articulo 5 hospitales

8/14/2019 ARTICULO 5 HOSPITALES

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FEATURE STORYDonna J. Cameron

AT A GLANCEA postacute strategic plan is important tor hospitalsto meet growing needs. Hospitals should:> Comple te a postacute bed demand study> Develop and/or convert postacute programs> Organ ize and integrate post-acute services> Manage DRG LOS> Monito r the transfer rule> Perform an ongoing operational assessment

of postacute services> Stay abreast of regulato ry changes> Stay curre nt w ith ongoing payment changes

postacute strategic planningpreparing for an aging populationIs your hospital prepared to offer patien ts high-quality, cost-effectivepostacute options? A postacute strategic plan can prepare yourorganization to serve an aging population.

The U.S. healthcare system is fast app roaching a time when having a postacute care strategy will not he simply ama tter of choice for the nation's h os-pitals and health system s. Demand for po stacute services will increase asbaby boomers in increasing numbers enter their retirement years.

Web Exclusive!For a look at tKe history of howprospective payment affected post-acute care, go to www .hfma. org/hfm.

The idea of developing a postacute care strategy is not new for hospitals.Postacute programs experienced significant growth in the early 1990s ashospitals, seeking to develop integrated delivery systems, implementedstrategies to transition patients through the continuum of care and managediagnosis-related group (DRG) lengths of stay (LOS).In the late 1990s, however, these efforts encountered obstacles. TheBalanced Budget Act of 1997 man dated that prosp ective payme nt system s(PPSs) he imp lemented for postacute services, with the result that th efinancial performance of many postacute programs declined significantly.Many hospitals evaluated whe ther they could afford to stay in the postacutehusiness.Yet an important trend is turnin g the tide again in favor of postacute pro -grams. With the retirem ent of the baby boomer gen eration, tbe nation is onthe verge of a significant demo graphic shift toward a more elderly popula-tion. And as a result, the postacute husin ess will become increasingly imp otant to bospitals. Inpatients will become older and sicker, and the likelihoodthat they will requ ire some form of postacute care will increase in step.


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The Strategic QuestionToday, it is com mon to find that hospitals andhealth systems are appropriately addressing theaddition and/or expansion of cardiovascular,orthopedic, and oncology services. These busi-ness development o pportunities are incorporatedinto hospital strategic plans. Capital hudgetsreflect significant dollars heing devoted to brin g-ing these new and enhanced services to fruition.But many hosp itals are not giving adequatestrategic attention to the healthcare needs of thispopulation following their acute treatment. Theneeds of the aging population will not end withacute medical services, such as a joint surgery orcardiovascular procedures.Tlie question hospital financial leaders today needto be asking is. "How well is my healthcare organi-zation positioned to serve the aging Americanafrom both an acute and postacute standpoint?"The Government PerspectiveGovernm ent officials have advised health p ro -grams to hrace themselves for increased demandson the healthcare system. Hospitals and healthsystems n eed to start focusing on prom otinghealth in older adults, preventing disahilities,and m aintainingquality of life.

Also, the C enters for M edicare and MedicaidServices recently awarded $547 million in grantsto i3 states and the District of Columbia to buildMedicaid long-term care programs that will helpkeep people at home and out of institutions.Leslie V. Norwalk. the acting adm inistrato r ofCMS from October 2006 through S eptember2007. said. "There is more evidence than everthat people who need lo ng-term care prefer toremain in their own homes and com munitieswhenever poss ible. This new program will helpstates shift Medicaid's traditional emphasis oninstitutio nal care to a system offering greaterchoices that include home-based services."^What Hospitals Should DoAs hospitals set about determ ining th eir postacutestrategy for the future, as with any strategic p lan-ning pro cess, they should execute six essentialsteps:> Review the mission> Complete an analysis of strength s, weaknesses,

oppo rtunities, and threats (SWOT analysis)> Complete a market analysis> Compile an environmental assessment> Establish strategic goals> Determine associated tactics with time lines

and accountable person s

For years, a nursinghome placement hasbeen a typical dis-charge option follow-ing a hospital stay. Thefederal and state gov-ernm ents are workinghard to develop home-and community-basedalternatives that provide more independence andautonomy for senior citizens and persons withdisabilities. To help make this change happen ,state and federal governments have increasinglyfreed up Medicaid dollars that traditionally wererestricted to nursing home care.'"'

