how to establish an accountable post-acute preferred provider
TRANSCRIPT
How to Establish an Accountable Post-Acute Preferred Provider Network November 14, 2016
How to Establish an Accountable Post-Acute Preferred Provider Network Maura McQueeney, MPH, DNP President, Baystate VNA & Hospice/ Post-Acute Care, Baystate Health Lissy Hu, MD, MBA Chief Executive Officer, CarePort Health
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Shifting Payment Landscape
3
MACRA Readmissions
IMPACT
Act Bundled
Payments
CJR
ACO
Background Problem discovery 2013 – Multiple vendor and provider relationships coming and going from the medical center and outlying hospitals
Strategic Question How should we partner for results in BCPI and ACO when we do not OWN post acute facilities? Embed MDs($)? Embed Mid levels($)? Partner for quality results ?
Decision Develop clear, post - acute partner scorecard, be transparent with results, select a preferred network based upon quality BEYOND star ratings, define monitoring and sustainable outcomes, create written agreements
Methods How we created an accountable preferred post acute network
Results and Takeaways Sharing our success tips
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Overview
Baystate Health
• Largest health system in Western Massachusetts
• One academic medical center, two community hospitals, 973 beds
• Owns a health insurance company – Health New England
• 250 Physician Practices
• Acquiring surrounding community hospitals to secure competitive boundaries
• Next Generation ACO
• Early entrant into MSSP TJR bundle
• Strategically not in the long-term care “space”
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• Strategic Post-Acute Care Committee (SPACC)
• Complex web of relationships and potential for conflict of interest
• Need to organize relationships around quality in context of BPCI and ACO
DME, Lab Services, Imaging Services
SNF Liaisons
HHA Liaisons
Hospital SNF HHA
Creating a Central Nervous System: SPACC
Strategic Post-Acute Care Committee (SPACC)
• SVP for Quality and Population Health
• President, VNA & Hospice
• Physician leader of ACO
• Geriatrician representing post-acute medicine
• Director of Quality (oversees BPCI program)
• Director for Post-Acute Integration
• Heart & Vascular service line director
• VP, Strategic Planning
• Director of Case Management
• Ad hoc members: Lab and Imaging, Medical Director of
Health New England (insurance organization)
• Identified relevant post-
acute stakeholders (ACO,
BPCI)
• Hired Director for Post-Acute
Integration
• Instituted monthly meetings
for group to discuss SNF
selection criteria, quality
measurement, and
performance improvement
Getting Started
Collaborative Partner Facility ProfileCollaborative Partner Facility Profile
Facility Name
Facility Address
City State Zip
Phone
Contact 1 name
Contact 1 Title
Contact 1 e-mail
Web Site
Ownership Type (private, profit, nonprofit, parent company)
What is your ability to manage pts with psychiatric
diagnoses
Individual Facility DemographicsIndividual Facility Demographics
Category Response Yes/No (Yes
= 1; No = 0)Comments/additional Information
License Types (please list all) LTC
Number of Sub Acute Beds Short Stay all private rooms
Number of LTC Beds
Number of LTACH Beds
Number of Specialty Services Beds (vent, rehab)
MDs Contracted-Internist, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)
1 Community PCP
MDs Contracted-Geriatrician, and days per week on unit
LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
MDs Contracted-Specialty MD, and days per week on unit
LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
MDs Contracted-Internist, and days per week on unit Sub
Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)1 Community PCP
MDs Contracted-Geriatrician, and days per week on unit
Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
MDs Contracted-Specialty MD, and days per week on unit
Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
Midlevel (RN/PA) Practitioner Contracted and days per
week on unit LTC (Enter 1 if once/week; 2 if 3-5 days; 3 if daily)1
Midlevel (RN/PA) Practitioner Contracted and days per
week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)?? 1
24/hr day RN (Y/N)? 1 Staff: 50% RN
Nursing Model: Primary Nursing Model (Y/N)? 1
Nursing Model: Consistent Alignment (Y/N)? 1
RN Specialty Certification: Rehabilitation (Y/N)? 1 RN, Cardiac Specialist
RN Specialty Certification: Geriatrician (Y/N)? 0
