – Reimbursement potential in the future
– Innovation i.e. falls assessment, diabetes education in the home, community care mgt post home health episode completion
– Be part of the care delivery redesign process
• Payers
• Health Care Systems
• Hospitals
• SNF’s/TCU’s
• IRF’s and LTACH’s
• Public Health
• Parish Nursing
• Payers & Health Systems – Utilization Review/Care Management
• Hospitals • Social Services Departments
– Directors
– Staff
• Health Plan Contracting – Clinical and Financial Leaders
• SNF/TCU – Admission Lead or DON
TCU/SNF partnerships ◦ Formal written agreements/Informal relationships
Accessibility
Patient types or specialty populations
Quality metrics-readmissions
Analytics
◦ Community Stakeholder Partnership-Stratis Health
Health Care Homes
Home Health Care
MSHO Care Management
Community Health Worker
Volunteer Core
Hospice
Parish Nursing
Senior Companion
Your Plan????
TCU’s SNF”s
Assisted Living Facilities
Questions?
