Integrating Acute Rehabilitation Within a Regional Comprehensive

Health Care System

Matthew N. Bartels, MD, MPH

Professor and ChairmanDepartment of Rehabilitation Medicine

Montefiore Medical CenterAlbert Einstein College of Medicine

Bronx, NY

Disclosures

• None related to this talk unfortunately, but working on it………

Why Care About IRF in Regional Comprehensive Health Care

System?• IRF Growth has stalled, potentially

reversed• Insurance trends are not in IRF favor

– Favoring cheaper over better– 60% (or whatever) rule– Bundling

• Low return on high capital expenses• Intense manpower requirements• Small specialty/presence with powerful

competitors

IRF in the US

Numbers of IRF in US

• Progressive decline in IRF since 2004• A few more self standing IRF, less Hospital Based

IRF

Use of IRF ServicesDecline in volumes, but increased cost per patient

Discharges by Diagnosis• Orthopedic cases fading• Joints will be essentially gone in 2016

IRF Patient Mix• Brain injury, spinal cord, and stroke stable. • Debility mild increase

Top 10 Diagnoses in Free Standing IRF

• Diagnoses tend to neurological

• Do not take into account changing patient populations and needs

• Transplant, debility, ICU survivors not included

• Short term costs primary consideration

Medicare FFS vs. M’Advantage

• Worrisome trend for IRF in Medicare Managed Care

• Reduced use of IRF in favor of SNF

Medicare FFS vs. M’Advantage• Case weight is higher for MA, with lower use• MA is more selective in using IRF

IRF Quality/Efficiency Measures• IRF FIM efficiency has improved• Discharge to community stable

IRF Costs per Discharge• Interesting trends• Lower costs with:

– Freestanding– For profit– Urban– 60 or more beds

• Information helpful for assessing plans for your health network

Where is the Growth/Shrinkage?

How to Preserve Acute Rehab in this New Era of

Managed Care• This is in some ways an existential

moment!• Need to prove our worth• Establish that value is more than just in

dollars spent• Look to create new ways of providing

inpatient acute rehabilitation• Need to incorporate rehabilitation

specialists in the leadership of Post Acute Care (PAC)

Where Are the Opportunities?

• Coordination of care• Need to create pathways for appropriate

diagnoses• Need to look to the care of “non-classical”

diagnoses• Need to have the ability to move patients

between models of PAC• Need new models of home care and

subacute care

How Do You Make These Changes?

• Obstacles: – Medicare and its rules

• 60% rule• Classical Diagnoses• Managed care approvals• Bundles

– Private insurance• Approvals• Bundles• Coverage/contracting

Dream Solutions

• Be able to take all patients that need acute rehabilitation, regardless of diagnoses, insurance approvals, bundles and so on.

• Provide a flexible coverage that would allow individuals to move from level to level of care as needed and appropriate

• Spend more time on care and less on insurance and administration

An Approach to the Solution

• Incorporation of acute rehab as a part of the continuum of PAC

• Rehab central to all patients and discharge thought processes

• Need to have a health network willing to work with rehab and providers

• Need to be able to create innovative care models in conjunction with other providers

Creating the Ideal Solution at Montefiore Health System

• Montefiore Health System is the umbrella for a comprehensive medical network in the Lower Hudson Valley in New York State

• Montefiore has been a leader in managed care through the Care Management Organization (CMO), has worked to assume risk sharing with most payors, Pioneer ACO (savings for three years)

• Over 80% government payors creates both an opportunity and a challenge => risk sharing is the answer

• Allows for innovative care models

What is Montefiore?• Children’s Hospital at Montefiore• Montefiore Einstein Center for Cancer Care• Montefiore Einstein Center for Heart and Vascular

Care• Montefiore Einstein Center for Transplantation

• Clinical• Translational• Health

Services

• ~1,323 Residents & Fellows• ~420 Allied Health Students• ~1,552 Graduate &

Undergraduate Nursing• ~200 Home Health Aides• ~100 Social Workers

ResearchTeaching

• Home Health Programs

• Primary Care• House Call

Program

• 7 Campuses• 7 Hospitals• 2,200 Beds• 150 Skilled

Nursing Beds• 1 Freestanding ED• 3 Urgent Care

Sites

HomeCareHospitals

• Clinical support

• Network applications

• Finance• Legal• Planning• Purchasing• Compliance• Marketing• Human Resources

• Care Management(>300K Covered Lives)