Full time, licensed (RN, SW, OT, PT) Case Manager or
Navigator (Y/N)?1
Dietician available (Y/N)? 1
Special diet available: low sodium, ADA etc. (Y/N)? 1
Special diet available: TPN (Y/N)? 1
Certified Wound Care Nurse available (Y/N)? 1 Hospital CWOC NP
Palliative and Hospice Care (Y/N)? 1Palliative MD at to support;
Hospice w/ Affiliate
Pharmacy Name Formulary available (Y/N)? 1
Contracted Payers and Plans (list)
Medicare (Y/N)? 1
Medicare Advantage (Y/N)? 1
Medicaid (Y/N)? 1
Medicaid Pending (Y/N)? 1
CCA (Y/N)? 1
HNE (Y/N)? 1
Fallon (Y/N)? 1
BC/BS (Y/N)? 1
AARP (Y/N)? 0
Others (% Agency on Short Stay Unit?) No agency
Sub$Total 23
nonprofit
Psych serivce in 2-3 x/week
Process Expectations: Pre-Admission to DischargeProcess Expectations: Pre-Admission to Discharge
DRAFT 7 (9/24/13)/
• Assessed 30 facilities with high-volume
of Baystate patients
• Collected facility staffing levels, process
expectations, outcome reporting
expectations through site visits and
interviews
• Major criteria included CMS star rating
(3 and above), 24-hour nursing care,
physician staffing levels, readmission
rates, ability to take difficult patients,
and willingness to partner
Assessing Skilled Nursing Facilities
Category Response Yes/No (Yes
= 1; No = 0)Comments/additional Information
Preadmission Process: Liaison on site at BH (Y/N)? 1
Preadmission Process: Response Time for Decision (Enter
1 if ≤ 60 mins; 2 if ≤ 30 mins)2
Warm Hand-Off: Documented RN-to-RN Communication on
Admit (Y/N)?0
Warm Hand-Off: Documented RN-to-RN Communication
upon Discharge (Y/N)?1
Home Care Liasion at center for weekly
meetings
INTERACT** Tool Used or Alternative Tools (Enter # points
in Y/N column)5 INTERACT III
Electronic Medical Record (Y/N)? 0 Complete by 2014
Member of Data Exchange (Y/N) 0
Direct Admits from Home, MD Of fice, and other Community
Sites: 24/7 Clinical RN Supervisor (Y/N)?1
Direct Admits from Home, MD Office, and other Community
Sites: Med List (Y/N)?1
Direct Admits from Home, MD Office, and other Community
Sites: Payor Confirmation (Y/N)?1
List 24/7 Ancillary Contracted Services (lab, imaging,
pharmacy services) (Enter 1-3)3 Mobilex, O2 Solutions
List 24/7 Ancillary Contracted Services (lab, imaging,
pharmacy services) with 2 hour turnaround for reports
(Enter 1-3)
3
Rehab Services provided: frequency (Enter 1 for once per
week, up to 7 = daily)7 Contract w/
Rehab Services provided: coverage by all payors (Y/N)? 1
Physician or Mid-level Rounds: Describe (Enter 1 for once
per week, up to 7 = daily)1
IDT Rounds: MD involved (Y/N)? 0
IDT Rounds: Patients & Families involved (Y/N)? 0
IDT Rounds: RN involved (Y/N)? 1 MCR Meeting
IDT Rounds: Social Worker involved (Y/N)? 1
IDT Rounds: Done ≤ 48 hours after admit (Y/N)? 0 72 hr meeting
Sub$Total 29
Reporting Expectations: OutcomesReporting Expectations: Outcomes
Category Response Yes/No (Yes
= 1; No = 0)Comments/Additional Information
CMS Star rating (most recent) (Enter rating in Y/N) 3 AHCA:/ :/ /App/in;/JCAHO/
DPH (Date of last survey, status and deficiencies) 2013 DPH Score :
Flag on Admission to BMP: To PCP (Y/N)? 1
Flag on Admission to BMP: By Diagnosis (Y/N)? 1
Population reports available: List
D/C Dx, dispostion and HC provider ,
PCP, LOS, Referral info: adm, lost,
declined
ALOS – Sub Acute (Enter 1 if ≤ 15 days) 0 Ortho: 19; Cardiac: 18
30 Day Re-hospitalization Rates Subacute- average of last
3 months (Enter 1 if ≤ 20%; 2 if ≤ 15%; 3 if ≤ 10%)3 9%
Mortality Rate – Sub Acute TBD
Patient Satisfaction benchmarked with national database
(Y/N)? 1
If Yes, please record database Vendor and Quartile rank for
Overall Satisfaction MyInnerview: 98%
If No, please record how Patient Satisfaction is measured
AND last 6 months trend for Overall Satisfaction
Will you be able to schedule a Baystate Health Post Acute
Team site visit within the 4 weeks (Y/N)? 1
Sub$Total 10
For Internal Use OnlyFor Internal Use Only
Category Response Yes/ No Comments/Additional Information
STAAR Attendance 1
Baystate MD Affiliation/Presence 1 Cardiac:
Top 70% referral 2012 0
Citizenship (difficult patient placement) 0
Affiliation (ACO, PHO, other) 0
Total 62
**INTERACT- Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification,
assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal o f INTERACT
is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous
complications of hospitalization, and billions of dollars in unnecessary health care expenditures.
