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Welcome

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Jaime WelcherCalifornia Hospital Association

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Continuing Education

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Continuing education will be offered for this program for health care executives and nursing. Application is pending for nursing home administrators. Occupational Therapy, Physical Therapy and Speech/Language Pathology professionals should submit a Certificate of Attendance to your professional organization.

Full attendance and completion of the online evaluation and attestation of attendance are required to receive CEs for this webinar. CEs are complimentary and available for the registrant only.

Faculty

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Pat Blaisdell is the Vice President, Continuum of Care with the California Hospital Association. She provides membership support and advocacy for hospital-based medical rehabilitation and skilled-nursing services, policy analysis and interpretation, communication with regulatory bodies and third-party payers, and planning and implementation of educational programs. She has particular expertise in clinical operations and reimbursement across the post-acute continuum of care and is a Fellow of the American College of Healthcare Executives.

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Faculty

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Andy Edeburn, MA, is a Principal with Premier, Inc. His areas of expertise include strategic planning, acute/post-acute integration, provider network development, and managed care. Mr. Edeburn guides organizations through their strategic thinking and planning around acute and post-acute partnerships, new program and facility development and redevelopment efforts, and establishing value and outcome-oriented relationships as organizations transition from the fee-for-service environment.

Faculty

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Donna Cella, RN, MMHC, is a Director with Premier’s Clinical Transformation team and a subject matter specialist in care management program assessment and redesign, clinical transformation strategy, and post-acute care. Ms. Cella is an accomplished facilitator who works closely with clinicians, leaders and aligned stakeholders to evaluate and adapt current models of clinical service and care management to address shifting perspectives around healthcare performance and payment.

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Major Changes Underway

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• The dialog about health care cost and quality has brought the conversation about post-acute care to the forefront.

• Hospitals and health systems are grappling to better understand the services provided after a hospital stay.

• This education program is designed to help California hospital leaders better understand post-acute care (PAC) and the continuum of care.

Why Post-Acute Care?

8Source: MedPAC June 2013; MedPAC Post Acute Care Reforms Congressional Testimony

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Post-Acute & Fee-for-Service (FFS) Thinking

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• While the risk is not direct, hospitals in FFS still have risk for post-acute cost and quality:

• PAC provider behavior will impact hospital payment in both areas.

Readmissions

Medicare Spend per Beneficiary

Post-Acute & Value-Based Thinking

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• In a value-based or population health environment, an ACO or a risk-bearing system typically carries direct risks for utilization of PAC services, as well the issues discussed previously in FFS.

o Example – Medicare ACOs encompass all Part A and Part B costs. Most PAC is paid under Part A. Thus, every day an ACO beneficiary spends in a skilled nursing facility bed or under home health coverage impacts the ACO’s total costs.

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Post-Acute Use & Spend is Highly Variable

11Source: MedPAC June 2013; MedPAC Post Acute Care Reforms Congressional Testimony

ACOs Look at PAC as a Key Savings Opportunity

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If an ACO can improve PAC performance through better engagement and management, it can save substantial dollars.

Impact of Improved SNF Management in MSSP ACO

Current State Financial Impact Future State Financial ImpactDischarges to SNF 500 425 15% reduction in SNF useSNF Days 26.5 13250 $7,950,000 10600 $6,360,000 20% reduction in SNF LOSReadmissions 11850 23% $1,344,975 17% $857,422 25% improvement in SNF readmits

Total $9,294,975 Total $7,217,422

Savings $2,077,553

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Bundle Payment Participants Also Look at PAC

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PAC can often account for up to half of total episode cost and bundled payment risk demands PAC engagement to realize savings.

Source: MedPAC September 2012; MedPAC Analysis of 2004-2006 5% Medicare claims files

Engaging with PAC is Becoming Essential

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Through ACOs and bundles, hospitals are learning that much of their risk lies in PAC.

Rather than leave it to chance, hospitals need to evaluate and engage the right post-acute providers to:

• Define appropriate use• Establish performance expectations• Partner with providers for success

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Question #1

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What is your organization’s mindset or status when it comes to post-acute care?

A) We haven’t even thought about post-acute care.

B) We’ve been talking about post-acute care. We know we need to do something, but we’re just in our infancy.

C) We’ve built our plan around working with post-acute but haven’t really implemented anything.

D) Our plan for PAC is well underway, and we are seeing positive results.

Why the Disconnect with PAC?

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• Historically, most PAC alignment has been transactional – hospital discharge planner or physician to PAC organization contacts, such as admissions or intake.

• PAC relationships are formed out of years of use and habit, oftentimes bad habit — with no regard for cost or quality.

• Changing alignment to be more strategic requires overcoming historical behavior and changing culture.

• Hospital leaders need to elevate PAC engagement as a strategic priority that shifts culture to understand cost and quality impacts.

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We Already Own PAC Assets, So We’re Good

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• Owning PAC assets — like an inpatient rehabilitation unit or a home health agency — is a great opportunity, but it does not automatically imply alignment or high-quality.

o Some use PAC for less-expensive management of challenging discharges or non-paying patients.

o Other organizations have not optimized operational or quality performance of a PAC asset. They are neither efficient, nor desirable.

