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“A Marriage Made in Heaven” -Choosing the Right Partners in Care
to Achieve the Best Quality Outcomes
Luz S. Ramos-Bonner MD, MBA, FACP, AGSF, CMDNetwork Medical Director
NewCourtland Senior ServicesOctober 24, 2016
NEWCOURTLAND.org 1-888-530-4913
Speaker Disclosures
Dr. Ramos-Bonner has disclosed that she has no relevant financial relationship(s).
Objectives
At the end of the session the following objectives will be achieved:
1. Identify successful nursing home facilities that will partner in care of PACE participants
2. Establish clinical protocols and an education plan with key stakeholders in the process
3. How to engage nursing home administrator and nursing staff to undertake innovative projects
4. Establish accurate contractual relationships with nursing facilities that will partner with the PACE program to achieve targeted quality metrics
5. Establish quality improvement activities to measure success and lessons learned.
Medicare Spending
James, B. and Poulsen, G. “The Case for Capitation.”Harvard Business Review. July-August 2016.
• U.S expenditures on health care as a percentage of GDP are still rising
• At least 35% or more than $1 trillion of the amount spent annually in health care is waste
Three Kinds of Waste
Inefficiencies producing
"units of care" drugs, lab tests, xrays, nursing support, 5%
unnecessary tests hospital, outpatients,
50%
preventable care especially
to patients who expressed they don't want test,
surgery, …
Shift to Value-Based Payment
1982• Hospital
Prospective Payment
1998• Skilled
Nursing Facility Prospective Payment
2013• Hospital
Value Based Purchasing
2019• Skilled
Nursing Facility Value Based Purchasing
Protecting Access to Medicare Act of 2014 (PAMA)
•Part of the 2014 law that addressed the Medicare Sustainable Growth Rate formula – “doc fix”•SNF’s will share the responsibility with hospitals for 30-day readmissions•Provisions for hospital readmission penalties for skilled nursing facilities starting 2018Section 215 – SNF 2% reduction reimbursement CMS Recoup the portion demonstrating an acceptable risk-adjusted readmission ratio and nationally benchmarked rate
Protecting Access to Medicare Act of 2014 (PAMA)
•October 2016 – CMS will provide SNFs with feedback on readmission rates
•October 2017 – rates will be reported in the Nursing Home Compare website
•October 1, 2018 – application of measure and associated penalties will start for Medicare fee-for-service beneficiaries
SNF Readmission Penalties Announced: Is your facility prepared?
• Skilled Nursing Facility Value-Based Purchasing Program by Josh Luke Founder, The National Readmission Prevention Collaborative Included in the "doc fix" passed in April 2014, H.R. 4302, the Protecting Access to Medicare Act of 2014 (PAMA), was a value-based purchasing (VBP) program for skilled nursing facilities (SNFs). PAMA establishes an incentive pool for high performing SNF's as it pertains to preventing unnecessary hospital readmissions. The Congressional Budget Office projects the program will save Medicare $2 billion over the next 10 years.
• Health and Human Services (HHS) will specify a SNF an all-cause, all-condition readmission measure prior to October 1, 2015, and then a risk-adjusted potentially preventable hospital readmission rate by October 1, 2016.
• PAMA requires public reporting of readmission rates for each SNF on Nursing Home Compare beginning on October 1, 2017.• Based on the SNF readmission measure, the HHS must establish a performance standard for SNFs, along with levels of
achievement and improvement. HHS will then develop a scoring methodology for each SNF in order to create a ranking system which will rank SNFs annually.
• Medicare reimbursement rates for SNF will be based partially on their performance scores beginning on October 1, 2018.• SNFs with the highest rankings receive the highest incentive payments and SNFs with a zero or low ranking will receive the
lowest incentive payments.• Effectively, the lowest 40 percent of SNFs will be reimbursed less than they otherwise would in the absence of this program.• To fund the payment pool, CMS will withhold 2% of SNF Medicare payments starting October 1, 2018. CMS will then
redistribute 50-70% of the withhold back into to SNF's by way of incentive payments• CMS will keep the balance, 30-50% as savings to Medicare.
