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©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
10
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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