Because of the role postacute program s play in ahospital's continuum of care, it is worthw hile toconsider a centralized organizational structurefor the prog ram s.Beyond these ste ps, however, hosp itals need toconsider a range of addition al measures, such asthose discussed below, as they develop andimplement a postacute strategic plan.

a, 'Nurs ing Care Takes a Smart Delour," Philadelphia Inquirer,M ay 27 .2007 ,

b. "CMS Awards Grants to 13 States (o r Alternatives to NursingHome C are," CM S Press Release, May 14 ,200 7.


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FEATURE STORY

WHAT ARE POSTACUTE SERVICES?The simplest way to define postac ute services is asthose programs in which patients are served follow-ing an acute hospital stay. Postacute services includeinpatient reh abilitation facilities (IRF), skilled nurs-ing facilities (SNF ), long-term acute care hospitals(LTCH ), home h ealth agencies, assisted-living facili-ties, and some outpatient services such asphysicaltherapy, occupational therapy, and speech therapy.Some argue that programs provided in acutehospital licensed beds (such as at a LTCH) are not"postacute." However, patients who benefit fromthese services are typically referre d directly f roman acute care stay.

r POSTACUTE SERVICESInpatient Rehabilitation Facility> Ac ute hospital licensed beds> DR G exempt reha bilitation beds> Intensive rehabilitation (three hours of therapy

per day in at least two disciplines plus rehab ilita-tion nursing)

> Specific medical director requirements> Average length of stay is 13.4 daysSkilled Ntjrsing Facility> Nursing home regulations> M ay be hospital-based (subacute, transitional

care) or community-based> Patient may be "skilled for M edic are" by need

for ther apy or a specific medica l issue> Requires a 72-hou r acu te hospital stayOutpatient Rehabilitation> Typically includes physical therapy, oc cupatio nal

therapy, and speech therapy> Also t ime-l imited

A primary role of postacute programs in the health-care continuum is to provide options for patients toreceive necessary clinical treatm ent following anacute medical episode or surgical procedure.Frequently, a patient cannot go home independ-ently and needs postacute options to transition toindependent living in the comm unity. An effectivepostacute continuum can reduce rehospitalization.particularly if the discharge situation and ongoingsupport minimizes crisis admissions. Additionally,postacute services offer opportunities fo r hospitalsto provide high-quality alternatives for continuedcare while managing DR G length of stay in theacute hospital beds. 1Long-Term Care Hospital> Acute level of care> intended for medically complex patients who

need continued acute hospitalization> Average length of stay must average at least

25 days> DRG exemptAssisted Living> Com bination of housing, personalizedsupportive services, and healthcare services> Allows each resident a choice of care and lifestyle> Fosters independ ence in a safe residential

environmentHome Care> Patients must meet the federal definition of

"homebound" for Medicare and require skilledservices

> Time-limited> M ay include therapy, nursing, and home health

aide services

Complete a postacute bed demand study. This studyshould use a i:^-month data set of acute hospitaldischarges to determine the type and num ber ofpostacute beds that the ho spital may need to meetpatien ts' discharge needs . At discharge from thehospital, some patients maybe candidates formultiple postacute venues such as inpatient reha-bilitation facilities (IRFs) and skilled nursingfacilities (SNFs). It therefore is critical that anoverlap analysis be done as part of the bed

demand study, to account for patients who cpaalifor multiple levels of care.Con ducting such a study can be b eneficialregardless of the current IRF, SNF. or lon g-termcare bospital (LTCH) beds currently being operated. Including assessment of current bed capacity in tbe study may influence tbe o rganization tconsider exp anding or reducing bed s. The analysis also could identify a bed need not currently


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FEATURE STORY

being met by the hospital continuum or apartnering facility.Develop and/or convert postacuie programs.Following the post-acute bed demand study,the hospital should inventory current postacuteofferings and d eterm ine what is lacking fromthe continuum . If the hospital does not wantto own and operate a particular postacute service,relationships with other providers may beconsidered.

Mon itor the TransferRule. For discharges occurr ingon o r after Oct. i, 1998, a discharge of a hospitalinpatient is considered a transfer when assignedto one of the qualiiying DRGs and the patient isdischarged to a distinct part of the hospital unitsuc hasa nlR Fo r LTCH. aSNFbed, or to homeunder a written plan of care for the provision ofhome health services within three days after dis-charge. For a transfer case, the h ospital forfeits aportion of the DRG payment if a patient's acutestay is shorter than the geom etric mean length ofstay (GMLOS) for th at DRG.