• In either of these scenarios, the owned PAC asset is likely not positioned, nor capable of being an ideal partner.

Post-Acute is First Key Step

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Given performance and payment realities, hospitals must learn to work collaboratively with other providers to achieve the triple aim of better care, better quality and lower cost.

• Directing patients to community providers and engaging with community providers is not the same thing.

• Learning to work more closely with PAC outside our walls is the ideal first-step. Create a “learning laboratory” to connect with the broad array of community providers.

• Many organizations have used their post-acute “lessons learned” to build stronger ties to behavioral health, improve management of ESRD populations, and better engage around social determinant issues that drive spending.

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There is No Looking Back

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• The arc of health care change in our country demands that acute and post-acute work more closely together.

• Successful engagement with post-acute care is driven by a clear understanding of shared challenges and well-defined strategies to engage through hard work and collaboration.

• The focus of this curriculum is to provide tools and resources for California hospital leaders to plan their path for improving acute and post-acute engagement.

What is Post-Acute?

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“… a range of medical care services that support the individual’s continued recovery from illness or management of a chronic illness or disability.” *

• PAC typically encompasses services provided after a hospital stay.

• PAC is not a specific place, nor is it a “continuum of services.” Post-acute is a group of specialized care settings designed to treat patients depending on a specific condition or diagnosis.

• While some post-acute settings have similarities, they are not all the same, nor are they always interchangeable.

* Source: Trilogy Foundation – Terminology Sheet, www.thetrilogyfoundation.org.

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The Post-Acute Landscape

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Source: MedPAC, Report to Congress, Medicare Payment Policy, March 2018

Question #2

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Does your organization have any post-acute assets?A) We do not own or operate any PAC assets.

B) My organization has a home health agency or skilled nursing facility.

C) My organization has an inpatient rehabilitation facility.

D) My organization has two or more post-acute services.

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Home Health Agencies (HHA)

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• Home health agencies encompasses a range of health care services that are provided after an illness or injury — like wound care, IV therapy, serious illness management and therapy.

• Services are typically delivered by a nurse or therapist depending on the patient’s needs or plan of care. Aides are often deployed in the home to support these service needs.

• Most patients access HHA following an acute hospital discharge or through a primary care physician order.

• For a patient to qualify for HHA, he/she must be homebound and have an intermittent skilled service or therapy need.

BY THE NUMBERSThere are more than 1,300 home health agencies in California, many of which are privately owned and operated.

Skilled Nursing Facilities (SNFs)

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• Skilled nursing facilities, also more commonly referred to as “nursing homes,” offer a range of services for individuals who require 24/7 medical oversight, but do not require hospital-level care.

• SNF-level care is also sometimes called “subacute care” or “transitional care.” A hospital-based “skilled nursing unit” or “SNU” is typically licensed as a SNF.

• Common SNF services include therapy and rehabilitation, complex medical care, IV therapy, post-operative infection management and similar needs.

• SNFs work to stabilize and restore functional capability to discharge the patient to home or a lower level of care.

BY THE NUMBERSIn 2015, there were nearly 1,200 SNFs in California, down nearly 10% from the previous decade.

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Skilled Nursing Facilities (continued)

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• Some patients discharged to a SNF can transition to long-term care service, which is also often provided in nursing homes.

• Most SNF patients are admitted after hospital discharge. • To qualify for Medicare-covered (and typically Medicare Advantage-

covered) services in a SNF, a patient must have spent three preceding days in an acute hospital.

Inpatient Rehabilitation Facility (IRF)

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• Sometimes called “Acute Rehabilitation,” IRF is a highly-specialized setting that provides intensive rehabilitation and therapy services (3+ hours per day) to patients who require hospital-level care and must ideally be seen daily by a physician.

• Typical IRF patients include individuals with traumatic brain or spinal cord injury, stroke or major cerebrovascular event, and complex neurologic or orthopedic issues.

• Nearly all IRF patients are admitted following an acute hospital discharge, and their admission is contingent upon evaluation and approval of a physician with expertize in rehabilitation.

BY THE NUMBERSThere are nearly 75 IRFs in California, most of which operate as hospital-based units.

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Long-Term Acute Care Hospital (LTACH)

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• LTACHs encompass specialized settings that provide intensive medical management and rehabilitation of highly-complex patients who require acute, hospital-level care and should be seen by a physician daily.

• Typical LTACH patients include individuals with complex pulmonary illness, most commonly on a mechanical ventilator and require weaning to discontinue.

• Additionally, LTACHs manage multiple complexities, substantial wound management, infectious disease and multiple IV management.

• LTACH patients are most commonly admitted after hospital discharge.

BY THE NUMBERSThere are about a dozen LTACHs in California, many of which are operated by national LTACH companies.

Post-Acute Payment & Reimbursement

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Most PAC services are paid for by Medicare or Medicare Advantage, and each PAC setting has its own reimbursement system.

