“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