4/16/2015 Determining Where You Need to Change Course to Prepare for the Affordable Care Act MHHA 2015 Arnie Cisneros ● 30 year Home Health rehab clinician ● 30 year Home Health contract Provider ● Home Health Strategic Management (2004) ● Hospital-2-Home Strategic Management (2014) ● Pioneer ACO (x3) – Post – Acute Strategist ● Model 2 BPCI Award – DMC – DRG 469/470 ● JUMP = Joint Utilization Management Program PATIENT PROTECTION & AFFORDABLE CARE ACT 1
4/16/2015 ACCOUNTABLE CARE ORGANIZATIONS Accountable Care Organizations An ACO is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. CARE TRANSITIONS MANAGEMENT 2
4/16/2015 Care Transitions Management Care Transition refers to the movement patients make between health care settings as their condition and care needs change during the course of a chronic or acute illness; each shift from care providers and settings is defined as a care transition. ● Post-Acute Bundling – 30 day episodic ● Acute Discharges - Reinvention ● Readmission focus – Episodic Result ● Find Savings/Efficiencies ● Redefine Acute Care – Care vs Provider ● IT Use – connectivity thru episode ● Traditional Versus Episodic EPISODIC CARE DELIVERY 3
4/16/2015 Episodic Care Delivery The re-engineering of the acute episode derived from acuity-based expectations of patient care requirements, devoid of Provider preference, and driven by the least restrictive/costly care environment. SILO EFECT ON THE CARE CONTINUUM The Silo Effect The Silo effect refers to the lack of communication and support often found in acute care episodes. Provider types focus primarily on their own goals, often ignoring the needs of others. 4
4/16/2015 Silo Effect Concerns ● Intake Accuracy ● Inadequate SOC Response times – 24 hours? ● SOC/OASIS Accuracy ● 60 Day Certification (versus Post-Acute) ● Clinical Efficiency/Productivity ● Lack of Safety-Based Frequencies? ● Disconnected Rehab Services ● Lack of In-episode Control EPISODIC CARE DELIVERY Episodic Care Delivery The re-engineering of the acute episode derived from acuity-based expectations of patient care requirements, devoid of Provider preference, and driven by the least restrictive/costly care environment. 5
4/16/2015 POST-ACUTE BUNDLING ACO INTEGRATION FOR POST-ACUTE CARE ACO Integration for Post- Acute Post-Acute Providers seeking to participate in the ACO era must integrate ACO programming goals to counteract the legacy of silo-based care present in the PPS Care Continuum. Clinical accuracy, staff control, and care insight required for value concerns are paramount. 6
4/16/2015 JUMP Joint Utilization Management Program Detroit Medical Center/HHSM Episodic Bundling Concerns ● Traditional Payer – Medicare at Risk ● BPCI Model 2 Program – DMC at Risk ● An Informed Patient – Provider - Clinicians ● BPCI Clinical Pathway Compliance ● BPCI Clinical Documentation ● Lack of UR In-episode Control – Directability ● Evidence – Based, Best Practice Care Episodic Bundling Clinical Parameters • Traditional 469/470 Utilization – SNF (21 days) – HH (9-14 vis) • 2014 SNF LOS/Utilization Target – 8-11 Days @ High RUG • 2014 HH LOS/Utilization Target – 7- 10 Days @ 6/7 rehab visits • Clinical Program Focus - ROM, Pain, Safety, Transfers, Mobility • DC Planning – Mimic Acute Care – Care Completion Approach • Problems/Concerns/Modifications – Authorize with Payer (JUMP) 7
4/16/2015 J.U.M.P. 2015 February Utilization Weekly OP OP JUMP HHC HHC RIM IN IRF SNF Therapy Therapy Volume SNF IN Referrals Referrals (IRF) OON OON Services Services T otal IN OON IN OON Cases 20 2 0 7 4 12 2 8 2 Utilization 5% </= 25% >/= 70% 75% Target IN Target 100% 75% 75% 75% Total % 10% 55% 70% 50% Utilization % IN 100% 64% 86% 80% Referrals % OON 0% 36% 10% 20% Referrals J.U.M.P. Partner 2014 SNF Utilization PAC Q1 Q2 Q3 Q4 Target Provider JUMP 1 0 12 6 15 11 JUMP 2 14 13 10 11* 11 JUMP 3 15 13 17 0 11 JUMP 4 21 18 13 14 11 JUMP 5 17* 9* 12 11 11 JUMP 6 0 21 10 2* 11 JUMP 7 19 15 11* 11 11 J.U.M.P. Partner 2014 HHC Utilization PAC Q1 Q2 Q3 Q4 Target Provider JUMP 1 12 10* 5 6 7 JUMP 2 7 8 7 8 7 JUMP 3 11 11 10 9 7 JUMP 4 9 5* 5 0 7 JUMP 5 7 6 7 6 7 JUMP 6 15 14 12 10 7 JUMP 7 5* 12 12 9 7 JUMP 8 8 15 12 6 7 JUMP 9 18* 0 8 7 7 8
