Preparing for Health Care Reform: An Opportunity for

CP Rehab Professionals

Zack Klint, MS, CESCoordinator, Cardiopulmonary

RehabilitationVanderbilt University Medical Center

Disclosure InformationI have no conflict of interest.

AcknowledgementsJay Groves, EdD, MMHC

EB Jackson, MBAAllison Jagoda, MS, CES

The US Health Care Spend

Per Capita Health Care Spend

Care Quality; How do we Compare?

Health Spending and Longevity

“The cost of sickness in America is a threat

to the country’s economic security”

D.W. Edington, PhD University of Michigan, HMRC

HC Reform and Family income

“The Health Care Reform Crossroads”

Health Care Reform; It is all About the Change

“Ultimately, all change efforts boil down to the same mission; Can you get people to start behaving in a new way?”

Chip Heath, Dan Heath, “Switch: How to Change Things When Change is Hard” 2010.

The “New Way” of Health Care

For Health Care reform, the “New Way” must include changes from:

– Government– Payers– Providers– Employers– Individuals

The Business of Health

“We are in the sickness business. We need to get into the health business”.

Dr. Delos Cosgrove, Chief Executive OfficerCleveland Clinic, Time Magazine, June, 2009

Health Care Shift

Treating Disease

Passive Participant

Health Care Cost

Cost-Shifting

Managing Health

Informed Decision Maker

Realigning Cost-Share

Integrated / ConnectedFragmented

Health Care Investment

Core Elements of Health Care Reform

• Accountable Care Organizations

• Bundled Payments

A Model for ACO’s

Proposed Benefits of ACO’s

Potential Impact of ACO’s on the Delivery of CP Rehabilitation Services

• Premium on care coordination. • Expanded and new care coordination teams.• Consistent outcome measures across the

continuum of care.• Must expand your reach and impact.• “The right care, for the right patient, at the right

time”.• Outcomes! Outcomes! Outcomes!

Bundled Payments for Care

Bundled vs Fee-for-Service Payments

What is Included in the Bundle?

• In-patient costs• Out-patient costs (0-180 days)• Diagnostics• Prescriptions • Bonus payments for achieving cost and quality

standards

Value-based Metrics

The Importance of Wellness in Health Care Reform

The Causes and Costs of Avoidable Chronic Illnesses

• The combined cost of the top 7 modifiable chronic diseases (cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions and mental disorders) exceeds $270B annually in direct costs and reaches over $1T annually with lost productivity.

• It is estimated that 70% of avoidable health care costs could be mitigated by behavior changes that involve healthy lifestyle development, wellness enhancement and early detection for the conditions listed above.

(Source: “A Wellness Initiative for the Nation”, February 6th, 2009, The Samueli Institute)

The Causes and Costs cont….Five behavioral risk factors have been shown to contribute the most to mitigating these costs;

1) Reducing toxic substance exposure- smoking, alcohol, drugs and pollution

2) Sufficient exercise and physical activity3) Healthy diet4) Psychosocial integration and stress management 5) Early detection and intervention

It is estimated that even modest gains in smoking and obesity control would reduce illness in the top seven modifiable chronic health conditions by 24-30 million, save up to $100B in treatment costs.

Potential Impact of Bundled Payments on the Delivery of CP Rehab Services

• A chance to “re-invent the wheel”.• Must contribute to the “value proposition”.• Renewed emphasis on sustainable, behavior

change (patient engagement).• Must have “real time” data to drive care

decisions.• May need a different skill set.• May need to do more with less.

Opportunity is here

Value

(BETTER) QUALITY•Safe, Evidence-Based Best Practices•Coordinate Care Across Continuum•Patient Service Experience

(LOWER) COST•Eliminate Unneeded Care•Efficient Workflows•Practice at Top of License

• How do we give patients “everything they need and nothing they don’t?”– Standardize care according to evidence-based care pathways– Improve the “tools” our teams rely on to deliver the best care for

every patient, every time– Facilitate personalized medicine by building in appropriate flexibility

and customization based on clinical presentation, patient history

Patient Arrival

Diagnostic Cardiac Cath

Non-Invasive Diagnostic

Testing

Medically Mgd. Pathway

Interventional Pathway

Surgical Pathway

High Risk of Another Ischemic Event

Low / Moderate Risk of Another Ischemic Event

Not Applicable (SNF, Hospice, etc.)