Organize and integratepost-acute services.Because of the rolepostacute program splay in a hospital'scontinuum of care, it isworthwhile to considera centralized organiza-tional structure for theprograms. A central-ized organizationalmodel can facilitatesynchronized leadership, common operationalprocesses (e.g., preadmission assessment), elimina-tion of duplicated personn el functions, integration ofcase m anagement, and coordination of strategicplanning across the postacute venues of care.Manage DRG LOS. Managing DRG LOS entailsaddressin g various factors that can influencetimely discharge to postacute care, includin g casemanagement and discharge planning effective-ness, physician support for discharge placement,efficiency of operationa l pro cesses, effectivenessof the u tilization review pro cess, and capacity inpostacute discharge options. Unnecessary delaysin discharge to postacute prog rams can he costlyto the ho spital system and can im pact availabilityof acute care beds. To address the delays, it isimportant to consider a variety of strateg ies,including redesigning postacute p readmissionprocesse s, developing clinical pathways for keydiagnostic groups, and taking steps to improvethe effectiveness of case management betweenacute and p ostacute care.

To be well positioned for a successful future,a hospita l must be able to offer pa tien tsa full range of postacute service option s.Bottom line: Initiate a postacute strategicplan ning process today.

When the Transfer Rule was initially im ple-mented on Oct. 1,1998, it included only 10 DRGs.The nu mb er of affected DRGs was expanded in2oo3 to 29, and then to 3o in 2 004 . With theissuance of a final rule in August 2005 , CMSexpanded th e list of DRGs subject to the transferpolicy toi82 by adopting the following criteriathat the DRG must meet:> Tbe DRG must have a GMLOS of at least three days.> The DRG must have at least 3,050 postacute care

transfer cases.> At least 5.5 percen t o fthe cases in the DRG aredischarged to postacute care prior to the

GMLOS for the DRG.> If the DRG is one of a pair ed set of DRGs

based on the presence or absence of a comor-bidity or complication, both paired DRGs areincluded if either one meets the three criteriaabove.

Under th e new Medicare-severity DRGs (MS-DRGs) effective Oct. 1, 2007, the n umber hasbeen increased again to 272 DRGs. It should be


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FEATURE STORY

noted though th at the percentage of DRGswithout complications has almost douhled from23.3 percent to 41.1 percent. Asa result, therecould be a significant decrease in payment due tothe increase in cases without co mplicationsapplicable to the Transfer Rule.Because the Transfer Rule does no t affect a post-acute provider's payment, postacute providersrarely mo nitore d it. H ospitals would be welladvised to mo nitor the rule for potential changes.A Transfer Rule analysis can enahlc a hospital toevaluate the impact of the changes and identiiydiagnostic groups for review of clinical pathways.

Hospitals also shou ld m ake sure th at GMLOSdoes not drive the discharge date. Rather. GMLOshould he a consideration w hen facilitating c lincally approp riate, physician-directed dischargeThe decision to discharge a patient from a hosptal should be m ade by the attend ing physician incoordination with the case m anager/dischargeplanner. This decision should he made in con-junction with tbe patient and family mem bers taccomplish wbat is in the hest interest of thepatient.

Perform an ongoing operational assessment ofposttKute services. For mos t postacute venues o f

HERE CO ME THE BABY BOO MER S!The need for hospitals to develop a postacute ca restrategy is underscored not only by the effects theBalanced Budget Act of 1996 , but also by the nation'sshifting demographics to an older population. By201 5, people older than age 65 w ill account fo ralmost one in every Jive people, according to a reportby the U.S. Agency ior Healthcare Research andQuality issued Aug. 2 3, 2 0 0 5 . Moreover, a recentreport by the American Hospital Association (A HA )projects that Americans age 65 and older willnearly double in number by 2 0 3 0 {When I'm 64:How Boomers Will Change Health Care, M ay 2 0 0 5 ) .As a result of this population g rowth , senior citizenswill make up an increasing percentage of the overallpopulation on M edicare.