HHA60-day Episode

Paid through HHRG

Amount determined by acuity

SNFPer Diem PaymentPaid through RUGAmount determined

by acuity

IRFEpisodic PaymentPaid through CMGAmount determined

by condition and functional status

LTACHEpisodic Payment

Paid through LTCH-DRG

Amount determined by diagnosis

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Variation & Post-Acute Payment

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• Much of the variation in PAC spending grows from the different PAC payment systems.

• Historically, few criteria guide the hospital discharge planner about the “right” post-acute setting for a patient.

o For instance, a patient who might be managed in a SNF could also go to home health. The same may be true for a patient in IRF vs. SNF.

• Without specific tools to inform selection, hospitals rely on patient choice, physician advice, and — too often — old habits.

Site Neutral or ‘Unified’ Post-Acute Payment

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• Policy leaders are seeking to collapse post-acute payment into one system (rather than the four current systems).

• The IMPACT Act of 2014 directed CMS to study the potential of a site-neutral payment system for post-acute care.

• The results of the study and follow-up analysis determined that such a system would be viable and should be implemented by 2021.

• The current recommendation is to begin migration to a unified system in 2019.

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Site Neutral or ‘Unified’ Post-Acute Payment (continued)

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PAC Unified PPS Goals• Payments would be based

on patient acuity rather than the PAC setting.

• Providers would have fewer incentives to selectively admit some patients over others because payment would track patient resource needs better.

Payment Model Features• Common unit of service (i.e., a stay or

episode) with a patient characteristic risk-adjustment system.

• Payment adjustment to reflect lower costs in HHA settings.

• Separate payments for routine and therapy services and for non-therapy ancillary services such as drugs.

• Outlier policies for unusually high-cost stays and unusually short stays.

Site Neutral or ‘Unified’ Post-Acute Payment (continued)

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• Site-neutral payment represents a substantial paradigm shift for PAC.• While LTACH and IRF traditionally paid through an episodic model,

site-neutral amounts would likely be lower. • SNFs (who are used to per-diem thinking) would shift to an episodic

model that will emphasize much shorter lengths-of-stay.• For hospitals and health systems who own these assets, the shift in

payment carries financial and operational impacts.

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Post-Acute Quality

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• Until recently, data about post-acute quality and performance has been fairly limited.

• CMS has taken many steps to improve both the quantity and depth of information that is publically available about post-acute quality.

• As with hospitals, CMS uses a five-star rating system to rank post-acute providers. This information is available online through Medicare’s public-facing website.

• Improved data offers an important resource for hospitals seeking to better understand their potential post-acute partners.

Post-Acute Operations

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Like their hospital cousins, post-acute facilities face similar operational challenges endemic to health care, as well as unique challenges.

Home Health • Payment has undergone

rebasing, impacting bottom line performance

• Considerable buying and selling of agencies

• Preference to use HHAabove other PAC venues is increasing demand

Skilled Nursing• New Conditions of

Participation that challenge operators

• Decreased rehabilitation means shift in clinical focus — more complex

• Oversupply of SNF beds drives competition for quality referrals

• Industry is likely to downsize over next 5-7 years

Acute Rehab• Very narrow range of

patient types are appropriate for IRF

• Commercial payers increasingly deny IRF coverage in favor of SNF or HHA

• Shifting patient target requires greater specialization and reinvention

Long-Term Acute Care• Absence of defined

LTACH criteria has resulted in CMS narrowing types of patients that quality for LTACH payment

• Moratorium on LTACH development precludes growth

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Thank you

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Patricia Blaisdell California Hospital Associationpblaisdell@calhospital.org

Andy Edeburn, MAPrincipal, Premier, Inc.Andy_edeburn@premierinc.com

Donna Cella, RN, MMHCDirector, Premier, Inc.Donna_Cella@premierinc.com

Question and Answer

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Online questions:Type your question in the Q & A box, then press enter

Phone questions:To ask a question, press *1

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Upcoming Programs

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Sterile Compounding Pharmacies: Guidance for Implementing Regulatory ChangesApril 17, 2018 10:00-11:30 a.m., Pacific Time

This webinar will provide information on “how” to navigate the processes of each regulatory agency in order to meet the regulatory requirements. Experts will also share common pitfalls that hinder compliance with the new requirements.

Upcoming Programs

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Consent Law SeminarApril 24, FresnoMay 9 San DiegoCHA’s Consent Law seminar will keep you informed and prepared for those challenging cases hat demand immediate action. Expert faculty will help you understand changes in the laws surrounding patient treatment, and hone your critical thinking skills with scenarios that apply to real-world experience.

All attendees receive a 2018 Consent Manual-both in print and PDF versions.

More dates and locations are listed online www.calhospital.org

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Thank YouEvaluation, Recording and Guidebook

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Thank you for participating in today’s webinar. An online evaluation will be sent to you shortly.

A recorded version of this webinar will be emailed to each registrant. In addition, the Productive Partners: Hospitals and the Continuum of Care Guidebook will be sent to each registrant following the final webinar on May 29th.

For education questions, contact Jaime Welcher at (916) 552-7527 or jwelcher@calhospital.org.