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The Health System of the Future: Surviving and Profiting in a Patient Centered Model
JOSH LUKE, PH.D., FACHEUniversity of Southern California, Price School of Public Policy
Author, Readmission Prevention: Solutions Across The Provider Continuum
Founder, National Readmission Prevention Collaborative
Founder, National Readmission Prevention Collaborative
The Health System of the Future: Surviving and Profiting in a Patient Centered Model
JOSH LUKE, PH.D., FACHEFounder, National Readmission Prevention Collaborative
University of Southern California, Price School of Public Policy
Author, Readmission Prevention: Solutions Across The Provider Continuum
National Advisor, Strategic Transformation, Health Dimensions Group
About Your Presenter:Josh Luke, PhD, FACHE
• Hospital CEO
‒ Memorial Hospital of Gardena
‒ Western Medical Center Anaheim
‒ Anaheim General Hospital
• VP, Post Acute at Torrance Memorial Health System
‒ Home health and hospice oversight
‒ Developed award-winning post acute network
• CEO for HealthSouth Las Vegas Rehab Hospital
• SNF Administrator/AL Executive Director
‒ Kindred, Windsor/SNF Management, California Friends Homes,
AIT for Life Care Centers of America
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Presentation Objectives
• Delivery model of the future: Discharge Home
• New readmission penalty: Medicare Spending Per
Beneficiary (MSPB)
• Post-acute provider guidelines for success
4
Let’s get off the starting line and
skate to where the puck will be!
It’s time to innovate and transform!
2015
1998—It Was a Very Good Year
52015
1998—It Was a Very Good Year
62015
7
Grandma BelvaMarch 1920–July 2002
2015
Dementia & Congestive Heart FailureThe Summer of 2002
Home $0
Hemet Valley Medical Center $48,000
LTACH $52,000
Nursing Home $12,000
Home with Home Health $4,000
Hemet Valley Medical Center* $36,000
Nursing Home $18,000
Assisted Living with Home Health $4,000
Hemet Valley Medical Center* $42,000
Nursing Home $24,000
Hemet Valley Medical Center* $58,000
$298,000*Readmission
Services for Dementia Patients in 1999-2002
• Limited Outpatient support for dementia
• Over-prescribing of pscyhotropics
• Emergency Department as gatekeeper
• Inpatient acute psychiatric unit for elevated symptoms
(geropsychiatric unit)
• Skilled Nursing Facility
‒ Dementia Unit, locked unit or secured unit
• Assisted living, group home or home-based care taker
2015 8
Career Change
• Entered AIT program for Life Care Centers of America
‒ The best leadership lessons of my career
• Became a hospital CEO two years later
2015 9
Are You Ready for the Truth?
• Affordable Care Act is not a request, but a MANDATE
• Goal is to create a model for individuals to age and heal at
home
• The truth is that my job is not to teach you how to prevent
readmissions, it’s to teach you to prevent…admissions
• Welcome to the world of…
ADMISSION PREVENTION
102015
The Transformation of the Acute Hospital: The C-suite Must Take Action
Coordinating care for improved
outcomes:
• Hospitals must act like
health systems
• Health systems must act like
managed care organization
• Thus, the hospital must act like a
managed care organization as well
11
Hospital
Health
System
Managed Care
2015
What Does This Mean for You?
Hospitals = Last resort
SNF = Second-to-last resort; increase capability to handle medical-surgical level patients
Home health = Networks will be narrowed
Winners = Home care, private duty, and assisted living
122015
Tommy Olmstead v LCU.S. Supreme Court Decision, June 1999
U.S. Supreme Court concluded:
“Patients in an acute hospital have the right to be discharged
to the least restrictive environment when the care team
determines that community placement is appropriate and the
patient does not oppose the transfer.”
“Continued institutionalization of patients who may be placed
in less restrictive environments often constitutes
discrimination based on disability.”
2015 13
Tommy Olmstead v LCU.S. Supreme Court Decision, June 1999 (continued)
U.S. Supreme Court further concluded:
“Operationally, this means that both
physicians and hospital case managers
must first rule out the least restrictive
environment as a safe discharge
before considering institutionalizing a
patient for post acute services.”