Baby boomers, defined as the 76 million Ame ricansborn between 1946 and 1964, are the nation's largestand potentially wealthiest generation ever. Everyday, almost 11,000 boomers turn 5 0 -o n e everyeight seconds, according to The Boomer Project,a Richmond, Va.-based marketing research andconsulting company. The first baby boomers willturn 65 in 2011.The population shift that w ill result from the ag ing ofthe baby boomers also will profoundly affect health-care deliver y People older than age 65 occupy abou thalf of all hospital beds, represen t 2 5 perce nt of allphysician office visits, andconsume about 6 0 percentof all healthcare dollars, according to a recent articlepublished in Hospitals & Health Networks (Henry,J.D., and Henry, L.S., "Be tter C are fo r Elders," June20 , 20 07 ). W ith the increasing senior cit izen

population, there will be a continued impact basedon how the elderly move through the healthcarecontinuum.By 2 0 30 , more than six of every 10 boomers v/illbe managing more than one chronic condition("Prevalence, Expenditures, and Complications ofMultiple Chronic Conditions in the Elderly," Archiveof Internal Medicine, 2002). Because the biggestfactors influencing m edical spending are chronicillness and a patient's level of disability, the grow ingincidence of mu ltiple c hronic conditions also willput increasing demands on our healthcare system.Data from the National Center for HealthcareStatistics' National Hospital Discharge Survey 2004indicate that senior citizens constituted nearly2 8 percent of the U.S. hospital admissions in 2 0 0 4Based on these data, the First Consulting G rou pprojected in May 20 0 6 that by 2 03 0 , seniors wil laccount for 51 perce nt of admissions, and thai in25 years, U.S. hospitals could annually admit 14 million more seniors than curre nt levels. Although whathe actual impact on inpatient admissions will be isas yet uncertain, baby boomers will without questionplace a substantial strain on healthcare resources.And with the aging population will come an increasedprevalence of certain diseases and associatedhealthcare needs that will require treatm ent.

Despite this trend, however, costs are not pro jectedto increase uniformly across major categories ofmedical practice. A 2 0 0 6 study conducted byHealthPartners estimated that the change in percapita costs due to aging will be highest in the field


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FEATURE STORY

care, the PPS has been fully implem ented.However, hospitals should routinely reassess theeffectiveness of systems and p rocesses that wereput into place to determine whether opportuni-ties for improvem ent exist. Even though a partic-ular pro cess may have worked adequately,alternative strategies could he identified toimprove efficiency and improve payment.There are many ways to assess the effectiveness ofan already implemented system. Examples includecoding etiologic diagnosis and com orhidities onthe IRF PAl, capturing therapy minute s for SNFs,and m onitoring missed therapy visits for home

health agencies. Industry benchmarks are alsouseful for analyzing costs and identifying opportu-nities for operational process redesign.Stay abreast of regulatory changes. Changes andrefinements in regulatory issues are constant, sohospitals should assign responsibility to an indi -vidual to continually m onitor changes and howthey impact the postacute program s and tbehospital's co ntinuum of care.As an example ofthe types of regulatory changesthat should be monitored, consider the 75 PercentRule for IRFs. T he 75 Percent Rule was implem ented

of kidney disorders, with spending projec ted to rise by55 percent between 20 0 0 and 20 50 . (Martin i, E.M.,Ga rrett, N., Lindquist, T., Isbam, G.J., The Boomers AreComing: A Total Cost of Care Model of the Impact ofPopulatior}Aging on Health Care Costs in the United States byMajor Practice Category, Health Services Research, 2006).Mea nwhile, the study projected tbat per capita spendingwiil increase 44 percent dunn g that time pe riod io r heartand vascular conditions.Particularly asbaby boomers grow older, it is expec ted thatelective joint replacem ent volumes will accelerate. Spineand sports m edicine are expected to receive the greatestboosts fro m tbe aging baby boomers. The previously c itedreport by tbe AH A says tbat eigbt times m ore knee replace-ments will be perform ed tban today. Onc ology prevalenceis anticipated to continue increasing. Meanw bile, an articlein USA Today projects a 55 percent increase in the numberof cancer patients and survivors by 2 0 2 0 ("Cancer BurdenExpected to Soar, Overwbe lm D octors," Feb. 13 ,20 07 ).Hypertension and arthritis are the most comm on cbronicconditions among Am ericans age 65 or older, andAlzheime r's disease is tbe most prevalent chronic c onditionamong tbose 8 5 and older.

