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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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
Heart Failure Population Care ManagementTransitional Care Program
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
Heart Failure Population Care ManagementTransitional Care Program
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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
Partnering for Home Care
• 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
Partnering for Home Care
On Site Review
• General organization
• Quality Measures• Accreditation Survey Results
• Policy and Procedures
• Personnel
• Interpreter Services
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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?
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CAHSAH® 2016 Annual Conference & Home Care Expo
2016 California Association for Health Services at Home
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