14
What do you think CMS
would say about this?
MSPB?
2015
Many Reasons to Coordinate Care
1. ACO’s volume expected to triple by 2020 (passed with ACA in 2010)
2. Bundled payment initiatives (2010)
3. Value-based initiatives (2010)
4. Readmission penalties (2010)
5. RAC audits (2010)
6. MSPB (2014)
7. IMPACT (2014)
8. Better, smarter, healthier: In January 2015, HHS announced goal for 30% of Medicare spending in ACO/Bundle by 2016 and 50% by 2018 (2015)
9. CCJR – Mandated Orthopedic Bundles (2015)
10. Coming soon…. (2015 or 2016)
11. It’s a matter of fact…. (2015 or 2016)
152015
Alignment with Home Health
• SNF’s MUST align with hospital based home health
‒ Hospital owned are usually sub par
‒ Great opportunity to engage the hospital in conversation on this topic
‒ With growth the home health will need two other agencies to extend
reach
• If hospital does not own a home health, ask their top 3
‒ The home health your SNF doctor uses may NOT be one of their top
three
‒ Example: UCSD aligning exclusively with Accent for home health
2015 16
Milestones for Care Coordination in 2015
1. Better, Smarter, Healthier in January 2015
‒ 30% of Medicare payments by 2016; or 85% attached to quality
‒ 50% of Medicare payments by 2018; or 90% attached to quality
2. Modern Healthcare, May 9, 2015
By Melanie Evans
Hospitals Select Preferred SNFs to Improve Post-Acute Outcomes
3. UCSD/AccentCare; Marina Del Rey/24HR Home Care joint ventures
4. Comprehensive Care for Joint Replacement (CCJR Mandate),
- 75 markets nationwide; no downside risk in year one
172015
More Recent “I told you so’s…” (recommendations)
1. TCC codes, Chronic care codes, end of life codes
2. ACO/Bundle Fraud and Abuse Waivers to narrow
3. Bundle Models and Next Generation ACO’s requiring
‒ Narrowing of SNF network
‒ Partnering with 5 star and 4 star SNF’ s
‒ Three midnight rule waiver
182015
What’s Hot? What’s Happening this Month?
• Health systems calling to request help narrowing their network
of SNF’s and home health
• Three hurdles to health systems narrowing their post acute
network
1. Legal: Will compliance department sign-off?
2. Criteria: What criteria do we use to select providers who will be in the
network and how many get in?
3. Operationalize: Implementing new, sustainable care management
process
Hint: The hurdles are getting lower and lower by the week
2015 19
Transitional Care, Wellness, and Revenue Streams
• Direct-to-SNF transfers from the ED
• Remote monitoring at home and in SNF
• Home visits
• Expansion of home health to ambulatory case managers
• Track 3 ACO’s – 3 midnight waiver
• CCJR – waiver at 3 star or above
20
Home
SNF
Home Health
Dr. Office
Everyone is being incentivized to avoid the hospital
Hospital
2015
SNF Providers: Are You Ready for the New Normal?
What if, on December 31, 2015, you received a notification
from CMS advising you that…
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…And also, what about SNF Avoidance?
Obama, AlaskaHypothetical New City
Health System of the
Future
Home
Doctor’s office
Wellness clinic/gym
OP/Ancillary services
Assisted living
SNF
Hospital
222015
Obama, AlaskaThe System of Old—The Fee-for-Service Free-for-All
Hospital
23
Home
Doctor’s office
Wellness clinic/gym
OP/Ancillary services
Assisted living
SNF
Insert Hospital Here!
