session 101: directions: evaluating an ...specializedmedical care for people with serious illnesses...

7/15/2013

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Session 101:Future Directions: Evaluating d E i P lli i C

2013 NAHC Financial Management Conference

and Executing a Palliative Care Strategy

Diana Franchitto, Home Care & Hospice of New England

Bill Musick The Corridor GroupBill Musick, The Corridor Group

Robert Parker, PRIME by AseraCare

Overview

INTRODUCTION

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What is Palliative Care?Center to Advance Palliative Care (CAPC)

Specializedmedical care for people with serious illnesses

d li f f h i d f• Focused on relief from the symptoms, pain, and stress of a serious illness

• goal is to improve quality of life for both the patient and the family

• provided by a team of doctors, nurses and other specialists who provide an extra layer of support at any age and at any stage in a serious illness and can be provided along with curativea serious illness and can be provided along with curative treatment

• support patient and family, not only by controlling symptoms, but also by helping to understand treatment options and goals

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What is Palliative Care?Center to Advance Palliative Care (CAPC)

• The palliative care team provides:• Expert management of pain and other symptoms• Expert management of pain and other symptoms

• Emotional and spiritual support

• Close communication

• Help navigating the healthcare system

• Guidance with difficult and complex treatment choices

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It’s Place in the Continuum of CareDeath

Serious, progressive conditions that limit d il ti iti

Advanced Illness Management

Hospice Care

Palliative C

Bereavement Support

Manageable, early, stable conditions

daily activities

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Disease Progression

CareCareTerminal Phase of Illness

Support

Diagnosis of Life-threatening or Debilitating

Illness or Injury

Objectives

• Determine what types of palliative care programsDetermine what types of palliative care programs operate today

• Identify the services that are provided in a Palliative Care Program and how palliative care is reimbursed

• Recognize the issues involved in integrating palliative care with Home Health Agency and Hospice programs

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Flow1. Survey of Models/Issues

2. Specific Case Studies• Home Care & Hospice of New England

• PRIME (Progressive Illness Management Expertise) by AseraCare

3. General Comments/Tips

4. Q&A

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Caveats• “If you’ve seen one palliative care program, you’ve seen one palliative care program.”one palliative care program.

• Beware of relying too much upon someone else’s experience

• Regulations vary by state and by payer and are continually evolving – please don’t take our comments as legal advice

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Who’s in the room…

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Palliative Care Models

CONTEXT

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What we know dimly…• Not a standardized benefit

• No common tracking/data base• No common tracking/data base

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Variations

• Setting

Acute

Skilled Nursing

Primary

Specialty Clinic

• Task‐specific (Advanced Directives vs P&SM)

• Disease‐specific (Cancer vs CHF)

Hospice

Home Health

Primary Care

• Symptom‐specific (Pain)

• Delivery method (Face to face, telephonic, video)12

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Continuum• Insert slideCommon Options for Palliative Care Delivery

Consultative IntegrativeConsultative Integrative

SettingConsult Service

Comprehensive Service *

Dedicated UnitCase‐Managed

Team

Acute

SNF/ALF

Clinic

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Home

Typical Focus

Pain & Symptom Management

(PSM)

PSM + Decision Support +

Emotional/Spiritual Support

PSM + Decision Support +


PSM and/or Decision Support and/or


* internal or outsourced; includes QA/PI of palliative services, staff in-service education, compliance with accreditation, development of policies and procedures, serving on Committees, input to strategic planning related to palliative care


PAYMENT VARIATIONS

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Payment Billable Entitlement Programs • Medicare Part B

• Physician/NP

• LSCW (using mental billing codes only)

• Home Health

• Concurrent Hospice Care• Medicaid Pediatric Concurrent Care

• Commercial Insurers

• CMS Demonstration Project?? 15

Payment (continued)Entrepreneurial

• Contracts• Commercial Insurer

• Hospital/Health System

• Innovation Award/ACO/Bundled Payment

• Philanthropic• Research

• Foundations

• Private Pay Fee for Service (Concierge) 16

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Cost Avoidance in Lieu of Payment

System-wide Cost

Net Investment in Palliative Care

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Cost Savings/Outcomes


Examples of Variation in Delivery Models

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Examples: Advance Care PlanningGundersen Health System’s Respecting Choices Program• First Steps® ACP

T t di 55 ld• Target audience: 55 or older

• Focus: importance of ACP; select a healthcare

decision maker

• Outcome: a basic written advance directive for life‐sustaining treatment

• Next Steps® ACP• Target audience: patients with chronic, progressive illness + decline in functional status + risk for complications leaving them unable to make own healthcare decisionsown healthcare decisions

• Focus: assist patients in understanding…the progression of their illness

potential complications

specific treatments that may be considerations if their illness progresses

• Outcome: informed decisions19

Examples: Advance Care PlanningGHS Respecting Choices Program ‐ continued• Last Steps® ACPLast Steps ACP

• Target audience: Frail elders/others whose death with next 12 months would not be surprising

• Outcome: Physician Orders for Life‐sustaining Treatment (POLST) CPR

artificial nutrition and hydration

comfort care options

ACP b i ti idACP subscription videos • Designed to educate and empower patients about advance care planning and their informed/realistic choices for medical care