LIFE NewCourtland
• 04/2007 –Pre-PACE Program
• 10/2010 –approved as a Dually Capitated PACE Program-Total Census (October
2016): 517participants
- Centers: 3 centers, 2 alternative care sites
Germantown Home
• 180 bed - skilled nursing facility• 5 Stars• Memory Care Program – Four Seasons
LIFE Hospital/ ED from Nursing Home
Hospital/ED Day of the Week
Uncontrolled pain12%
SP/Foley tube change
50%
Cellulitis of foot12%
Syncope/ Dehydration
13%
CHF13%
Hospital/ED at NH July - September 2 Total of 8 admissio
0
1
2
3
4
5
6
Weekday Weekend
Sub-Acute Nursing Home Project
• Trend analysis of 2015 hospital transfers– Pneumonia– Dehydration– Congestive Heart Failure
Sub-Acute Nursing Home Project
• Gap analysis– Checklist
Sub-Acute Nursing Home Project
• Establish clinical protocols : facility staff and providers– Flow charts, step-by-step assessment and
management
Sources: AMDA Clinical Practice Guidelines, AGS, INTERACT
Care Pathways
Treatment protocols
Pneumonia• Predominant Organisms
– Strep pneumonia, Gram negative bacteria, Staphylococcus aureus (including MRSA), Anaerobes, H influenzae, Group B Streptococci, Chlamydia pneumonia
• Empiric Antibiotic Therapy– Floroquinolone alone or Azithromycin, or erythromycin plus
amoxicillin (high dose) or amoxicillin-clavulanate
• Alternative Treatment– Antipseudomonal cephalosporin (cefipime or ceftazidime) or
Antipseudomonal carbepenem (imipenem or meropenem) or Beta-lactam/ Beta lactamase inhibitor (piperacillin-tazobacam)
– Plus– Antipseudomonal floroquinolone (ciprofloxacin or
levofloxacin) or Aminoglycoside (gentamicin or tobramycin)– Plus– Linezolid or Vancomycin (if MRSA risk factors present or local
incidence high)
• Duration of Treatment– Usually 10 to 14 days
• Sources: • Mandell, LA et.al. Clin Infect Dis. 2007; 44: S27-72.• ATS and IDSA Guidelines for management of adults with hospital-
acquired, ventilator associated and healthcare-associated pneumonia. Am J Resp Crit Care Med. 2005; 171: 388-416.
Congestive Heart Failure • Diuretics
• ARBs or ACEIs to target doses
• Beta-blockers to target doses once volume status stabilized
• Adding aldosterone antagonist can reduce mortality in patients with NYHA Class II-IV Failure
– Spirinolactone 25 mg/day or Eplerenone 25-50 mg/ day
• Add low dose digoxin 0.0625-0.125 mg/day if heart failure not controlled on diuretics and ACEIs, with or without aldosteroneantagonist.
• Adding a combination of isosorbide dinitrate and hydralazine can be helpful especially in African Americans with persistent symptoms.
• Sources: • Yancy CW et.al. Circulation 2013; 128: e240-e327.
Sub-Acute Nursing Home Project
• Education and acquiring necessary tools• Staff• Equipment• Contracts• Binder• Implementation Deadlines• Monitoring
Barriers to Health Care Change and Potential Solutions
Source: Pexton, C. https://www.isixsigma.com/implementation/change-management-implementation/overcoming-barriers-change-healthcare-system/
Factors Inhibiting Change Potential Solutions
Lack of Leadership support Facilitate contact with peers successful in deploying methodologies
Resistance or Skepticism from Staff
Develop stakeholder analysis and use a team-based problem-solving approach
Hesitancy to Invest Time and Money
Create a business case supported by sound data
Shortage of Internal Resources to Lead Change Initiatives
Enlist outside help to drive initial projects or receive training and mentoring in conjunction with projects that produce immediate results
Waning Commitment or Flavor-of-the Month Syndrome
Implement a solid communication plan that reaches all levels of the organization and build momentum through early visible wins
Uncertain Roles and/or Lack of Accountability
Adopt management systems and structures that clearly link projects and performance with overall strategies
Barriers & Solutions
Factors Inhibiting Change Solutions
Lack of Leadership support Clear alignment with mission
Resistance or Skepticism from Staff Partnered with staff to develop solutions
Hesitancy to Invest Time and Money
Provided with education, tools and resources
Shortage of Internal Resources to Lead Change Initiatives
Provided with education, tools and resources
Waning Commitment or Flavor-of-the Month Syndrome
Communication and updates of timelines and achievements
Uncertain Roles and/or Lack of Accountability
Role definition from project onset
Admission Rates (LIFE)
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
CHF Pneumonia Dehydration COPD (New)
20152016
30-Day All Cause Re-Admission Rates (LIFE)
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
2013 2014 2015 2016
30-Day Readmission RateTargetLinear (Target)
Hospital Inpatient Admissions (Germantown Home)
0
50
100
150
200
250
2015
2016 (September 2016)
30-Day All Cause Readmissions(Germantown Home)
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
2015
2016
Next Steps
• Dehydration• Add additional clinical protocols:
• Urinary Tract Infection• Cellulitis /Wound Infection• Chronic Obstructive Pulmonary Disease
• Continue to monitor, share results and lessons learned
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