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Reducing Fragmentation in Post-Acute Care: A Citra Health Solutions Case Study
Ken Van Cara
VP New Products & Innovation
MedSolutions
Krista K. Sultan
Program Development Manager
Citra Health Solutions
Today’s Intent
• The Current Environment of Post-Acute Care
• Key Steps to Coordinating Care in the Post-Acute Care Setting
• Exploring the Partnership Further: Aligning Post-Acute Care for Citra Health Solutions
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The Current Environment of Post-Acute Care
Acute Symptoms InpatientPost-Op
Longitudinal Experience of Health Care
Cumulative Costs of Patient Health Care Experience
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Fragmentation
Acute Symptoms InpatientPost-Op
The lack of coordination between acute and post-acute care facilities creates severe
fragmentation, leading to higher costs, and over-treated, under-treated, and readmitted
patients.
Challenge is to align providers and post-acute care facilities to reduce
waste and patient harm.
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Tremendous Waste
“Over half of the residents who
experienced harm went to a hospital for
treatment, with an estimated cost to Medicare of $208
million in August 2011”
Department of Health & Human Services (2014). Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare
Beneficiaries
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Patient Harm
“1 in 5 Medicare beneficiaries who had post-acute SNF stays
that were 35 days or less experienced at least one
adverse event during their stays”
“79% of these events either extended the beneficiaries’
stays in the SNF or resulted in emergency department visits
or inpatient readmissions”“59% of these adverse events and temporary
harm were clearly or likely preventable”
Department of Health & Human Services (2014). Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare
Beneficiaries
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Readmission Penalties
“In 2013, the CMS began penalizing excess
readmissions by trimming up to 1% from payments for heart attack, heart failure,
and pneumonia.”“Maximum penalties reached 2% in 2014 and will rise to 3% in 2015, when they will also be assessed for COPD
and hip and knee replacements”
SG2 (2013). Performance Guide: Reducing 30-Day Readmission Rates
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Readmission Penalties
1/4Of Medicare FFS patients
discharged from a hospital are readmitted
within 30 days.
$227MTotal readmission
penalties for 2014. For 2015, the maximum
penalty increases from 2% to 3%.
< 40%Of hospitals have a process to alert physicians within 48
hours of a patient’s discharge or to inform patients about
test results.
ACO Providers share financial risk for
avoidable readmissions.
SG2 (2013). Performance Guide: Reducing 30-Day Readmission Rates
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What will it take?
“True coordination of care – defined as the
organization of services among the hospital,
physicians, post-acute care provider, and
patient to encourage the delivery of the
highest-value services – is required to ensure the best possible outcome
s.”Ackerly & Grabowski (2014). Post-Acute Care Reform – Beyond the ACA
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Improving Care Coordination:Keys to Success
Patient/Physician connectivityCreates transparency into the acute and post-acute care settings to improve continuity of careNurse outreach supports primary care follow-up visits
A Solution That Meets Multiple Needs
Improved post-acute experiences for members and their loved ones
Better clinical outcomes and medical cost reductionsPost-acute care site of service management
• Identifying facilities with the services and quality suited to the needs of each member
• Supporting patient decision making and care site selection with evidence based guidelines
Readmission reductions
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Individualized Plans of Care
• One Clinical Point of Contact
Coordinates a single, individualized plan of care throughout the entire post-acute treatment – ideally managed by a single point of contact.
Applies clinical decisions based on evidence-based guidelines.