The demographic change also is projected to reduce percapita costs in some areas, however. Tbe H ealthPa rtnersstudy points to postnatal care, chemical dependency, andpregnancy and infertility care as tbree sucb areas.Nonetheless, tbe overwhelming impact of tbe increasednumbers of senior citizens will make profound demands ontbe U.S. healthca re system. And hospitals and healtb sys-tems cannot afford to be unprepared to m eet thesedemands.

OVERALL SENIOR CITIZEN POPULATION GROWTH COMPAREDWITH MEDICARE POPULATION G ROWTH

Num ber of persons age 65 +(in millions)

2000 2010 2020 2030 2040 2050

Medicare population growthUnder 65 I Medicare population

2000 2010 2020 2030 2040 2050

Source; U.S. Department of Health andHuman Services, Centers for Disease Control andPrevention andNational Center (or Health Statistics, 20 05 .


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FEATURE STORY

in the mi d'i9 8o sas am ean sto discriminateDRG ~exemp trehahilitationheds from acute carebeds. The original rule states that 75 percent ofthe IRF's discharges need to he patients withdiagnoses from a defined list of 10 conditions. Amajor revision to the 75 Percent Rulepublishedin the May 7, 2004, Federal Registei^has revolu-tionized the IRF industry. The revised ruleexpanded the list of conditions from 1 o to i3 , butfunctionally restricte d the types of patients thatcan be admitted to the IRF level of care.

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Due to lobbying and persistent efforts from theIRF industry, the effects of this change have heenmitigated by further modifications of the 75Percent Rule in the Medicare. Medicaid. andSCHIP Extension Act of 3007, signed byPresident Bush on Dec. 3 i, 2007. As a result, thecompliance threshold has been frozen at 60 percent. M onitoring of this rule by CMS is retro-spective. Hospitals should implem ent effectivemonitors on an ongoing basis to ensure compli-ance and evaluate the impact on their postacutedischarge patterns.

As another example of major regulatoiy change,consider the 35Percent Referral Rule affectingLTCHs, whicb specifies tha t for an LTCH that is"hospital within a hospital" (HwH) or fora free-standing LTCH that is not deemed to be "off campus" by CMS, at least 25 percent of the admissionmust come from a source other tb an the hosthospital. This rule is being imp lemented via atransition period until tbe cost reporting periodbeginning on or after July i,51007, and beforeOct. 1. 2007. and it has significant implicationsfor moving patients from host bospitals to HwHsHost hosp itals will potentially see an impact oncontractual agreements witb HwHs. The rule creates an urgent need for bosp itals to devise a planto address this issue quickly, so that strateg iescan be executed during the transition period,

Moreover, the reach of the 25 Percent ReferralRule has heen b roaden ed via a final rule issuedMay 11. 2007. Under this change, the 25 PercentReferral Rule has bee n extended to all LTCHs,including freestanding and satellite facilities.Admissions over 25 percent from a single referrsource ho spital to any LTCH will be paid u singsho rt-ter m ho spital rates, which are lower thanthe LTCH PPS rates. This change will significantlaffect patient referrals to LTCHs. particularlythose affiliated with primary or secondary hospitals. For existing LTCHs, thi s expa nsion of the25 Percent Referral Rule will be ph ased inoverthree years.

Siay current with ongo/ng payment changes. It iscritical that hospitals have designated individuals


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FEATURE STORY

The effect of the various PPSshas heen to create a need for a strongeralliance and collaboration amongclinical operations, coding, and financepersonnel to estahlish systems tooptimize performance.

including finance person nel, wbo are chargedwitb continually m onitoring cbanges in paymentme tbodolog ies. The effect of the various PPSs basbeen to create a need for a stronger alliance andcollaboration am ong clinical op erations, eoding,and finance perso nnel to establish systems tooptimize performance.The Bottom Line?With tbe convergence of significant paymentchanges, aging demographics, associated

increases in disease prevalence, and cbangingexpec tations of aging baby boom ers to have hroaoptions for sustaining tbeir inde pendence in thecommunity, a hospital's need for future strategicplannin g does not stop witb addressing thepatient needs up to the poin t of discbarge fromthe acute bospital stay. To be well positioned forsuccessful future, a hospital also must be able tooffer p atien ts a full range of postacute serviceoptions. B ottom line: Initiate a postacute stra te-gic planning process today.

About the authorDonna ) . Cameronis a consultant, Health Evolutions, Inc.,Indianapol is {dcameron@ healthevolutjons.com).

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