Collaborative Partner Facility ProfileCollaborative Partner Facility Profile
Facility Name
Facility Address
City State Zip
Phone
Contact 1 name
Contact 1 Title
Contact 1 e-mail
Web Site
Ownership Type (private, profit, nonprofit, parent company)
What is your ability to manage pts with psychiatric
diagnoses
Individual Facility DemographicsIndividual Facility Demographics
Category Response Yes/No (Yes
= 1; No = 0)Comments/additional Information
License Types (please list all) LTC
Number of Sub Acute Beds Short Stay all private rooms
Number of LTC Beds
Number of LTACH Beds
Number of Specialty Services Beds (vent, rehab)
MDs Contracted-Internist, and days per week on unit LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)
1 Community PCP
MDs Contracted-Geriatrician, and days per week on unit
LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
MDs Contracted-Specialty MD, and days per week on unit
LTC (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
MDs Contracted-Internist, and days per week on unit Sub
Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)1 Community PCP
MDs Contracted-Geriatrician, and days per week on unit
Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
MDs Contracted-Specialty MD, and days per week on unit
Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)0
Midlevel (RN/PA) Practitioner Contracted and days per
week on unit LTC (Enter 1 if once/week; 2 if 3-5 days; 3 if daily)1
Midlevel (RN/PA) Practitioner Contracted and days per
week on unit Sub Acute (Enter 1 if once per week; 2 if 3-5 days; 3 if daily)?? 1
24/hr day RN (Y/N)? 1 Staff: 50% RN
Nursing Model: Primary Nursing Model (Y/N)? 1
Nursing Model: Consistent Alignment (Y/N)? 1
RN Specialty Certification: Rehabilitation (Y/N)? 1 RN, Cardiac Specialist
RN Specialty Certification: Geriatrician (Y/N)? 0
Full time, licensed (RN, SW, OT, PT) Case Manager or
Navigator (Y/N)?1
Dietician available (Y/N)? 1
Special diet available: low sodium, ADA etc. (Y/N)? 1
Special diet available: TPN (Y/N)? 1
Certified Wound Care Nurse available (Y/N)? 1 Hospital CWOC NP
Palliative and Hospice Care (Y/N)? 1Palliative MD at to support;
Hospice w/ Affiliate
Pharmacy Name Formulary available (Y/N)? 1
Contracted Payers and Plans (list)
Medicare (Y/N)? 1
Medicare Advantage (Y/N)? 1
Medicaid (Y/N)? 1
Medicaid Pending (Y/N)? 1
CCA (Y/N)? 1
HNE (Y/N)? 1
Fallon (Y/N)? 1
BC/BS (Y/N)? 1
AARP (Y/N)? 0
Others (% Agency on Short Stay Unit?) No agency
Sub$Total 23
nonprofit
Psych serivce in 2-3 x/week
Process Expectations: Pre-Admission to DischargeProcess Expectations: Pre-Admission to Discharge
DRAFT 7 (9/24/13)/
Process Expectations
Category Response Yes/No (Yes
= 1; No = 0)Comments/additional Information
Preadmission Process: Liaison on site at BH (Y/N)? 1
Preadmission Process: Response Time for Decision (Enter
1 if ≤ 60 mins; 2 if ≤ 30 mins)2
Warm Hand-Off: Documented RN-to-RN Communication on
Admit (Y/N)?0
Warm Hand-Off: Documented RN-to-RN Communication
upon Discharge (Y/N)?1
Home Care Liasion at center for weekly
meetings
INTERACT** Tool Used or Alternative Tools (Enter # points
in Y/N column)5 INTERACT III
Electronic Medical Record (Y/N)? 0 Complete by 2014
Member of Data Exchange (Y/N) 0
Direct Admits from Home, MD Of fice, and other Community
Sites: 24/7 Clinical RN Supervisor (Y/N)?1
Direct Admits from Home, MD Office, and other Community
Sites: Med List (Y/N)?1
Direct Admits from Home, MD Office, and other Community
Sites: Payor Confirmation (Y/N)?1
List 24/7 Ancillary Contracted Services (lab, imaging,
pharmacy services) (Enter 1-3)3 Mobilex, O2 Solutions
List 24/7 Ancillary Contracted Services (lab, imaging,
pharmacy services) with 2 hour turnaround for reports
(Enter 1-3)
3
Rehab Services provided: frequency (Enter 1 for once per
week, up to 7 = daily)7 Contract w/
Rehab Services provided: coverage by all payors (Y/N)? 1
Physician or Mid-level Rounds: Describe (Enter 1 for once
per week, up to 7 = daily)1
IDT Rounds: MD involved (Y/N)? 0
IDT Rounds: Patients & Families involved (Y/N)? 0
IDT Rounds: RN involved (Y/N)? 1 MCR Meeting
IDT Rounds: Social Worker involved (Y/N)? 1
IDT Rounds: Done ≤ 48 hours after admit (Y/N)? 0 72 hr meeting
Sub$Total 29
Reporting Expectations: OutcomesReporting Expectations: Outcomes
Category Response Yes/No (Yes
= 1; No = 0)Comments/Additional Information
CMS Star rating (most recent) (Enter rating in Y/N) 3 AHCA:/ :/ /App/in;/JCAHO/