• Appropriate Site Selection Support
Builds on individual risk assessment with an understanding each patient’s clinical, environmental, and psycho-social resources and needs:
• Caregiver
• Transportation
• Home Environment
• Health Literacy and Cognitive
Ability
• Activities of Daily Living13Confidential: Do Not Distribute
Individualized Plans of Care
• Length of Stay Management at Every Site
Work directly with patients and post-
acute care clinicians to review patient
progress and ensure appropriate
utilization of facilities
• Readmission Reduction
Reconnect individual with primary care
physician
Provide Transition Coaching /
Medication Reconciliation
Deliver Patient Engagement Materials
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Robust Transition Support
Transition to the Appropriate Site of
Care
Assessment and engagement with
members on acute admission
Continuous monitoring of
patient progression along
the care continuum
Transition coaching based on member’s
needs and readmission risk level
Transition Home as Soon as Appropriate
Transition Coaching to Reduce Poor
Outcomes & Readmissions
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Technology-Enablement
One of the keys to Citra Healthcare's success was their use of MedSolutions' post-acute care management system,
which: Tracks members over time
across sites of care
Ensures appropriate utilization of facilities
Performs medication reconciliation
Accesses evidence-based guidelines
Develops and delivers care plans and member education materials
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Exploring the Partnership Further:
Citra Health Solutions & MedSolutions
Krista K. Sultan RN, BSN, MSProgram Development ManagerCitra Health Solutions
Partnership
Citra Health Solutions partnered with MedSolutions due to a lack of care coordination for their Medicare ACO patients.
Medicare Shared Savings
ACO
Lack of Post-Acute Care
Coordination
Financial and Quality
ConcernsCommunication Gap
Little Visibility Into Hospital
PCP Only
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Post-Acute Care Process
MedSolutions was hired to create a coordinated approach that included all five elements of Citra
Health Solutions as part of the solution
We partnered to create and launch a collaborative approach that brought the hospital,
Citra, and hospitalist stakeholders together, without making any large-scale changes to the
processes already in place
Using the MedSolutions approach, which incorporates the keys to care coordination
success, Citra Health Solutions has realized a 43% reduction in utilization of Skilled
Nursing Facilities (SNFs) and a 25% reduction in Inpatient Rehab Facilities (IRFs)
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Program Results
Discharges To
InitialDischarge
Recommendation
Actual Discharge w/
MedSolutionsRecommendation
% Increase/ decrease
Estimated Saved
(PMPM)Discharges %
Discharges
%
Home 22 32.4% 27 39.7% 23% --Home Health
19 27.9% 21 30.9% 11% $1.08
SNF 16 23.5% 10 14.7% -38% ($18.54)IRF 4 5.9% 3 4.4% -25% ($6.17)Other 7 10.3% 7 10.3% 0% --
Totals 68100.0
%68 100.0% -- ($23.62)Program Effectiveness
20% of patients were discharged to a more appropriate post-acute settingSignificant reduction in SNF and IRF over-utilization and corresponding increase in use of Home Health and Home settings
(Important note: Medicare FFS setting – we could only recommend)
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Patient Scenario
The Discharge Planner took MedSolutions’ recommendation and sent patient “A ” home.
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Quotes of Success
“In a previously unmanaged patient environment, Citra and MedSolutions partnered to develop a unique solution for managing post-acute spend. Citra’s management of the patient-physician relationship and patient profile coupled with MedSolutions’ expert staff and clinical guidelines resulted in positive behavior change that out-performed traditional methodologies. The success utilizing influential techniques rather than denial truly embodies the transformation of healthcare today.”
Nicole Bradberry - President and COO of Citra Health
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Quotes of Success
“At [St. Vincent’s] Southside, the pilot has been a successful one. The MedSolutions team have been very supportive and responsive to the needs of the CM department and the patients they have serviced. The implementation was very seamless for all, while initially there were a few bumps in the road with communication, there now appears to be a solid/open line of communication established, which I think has been a huge factor to the success we have had this far.
We look forward to continuing the partnership.”LaRhonda Brown – Case
Management, St. Vincent’s Healthcare - Southside
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Reach UsKen Van CaraMedSolutions615-468-4266Kenneth.VanCara@MedSolutions.comhttp://www.MedSolutions.com
Krista K. Sultan RN, BSN, MSCitra Health SolutionsKSultan@CitraHealth.com
Q&A
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