2015
Story TimeOnce Upon a Time…
24
The Fee-for-Service
Free-for-All Era
Post-ACA Era
Old Hospital = 290 beds
New Hospital =
249 beds
Hospital Bed
Capacity
2015
Medicare Spending Per Beneficiary (MSPB): The New Readmission Penalty
• Effective October 1, 2014, MSPB episode includes all
Medicare Part A and Part B claims paid:
‒During the 3 days prior to the index admission
‒During the index admission
‒During the 30 days after hospital discharge
• Within these three time periods, average episode spending
levels are further broken down into seven provider types
(e.g., inpatient, outpatient)
2015 25
3 days prior 30 days after discharge
MSPB: Hospital Sample 1
Medicare.gov, Hospital Compare
During Index Hospital Stay Inpatient $ Spent Percent
Hospital A $7,889 29.70%
State $8,910 45.36%
National $8,534 45.63%
Complete Episode (MSPB) Total Spending Percent
Hospital A $26,560 100.00%
State $19,642 100.00%
National $18,704 100.00%
262015
MSPB: Hospital Sample 2
Medicare.gov, Hospital Compare
1–30 Days After Inpatient $ Spent Percent
Hospital A $8,967 33.00%
State $2,476 12.60%
National $2,532 13.54%
27
• Inpatient includes LTACH, IRF, and readmissions
• Readmission rate is only .04%, so there is LTACH and IRF utilization
2015
IMPACT: Improving Medicare Post-Acute
Transformation Act of 2014
• IMPACT Act of 2014 takes a crucial step toward
modernization of Medicare payments to post-acute care
(PAC) providers
• Who wins? Maybe no one; it appears to be more
documentation to prove medical necessity
• Three midnight rule:
‒Recommendation by October
‒My opinion?
oWhy have they not already changed it? The free-for-all,
of course…
282015
What’s the Future of Long-Term Acute Care & Acute Rehab? Alt Acute
• These services were originally created to serve unmet
niche’s—CMS aims to keep it that way
• Freestanding facilities will not survive in dual initiative
markets or if coordinated care models grow past 50% of
MCR spending
• Smaller, on-campus (HIH) may survive:
• LTACH must focus on Alternative Acute Strategies
‒ moving to sub-acute (still post acute)
• IRF: Specialty cases
292015
The Super SNF Lets take a Tour
• Stop looking at competitors within the SNF industry for the
answers and start innovating
• Hospital-based SNFs within a mile of your facility get paid
$800–$1,100 a day for SNF patients; why don’t you?
302015
Examples of Value-Added Innovation
Care Management • Community integration model
• Medline bringing continuum together
• MediGram Mobile App for Caretakers
Innovation• Sensiotec: virtual medical assistant system
• MedTainer – cost efficient, safe pill crushing
• Alt Acute
31
These are all MSPB solutions as well
2015
Post-Acute Expectations
1. POLST
2. SBAR
3. Stop and watch
4. Return to acute log (emergency department)
5. Return to ED root cause analysis
6. Technology differentiators:
a. Predictive software/electronic quality data
b. Nutritional focus
c. Wireless telemetry
322015
Key Action Items
• Outreach to your referral partners consistently
‒ On the 15th of each month: Share the tools below!
• Submit your case study
‒ Innovate and differentiate
‒ Readmission tool kits
• Providers must become certified to stand out
‒ Certified Readmission Prevention Professional program (for individuals)
‒ Certified Readmission Prevention Partner program (for teams)
332015
The Next Chapter: 2010
34
My Mom’s Journey
2015
Services for Dementia Patients in 1999-2002 2015
• Limited Outpatient support for dementia
• Over-prescribing of pscyhotropics
• Emergency Department as gatekeeper
• Inpatient acute psychiatric unit for elevated symptoms (geropsychiatric unit)
• Skilled Nursing Facility
‒ Dementia Unit, locked unit or secured unit
• Assisted living, group home or home-based care taker
Its not just the behavioral health sector,
this is consistent across the entire delivery system
2015 35
My Legacy: Going Purple for My Mom
36
•Passion
•Empathy
•Fight
•Use your gifts
•Legacy
Values
2015
Josh Luke, Ph.D., FACHE
Go Purple to Fight
Alzheimer’s Disease!
NRPC Aims to
donate $25k in 2015!
372015
Available at ACHE.org/publications
www.NationalReadmissionPrevention.com
www.NationalBundledPaymentCollaborative.com