• Disease Management• Care Coordination• Telemedicine• Pharmacy Education

Information Technology

CorporateFunctions CMO

• Health Education• Community Advocacy• Wellness• Disease Mgmt.• Nutrition • Obesity Prevention• Physical Activity• Reduce Teen Pregnancy• Lead Poisoning Prevention

Population Health

• ~23,000 Employees• ~3,450 Integrated Provider

Association Physicians• ~1,800 Employed MDs• ~4,270 RN/LPN

• ~3,300 NYSNA RNs• ~10,280 SEIU/1199

Workforce

Community

Academic HealthSystem

Notable Centers of Excellence

Primary & Specialty

Care

• Advanced Primary Care

• Sub-specialty Care• Dental• School Based Health

Centers• Mobile Health

• Neuroscience• Orthopedic• Ophthalmology• OB/GYN

Integrated Delivery System

Integrated Delivery System• Montefiore Locations–Over 2,200 Beds Across 7 Hospitals

– Including 120 beds at CHAM– Including White Plains Hospital

–Over 170 Sites including:• 64 Primary Care Sites

– 21 Montefiore Medical Group Sites• 21 School Health Clinics• 9 Mental Health / Substance

Abuse Treatment Clinics• 49 Specialty Care Sites

– 2 Multi-Specialty Centers– 4 Pediatric Specialty Centers– 15 Women’s Health Centers

• 5 Dental Centers• 5 Imaging Centers• Freestanding Emergency

Department• 3 Urgent Care Sites

–Schaffer Extended Care Center–Home Care Agency–School of Nursing–Burke Rehabilitation just added

Role for Rehabilitation

• Help to define the issues for post acute care

• Create a comprehensive PAC strategy– Incorporate a strong Acute Rehab

Presence– Also partner with and help to manage

risk in subacute care facilities– Establish and own a home care provider

• With shared risk:– Take on some risk, gain some freedom– Allows “breaking” some of the rules

Post Acute Care Opportunities

• Pathways with unique opportunities– Patients with slow acute care progress

• Subacute for brief time, then acute, then home

• Have 7 day a week home care with therapy

– Most Total joints go home: >80% in about 2 days• 7 day home care, presurgical prep• For other 20%: protocols with subacute

providers, acute for the select few with need

– Partner with subacute for short stays => make them part of the risk equation.

Where does Rehabilitation Medicine Fit?

• Need to make the right alliances• Be present in the planning and the

financial portions of the medical center• Post acute care is very expensive, very

risky, and very complicated– Rehab has very important skills to offer– Need to be flexible in our approach– Offer innovative solutions– Potentially with more risk, more

innovation

Rehab Innovations

• Can we save acute?– Yes! Need is for new patient populations– Innovative pathways and flexible

services/bundles– Transplant, complex cardiac and pulmonary– Medically complex debilitated – ICU

survivors– Cancer patients

• Live longer, more complex issues• Often can benefit from short rehab stays

to consolidate functional needs– Neurologically complex patients

For Acute Rehab/IRF

• Integration into the large at risk medical center/health care system will be essential

• Allows for innovation and growth/evolution• Staying with current models will lead to

eventual death by attrition• Issues are: costly and regulation• Could be the renaissance for acute/IRF

– But we (Rehab) need to do it and no one else knows or cares as much as we do.

Potential Benefits

• Save costs and improve post acute care outcomes– Allow innovative models/pathways– More patients served– As part of the bundle/continuum => not

forgotten– Potentially less regulation

• In at risk environment, CMO is the (internal) care management for multiple plans

• Re-admission, d/c to home all now counted

• Potentially the end of the RAC?!?!– “RAC” is new model is being cost

ineffective for your health system => internally determined

Conclusions

• The current model of acute rehabilitation/IRF is not likely to be sustainable

• Trends are towards smaller IRF presence– Limitation of diagnoses admitted not

realistic– Cost driven, not necessarily outcome

driven• However, we can change this course for IRF

– Need to look at IRF in the continuum of PAC

– Need rehab physicians to get involved in PAC

– Must present new and innovative models of care