• http://www.acpdecisions.org/#sthash.9DNIU9rU.dpuf 20

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Example: UPHS CLAIM ProjectUniversity of Pennsylvania Health System CLAIM Project (Comprehensive Longitudinal Advanced Illness(Comprehensive Longitudinal Advanced Illness Management)

• Home Health‐based program with supplemental disciplines

• Cancer• Goal: reduce unnecessary end of life care costs and decreased quality of lifedecreased quality of life

• Seed funding: Health Care Innovation Awards • Long‐term: Cost avoidance, outcome improvements

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Examples: Entrepreneurial Services• Contractual arrangements by hospices/home health agencies to provide a combination of:agencies to provide a combination of: • billable physician/NP services with

• hospital payment for social work/chaplain and/or physician/NP administrative time

• Palliative care providers at risk for achieving savings through identification and care of high‐cost chronic care patients (insurer or health system ACO)patients (insurer or health system, ACO)

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Example: Lehigh Valley Health Network

• Optimizing Advanced Complex Illness Support (OACIS)

• Three‐pronged service• OACIS Home‐Based Consult Service

• OACIS/Palliative Medicine Inpatient Consult Service

• Palliative Care Outpatient Clinic (PCOC) – Cancer Center

• Medical Director, APNs, RN Case Manager

• Cost avoidance/improved outcomes• Cost avoidance/improved outcomes

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Comments/questions…

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Case Study

HOME CARE & HOSPICE OF NEW ENGLAND

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History/Rationale• Home & Hospice Care of Rhode Island (HHCRI)

Stats• Stats:

• Hospice ADC: 440’s

• Palliative ADC: 150

• Core competencies:

• Hospice

• Palliative since 2001Palliative, since 2001

• Home care, 2005‐2009

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History/Rationale• Visiting Nurse Home Care (VNHC)

Stats• Stats:

• Home Care: 500’s

• Hospice ADC, through 2012: 20’s

• Core competencies:

• Home Care (Rhode Island & Massachusetts)

• Public Health ServicesPublic Health Services

• Innovative Programming

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Affiliation Rationale• Financial Strength, position for future HH/H affiliations

• Care Transitions• Care Transitions

• Strong Home Care; Strong Hospice

• Partnership opportunities

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Affiliation Structure• Formation of parent: Home Care & Hospice of New EnglandEngland

• VNHC transition of hospice to HHCRI

• HHCRI to drive Palliative Care strategy

• How to create a strong Palliative Care program for Visiting Nurse Home Care?

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Current Palliative Care ModelLocation of Care Staffing Model Availability

Inpatient Hospital PC Consultation (contractual)

MD / NP Daily, 7‐day week coverageConsultation (contractual) coverage

Inpatient Hospital PC Consultation (non‐contractual)

NP M‐F, as available

Outpatient Hospital‐Based Cancer Centers (contractual)

MD Weekly

LTC Facilities NP Daily/Weekly rela‐

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tionship w/Hospice

Outpatient Practice MD Weekly

Brown PC Fellowship MD One slot

BCBSRI PC Initiative MD / NP With contracted hospitals

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Palliative Care in the HomeThe “Why”• Partner with Visiting Nurse Home Care

• “True” PC capability• True PC capability

• Service differentiator

• Patient transitions to hospice; potential to impact hospice LOS

• Meet the needs of health care partners to reduce re‐hospitalizations

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Palliative Care in the HomeThe “How”• Utilization of predictive modeling data through SHP, as a startstart

• Establishment of PC business unit within home care

• Weekly case conference review, utilizing PC tool

• Education for Home Care RN Case Managers

• Hospice/PC Physician Leadership/Liaison with Home Care

• House Calls by MD

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Statistics

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Statistics

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PC Patients in Home Care

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Future Plans/Considerations• Regularly assess model and adjust as necessary

• Patient enrollment in HCPatient enrollment in HC

• Case conference

• Palliative Care education

• Building the relationship

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Case Study

PRIME by ASERACARE

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History/Rationale• Program Development

• 18 months (2010‐2011)18 months (2010 2011)

• Consultative Medical Model

• Inception November 2011• Piloted for 6 months in Omaha, NE

• Rapid expansion during 2012• 8 agencies

• Additional growth during 2013• 3 agencies

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Current Model• Target Population

• Chronically ill patientsChronically ill patients

• End‐stage disease trajectory

• Top Diagnoses• Chronic Obstructive Pulmonary Disorder (COPD)

• Cancer (cancer related symptoms)

• Alzheimer’s

• Cardiac (CHF, CVD, cardiac related symptoms)

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Current Model• Setting(s)

• Community based careCommunity based care

• Home, Skilled Nursing Facilities, Long‐term Care Facilities, Assisted Living Facilities, Personal Care Homes.