4/16/2015 UTILIZATION REVIEW IN HOME HEALTH Utilization Review in Home Health The development and delivery of Home Health services created from a Utilization Review, PPS - compliant perspective. Patient centered, case managed care; modified in an ongoing manner for patient response to treatment. UR-Managed HH produces levels of clinical/fiscal outcomes not regularly seen in homecare as it creates the episodic programs of the future. UR in Home Health Philosophy • Assure Combined Clinical/Fiscal PPS Programs • Manage PPS Home Health model Intrinsics • UR Admission Profile/Global Programming • Control Nursing Volumes – Therapy Volumes • Manage your clinicians & patients - in episode • Abandon Clinician-Managed Care Beliefs • Create a “Discharge for Outcomes” culture • OASIS Accuracy / Utilization Review Control • – • – • – 9 • • –
4/16/2015 UR ACA Opportunities in Home Health Care Programs UR in Home Health Targets • Intake Management • OASIS Accuracy / Utilization Review Control • OASIS UR Real – Time Global Programming • UR Nursing/Rehab – Safety-Based POC • Provider – Managed Scheduling/Productivity • IT Management for Clinical Control - DC • Changing legacy of clinician – centered care Weighted UR Home Health Episode 10
4/16/2015 UR in Home Health Outcomes • Case Mix Weight – HHRG Optimization • Visit Mgmnt Nursing/Therapy – Value Specific • OASIS Accuracy – UR Collaboration • In – Episode Care Management – Efficiency • Results: Improved Clinical/Fiscal Outcomes • Decreased Re-Admissions • Optimal Earnings – UR/Schedule/Productivity 2015 Case-Mix Weight/HHRG UR Results Agency 1 Agency 1 Agency 2 Agency 2 Agency 3 Agency 3 CMW (%) HHRG (%) CMW (%) HHRG CMW (%) HHRG (%) Month 1 1.40 (38%) $3771 (50%) 1.16 (31%) $2999 (36%) 1.26 (42%) $3318 (42%) Month 2 1.23 (22%) $3352 (33%) 1.18 (33%) $3040 (38%) Month 3 1.18 (16%) $3182 (27%) 1.22 (37%) $3136 (42%) Month 4 1.197 (18%) $3232 (29%) Month 5 1.35 (33%) $3650 (45%) Month 6 1.46 (45%) $3853 (53%) Month 7 1.44 (43%) $3855 (53%) Month 8 1.34 (32%) $3572 (42%) Month 9 1.34 (32%) $3570 (42%) Home Health 2015 UR Demo Case 11
4/16/2015 Home Health 2015 UR Demo Case ● Patient – 90 y/o Pneumonia/Weakness - w Cgvr ● Post-Acute hosp admission – Troubling SOB (2) ● OASIS score assist – SOB, Meds, Inc, Functional ● PLOF = Independent -- Now Unsafe Ambulation (3) ● M1860 score compromises dressing, toileting, etc. ● Concerns re falls, re-admit, frequent flyer profile ● Nursing POC orders – 2 x 4 ● Initial PT frequency – 1 x 1, 2 x 2 – safety – NO Home Health 2015 UR Demo Case ● Concerns – inadequate OASIS objective scoring ● Inadequate “C” & “F” scores creates $ 120 change ● Excessive Nursing visits originally proposed ($$) ● Lack of Safety-Based rehab frequency (3 x wk) ● Incomplete PPS HH programming re OT ADL ● Optimal rehab orders – PT (1 x 1, 3 x 4) OT (2x2) ● Resultant change in Case – Mix --- (+ 30%) ● Case Mix Example #1 – (0.9 – 1.29) 2015 terms Closing thoughts on Home Health for the ACA era 12
4/16/2015 Closing Thoughts for the ACA era • Home Health is the DESIRED Post-Acute site • Cost levels favorable, fluid, In-home delivery • HH Concerns limit ACA potential for value • Delayed SOC, SOC integrity, POC concerns • 60/day legacy, Inefficient delivery (MV), Cgvr • Clinician-led programs, Lacks UR & Innovation • Failure to internalize & manage PPS model Closing Thoughts for the ACA era • Previous HH era ends - changes Everything !! • Marketing, Referrals, LOS, Clinical Skill • 30-day care orbits, Re-admission risk, DC focus • Schedules, Productivity, Daily Reporting, UR • Cuts/Rebasing continue – Bundling Kickoff 1/18 • Culture Change Is Hard – Can’t do it ourselves? • UR Programs = Better Care, Better Outcomes CAN YOU MANAGE MANAGE TO IMPROVE YOUR CARE? 13
4/16/2015 Home Health Strategic Management 1-877-449-HHSM www.homehealthstrategicmanagement.com 14
Recommend
More recommend