Outpatient Pathway

Diagnosis & Pathway Selection

Diagnostic TestingCare by Risk LevelInpatient Pathways

Discharge

ACS Continuum(6 mos)

ACS Bundle

Acute Coronary Syndrome Bundle: Project Goals

Institutional Goals• Explore capabilities needed to deliver coordinated care and manage clinical and

financial risk under a bundled reimbursement model

Outcomes Goal• Reduce rate of non-value-added downstream encounters and downstream ischemic

events following an initial episode of Acute Coronary Syndrome

• Lower score for “9 Modifiable Cardiac Risk Factors” over the defined episode

Financial Goals• Create clinical capacity (inpatient, Dx and therapeutic)

• Limit healthcare spend over time for ACS patients, demonstrating value to payers & employers

– Reduce avoidable related readmissions

– Minimize repeat Dx tests, re-caths & downstream interventions

– Minimize avoidable complications 32

DEFINE STANDARD of CAREDesign Evidence-Based Continuum of Care Spanning 6-mo. Inpatient, Ambulatory + Ancillary

STUDY GAPSUnderstand Current State & Gaps Relative to Desired Future State

TEST CHANGESmall Tests of Change to Understand Implications

IDENTIFY HIGHEST-VALUE OPPORTUNITIESTransition Inpatient-to-Outpatient

Medications Across Continuum of CarePatient & Family Engagement Across Continuum of Care

LASTING CHANGEHardwire People, Processes and Technology to Deliver the Standard

ACS Demonstration Pilot Progress

Up Next!

33Crit Pathw Cardiol. 2011 Mar; 10(1):1-8

Clinical Success:Modifiable Cardiac Risk Factors

Circulation, 2007

ACS Cardiac Rehab Pilot

26 Week Comprehensive Risk Reduction Program

Cardiac Rehab – Fee For Service

Where does it fall short?– Missing eligible patients– Limited access due to finances– No reimbursement for medical management– Financial mechanism doesn’t incentivize value

• Quality – no premium on outcomes• VISITS = REVENUE

GLOVES ARE OFF– Improves flexibility for supervised exercise

• Visits ≠ Revenue• Risk Stratification

– Payment for LIFESTYLE MEDICINE• Supporting Change

– Opportunities to tap other disciplines expertise when appropriate

• Health Coaching, Health Psychology, RD, etc

Cardiac Rehab – Bundled Payment

“Everything they need, nothing they don’t”

Major Lifestyle DomainsWhat do we want to change?

CRPilot

TobaccoCessation

PsychoEmotional

Health

Exercise &

Physical Activity

Medication Adherence

Nutrition

Tools to address behavior by domain

Nutrition

Coaching

Mindfulness

RD

Shopping Demonstratio

n

Cooking Class

CHIP/Pritikin/Ornish

Exercise/PA

Coaching

Mindfulness

Exercise Testing

CHIP/Pritikin/Ornish

Movement classes (Yoga,

Tai Chi)

Pedometers

Medication Adherence

Coaching

Mindfulness

Medication Reconciliatio

n

Psycho Emotional

Health

Depression Screening

Mood Clinic

Coaching

Group Support

CHIP/Pritikin/Ornish

Smoking Cessation

Coaching

Smoking Cessation Specialist

Group Support

CHIP/Pritikin/Ornish

ACS Cardiac RehabKnown modifiable risk factors• Profile established by 7 day visit• OUTCOMES

• Evidence based measure of success

Coaching• Every participant – 12 phone coaching sessions

Coronary Health Improvement Project (CHIP)•Evidence based•Healthy nutrition•Moderate exercise•Group support

Clinical risk stratification•Cardiac Rehab Evaluation•Low – 8 monitored CR sessions (SES)•Moderate – 16 monitored CR sessions (SES)•High – 24 monitored CR sessions (SES)

Key Components

Vandy OCR

Low Risk

12 Coaching Sessions CHIP

Outcomes

8 SES

Moderate Risk

12 Coaching Sessions CHIP

Outcomes

16 SES

High Risk

12 Coaching Sessions CHIP

Outcomes

24 SES

ACS Cardiac Rehab Algorithm

Health Coaching – CR staff WellCoaches® Certification

– Strategic initiative at Vanderbilt Dayani Center and Vanderbilt Center for Integrative Health

– CR staff trained as Health Coaches• Outpatient - 3 of 4 staff certified (4 of 4

soon)• Inpatient - 1 of 3 staff certified

Clinical Success:

Circulation, 2007

Re-Define Care

Deliver Care Consistently

Evaluate Value (= outcomes / cost)

Iterative Small

Tests of Change

ACS 10 patient pilot Organization -Test the ACS pathway

(inpatient through 3 months + post-discharge)– Manually move 10 patients from admission

to 7 day visit and into outpatient management

Opportunity for CR– Pilot the Health Coaching model in

outpatient cardiac rehab

ACS 10 patient pilot Fee for service CR + 6 health

coach sessions 1 (60min) and 5 (30 min)

– Goals• Testing – Too many cooks in the

kitchen?• Test phone call model• Any influence on outcomes

Modifiable risk factor outcomes

Physic

al Act

ivity

Diabete

s Melli

tus

Weight

Manag

emen

t

Psycho

social

/ Dep

ressio

n

Tobacc

oLip

ids

Blood

Press

ure

Medica

tion A

dhere

nce0

10

20

30

40

50

60

70

80

% at goal - Baseline% at goal - 90 days

Improved Capture Rate?

VUMC CR Pilot0%

10%

20%

30%

40%

50%

60%

70%

80%

Improved Adherence?

Control Intervention Intervention participants0

5

10

15

20

25

30

35

Completed Visits

My Conclusions CPR programs/professionals are well

positioned to play essential roles as behavior change specialists in an era of health care reform– Health Coach– Health Navigator– Patient Engagement– Outcomes