Understanding Managed Care Goals within a …cahsah.org/asp/Conferencehandouts/2016/M1100.pdf ·...

1

CAHSAH® 2016 Annual Conference & Home Care Expo

2016 California Association for Health Services at Home

Susan Carmichael

MS, RN, CHCQM, ICM, COS‐C, FAIHQ

Chief Compliance Officer

Chief Clinical Officer

SELECT DATA

Neil Rotter, Accredited Home Health Services

Barbara Knott, Kaiser Permanente SCAL

Understanding Managed Care Goals

within a Payer/Provider Relationship

2



Kaiser FoundationHospitals

Kaiser Permanente StructureIntegrated Delivery Network

Kaiser Permanente is a HealthPlan, Hospital System and Medical Group, all working Together.

Permanente Medical Groups

Kaiser Foundation Health Plan, Inc.

Different departments addressing similar or overlapping problems

Challenge maintaining

inventory of local activities

Local initiatives designed to meet immediate needs Regional

initiatives implemented

National initiatives piloted

Lack of clarity on national

roadmaps/prioritiesChallenge

forming data driven strategies

Need for POCs and Pilots to assess system

viability

Different solutions for same problem

Challenge in reporting activities

Lack of regional/national

clarity

Sporadic success at influencing National Teams Requirements

RegionalSporadic evaluation of local

projects

Frustration with the pace of

regional direction

Frustration with the pace of national

roadmaps/direction

Challenge assessing requirements and

priorities with broad stakeholder groups

Limited funding and competing agendas

requires governance and prioritization

Lack of consistent visibility in activities in other regions

Challenges in sharing cross regional view with

the regions.

Local

National

…..Long and winding road to strategic alignment

Lack of visibility into possible solutions

3



Virtual Care is KP Strategic Priority ..

Home Health

Telehealth

Reduced Hospital Stay Empowering the Member

Regional Innovation Initiatives

Reimagine Ambulatory Design

Mobile Strategy

Remote Monitoring Virtual Care Work group

Home Health Members

Unqualified Members needing services

General Members

Video Visits Remote Monitoring

Mobile Workflows

Reduced Hospital Cases

Home Health: Foundation for Virtualized Care

4



Kaiser Permanente Southern California Home Care Services

Medicare Certified Home Health• Skilled care, homebound, physician’s orders, intermittent care

Advanced Medical Care At Home• Hospital at Home

Home Based Palliative Care• Chronically ill, prefer care at home, generally homebound, require skill of RN to manage complex plan of care

Medicare Hospice• End of life care for the terminally ill, symptom management, medical, spiritual and psychosocial support

Programs At Kaiser Permanente Making A

Difference Today

5



Advanced Medical Care At Home

Patients can receive hospital-level care at home

• Home from the ED• Physician oversees the care• Home Health visits support the care• IV antibiotics administered at home if required• Assessment• Teaching/training• Support

Community-Acquired Pneumonia program –Place of treatment based on the patient’s status. Home with Home Health is an option, even when IV antibiotics are required.

Heart Failure Population Care ManagementTransitional Care Program

In Kaiser Permanente Southern CA, there are approximately 40,000 patients with heart failure.A program targeting high risk members with heart failure was developed and implemented in 2007.

• Two physician co‐leads (cardiologist and primary care MD)• Health Education• Utilization Management• Pharmacy Analytic Services• Clinical Analysis• Home Care Services• Quality Assessment and Improvement

6




Goal is to optimize the functional status and quality of life for members with heart failure by providing a regionally standardized system of care transitions throughout the continuum.

Three basic components to the program:• Inpatient Care management• Home Health• Outpatient Care management

Home Health RN:• Specialty trained to assess and intervene on the member

with heart failure• Refers appropriately to Home Health, Palliative Care or

Hospice, if needed• Collaborates with the Inpatient and Outpatient Care

Managers


Transitions

Inpatient Care Management Home Health Outpatient

• TCP patient identification• TCP referral• Discharge planning coordination• Survival Skills education

reinforcement• Home Health/Outpatient Care

Manager• HF Bundle oversight

Inpatient Nursing• Patient identification• Survival Skills education• Discharge instructions provided and

understood by patient/caregiver• HF bundle

• Home Visit within 48 hours of discharge

• Medication Reconciliation

• MD appointment confirmation

• How and when to call Outpatient Care manager/ 911

• Symptom/ Fluid management

• HF Education/Diet/Adherence

• Outpatient care manager coordination

• Intensive post discharge follow‐up for up to six months

• Medication optimization

• HF education and self management optimization

• How and when to call KP/911

• Remote care monitoring

• Medical and palliative care coordination

• Inbound phone support by Outpatient Care manager and advice available 24/7 through KP OnCall

7



Palliative Care Services

Who Provides Palliative Care?

We ALL provide palliative care!

Hospice

Primary Palliative Care:Provided by Everyone –pain management,

goals of care

Secondary:Specialty Palliative Care teams – IPC,

Clinic, HBPC

Palliative Care Services

Home Based Palliative Care

• Physician would not be surprised if the patient were to pass in the coming 12 months – evaluated every 6 months

• Interdisciplinary team with core members

• Physician Home Visits

• Aggressive treatment of an acute exacerbation of an illness is provided at the patient’s or family’s request

• Requires ongoing evaluation and oversight of the care plan

8



Total Joint Surgery Program

23 hour discharge is now our standard – have begun same day discharge.

Collaboration throughout the continuum of care:• Orthopedics• Patient Health Education• Pharmacy• Physical Therapy• Inpatient Nursing• Home Health• Consistent messaging from all involved in the process

Partnering for Home Care

• Contracts sought based on service area volumes• Kaiser Permanente will provide training for specialty programs as needed

• Kaiser Permanente patients are internalized as much as possible.• LACE scores of >11 • Complex wound care • Specialty Programs i.e. Total Joint Surgery• Infusion

• Prior authorization and re‐authorization for visits required for Home Health

• Member Benefit

9




• An on‐site visit from a Kaiser Permanente Manager or Quality staff is required annually for the Home Health Quality Oversight Program and every 3 years for Regional Credentialing

• Accredited agencies (TJC, CHAP, ACHC) will not be required to undergo an on site visit for Regional Credentialing. An annual desk top review will be performed.

• Any unusual occurrence and complaint issues/actions/follow‐up with resolutions will be recorded and reported to Regional Contracting

• Agencies receiving a Final score of 85% or below will have a 6 month follow‐up visit


On Site Review

• General organization

• Quality Measures• Accreditation Survey Results

• Policy and Procedures

• Personnel

• Interpreter Services

10



Home Care’s Partnership Goals with Managed Care Entities

Receive Referrals

Improve Process

Support Macro Goals

Quantify Accountability

Proactive Home Health Utilization

Kaiser Metro‐ A microcosm of the Managed Care Environment

• Influx of Patients Creates Staffing, Patient Service Delivery Issues, & Patient Satisfaction Challenges

• Process Change – Necessary but not welcome

• Priorities Out of Sync – Temporary or Permanent. How to fix?

11



Comparison – Kaiser vs Other MC Entities

• Pros

Clinical & Process Cohesiveness

Advocacy

Accessibility

Vendor Support

Comparison – Kaiser vs Other MC Entities

• Cons

Variance between offices

Who’s more right?

Tricks of the trade

12



Date post:	01-Sep-2018
Category:	Documents
Upload:	hoangtuong
View:	213 times
Download:	0 times

Understanding Managed Care Goals within a …cahsah.org/asp/Conferencehandouts/2016/M1100.pdf ·...

Documents