• Acute/Long‐term Acute Care (LTAC)• Selected agencies with specific relationships

• Practice:• Unduplicated census 789 (2013 1st half)• Unduplicated census 789 (2013 ‐ 1st half)

• Current active census 413 (June 30th)

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Current Model• Core Staff

• Board Certified MDBoard Certified MD• Collaborative Agreement

• Advanced Practice Registered Nurse (APRN)• Provider

• Licensed Clinical Social Worker (LCSW)• DSM‐IV diagnoses

• Supportive Care Staff• Supportive Care Staff• Social Worker

• Spiritual Care Coordinator

• Volunteer 42

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Statistics• Quality

• Pain – 91% on a goal of 80%Pain 91% on a goal of 80%

• Dyspnea – 92% on a goal of 70%

• Anxiety – 94% on a goal of 70%

• Goals of Care – 95% on a goal of 98%

• Re‐hospitalization – 0.4% on a goal of less than 5%

• Initial Consults• 486 (2012)

• 336 (2013 – 1st half)

• Subsequent Consults• 952 (2012)

• 1091 (2013 – 1st half)

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Financials• Evaluation & Management CPT Coding

• Break‐even model• Break‐even model• Proforma builds month‐over‐month

• Break‐even within 12 months

• Consults• 18‐22 Initial Consults per month

• 80‐90 Subsequent Consults per month

• Revenue• Start‐up mode

• 40% of expense44

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Integration with HH/Hospice• AseraCare Hospice

• Core businessCore business

• Setting Management

• 30% conversion rate• 103 (2012)

• 154 (2013 – 1st half)

• Care ContinuumA tti ti• Across settings over time

• Home Health Agencies are an integral component

• Acute Care

• Specific partnerships 45

Future Plans/Considerations• Ongoing expansion

• Complement Hospice AgenciesComplement Hospice Agencies

• Urban and Rural

• Managed Care/Commercial Payors• Contracts

• Member benefits

• Healthcare Systems• LTAC

• Acute

• Build community care continuum46

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Palliative Care

PLANNING AND DEVELOPMENT CONSIDERATIONS

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Issues in Financial Viability• Incomplete payment mechanisms

• Optimal utilization of high‐cost providers• Optimal utilization of high‐cost providers

• Over‐extending services• Services provided

• Patients served

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Tips• Focus on local needs

• Assess local resources• Assess local resources

• Look for creative leveraging of community resources

• When possible, shoot bullets first, then cannon balls

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Tips (continued)• Think outside of legacy models

• Trust and compatible culture of partners ranked• Trust and compatible culture of partners ranked higher than logistics/systems by hospital executives

• Value of practice management

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Tips and Considerations from the Field

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Resources &Acknowledgements• Center to Advance Palliative Care ‐www capc orgwww.capc.org

• Amber Jones, CAPC Consultant/Advisor

• Palliative Care Center of the Bluegrass (Hospice of the Bluegrass) – Gretchen Brown, CEO• 1 of 8 CAPC Palliative Care Leadership1 of 8 CAPC Palliative Care Leadership Centers (PCLCs)

• Physician practice model providing services in academic and community hospitals, NFs and outpatient clinic

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Tips from the fieldCourtesy of Amber Jones, CAPC consultant

On Start‐up and Partnering• Pay attention to resistance ‐ it may be well‐founded and deserve further analysis

• No one knows what you will and will not do as a palliative care provider – tell them

• Don’t claim outcomes (cost avoidance, readmission rates, patient/family satisfaction) without having documentation to prove itprove it

• Your partner does not care/believe in cost avoidance findings from other providers – saying it louder won’t help

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Tips from the fieldCourtesy of Amber Jones, CAPC consultant

Especially for hospice providers…• Avoid palliative care as ‘hospice light’ – it is exactly as it sounds – less ‐ and not as good as should be expected

• Having the same provider offer both hospice and palliative care services contributes to the confusion

• Providers and consumers do not understand palliative care or hospice – saying one is not the other is not a clarification

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Tips from the fieldCourtesy of Amber Jones, CAPC consultantDiversify funding resources: • Learn or buy Part B billing expertise; obtain the necessary provider numbers; be sure to have all your ducks in a row

• Train clinicians to bill effectively and collect early and often –they will hate the first part and like the second

• Fund‐raise shamelessly – it’s a skill set we already own

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Tips from the fieldCourtesy of Palliative Care Center of the Bluegrass

Physicians• Remember that MDs are your most expensive staff, followed closely by NPs

• Set high expectations for productivity (8‐10+ visits/day)• MDs are your best marketers for PC• Use NPs in NFs to extend MDs

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Payment• Do not expect PC to generate a profit• Do bill Part B and do it well (attention to accuracy and coding)• Don’t give away PC ‐ get a fair payment from hospitals• Require hospital partners to measure the impact of PC

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Other• Think twice about offering palliative home care• Don’t provide PC to hospice patients or most of your discharged hospice patients

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Contact InformationDiana Franchitto – President & CEO, Home Care & Hospice of New England

[email protected](401) 415‐4201

Bill Musick ‐ Senior Associate, The Corridor [email protected]

(888) 942‐0405 (toll‐free)

Robert Parker – Program Manager, PRIME by [email protected]

(512) 422‐2911 60

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session 101: directions: evaluating an ...specializedmedical care for people with serious illnesses...

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