DPH (Date of last survey, status and deficiencies) 2013 DPH Score :
Flag on Admission to BMP: To PCP (Y/N)? 1
Flag on Admission to BMP: By Diagnosis (Y/N)? 1
Population reports available: List
D/C Dx, dispostion and HC provider ,
PCP, LOS, Referral info: adm, lost,
declined
ALOS – Sub Acute (Enter 1 if ≤ 15 days) 0 Ortho: 19; Cardiac: 18
30 Day Re-hospitalization Rates Subacute- average of last
3 months (Enter 1 if ≤ 20%; 2 if ≤ 15%; 3 if ≤ 10%)3 9%
Mortality Rate – Sub Acute TBD
Patient Satisfaction benchmarked with national database
(Y/N)? 1
If Yes, please record database Vendor and Quartile rank for
Overall Satisfaction MyInnerview: 98%
If No, please record how Patient Satisfaction is measured
AND last 6 months trend for Overall Satisfaction
Will you be able to schedule a Baystate Health Post Acute
Team site visit within the 4 weeks (Y/N)? 1
Sub$Total 10
For Internal Use OnlyFor Internal Use Only
Category Response Yes/ No Comments/Additional Information
STAAR Attendance 1
Baystate MD Affiliation/Presence 1 Cardiac:
Top 70% referral 2012 0
Citizenship (difficult patient placement) 0
Affiliation (ACO, PHO, other) 0
Total 62
**INTERACT- Interventions to Reduce Acute Care Transfers) is a quality improvement program designed to improve the early identification,
assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal o f INTERACT
is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous
complications of hospitalization, and billions of dollars in unnecessary health care expenditures.
Outcomes Reporting Expectations
• Developed scorecards with point system, reviewed with SNFs
• Chose 14 facilities as preferred providers
• Meet with preferred providers regularly, provide blinded scores and engage
in other quality improvement activities
Facility Score Card
Scoring Post Acute Providers
Balancing Transparency and Privacy
A
B
C
D
E
F G
H I
J
K
L M
N
O
P
Q R
S T U V
W, 10
0
2
4
6
8
10
12
14
16
18
20
0 2 4 6 8 10 12
Rea
din
ess
to P
artn
er/C
olla
bo
rate
(b
ased
on
Eas
e o
f P
lace
men
t &
Ove
rall
Surv
ey
Sco
re)
Quality of Care (based on 30-Day Readmits & CMS Star Rating)
Baystate Health Post-Acute Care Partner Prioritization Matrix
A B C D E F G H I J K L M N O P Q R S T U V W
Implementation Challenges
• Aligning with case managers who had concerns about patient choice
• Communicating preferred providers to patients
• Encouraging patients to select post-acute providers based on quality vs.
geography
Changing the Discharge Discourse
Standardized communication, developed by SPAC committee, case management leadership and legal:
“The Baystate preferred skilled nursing facility network is a select group of nursing facilities around the Pioneer Valley that meet quality and safety standards set for by Medicare and endorsed by Baystate Health
Engaging Patients in Post-Acute Decision-Making
• Baystate adopted an interactive tool for discharge planners and patients to choose post-acute care
• Preferred providers are highlighted and communicated to patients and families
• Integrates with case management workflow tools and available on a tablet; search results can be emailed to family members and other decision-makers
Post Acute Search Tool Benefits Case Managers, Patients & Supports Baystate’s PAC Strategy
Compliance with Impact Act and proposed changes to conditions of discharge planning
Proposed rule “require[s] that hospitals assist patients…in selecting a PAC provider by using and sharing data that includes but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures.”
With CarePort, Baystate has provided its patients with ' first-of-its kind' technology that helps them decide
where to go for post-acute care—a critical decision, as numerous studies show that post-acute providers
vary on quality and their ability to car e for different types of patients,” said Joel Vengco, VP/CIO,
Baystate Health . “In other words, it ’s not an easy decision for patients and families to make. Until now."
Tracking Baystate Patients Post-Discharge
• Integration with regional HIE (PVIX) and six post-acute providers
• Understanding post-acute outcomes for all Baystate patients
• Skilled nursing facility readmission rates and length of stay by patient population
• Leakage vs. Keepage
Sustaining the Network
Quarterly Quality Meetings:
• Sharing best practices
• “Preferred” Subset for BPCI
• Exiting SNF partners
Outcomes
19
Outcomes
20
Outcomes
Success Factors
• Personal Touch – RFPs vs. personal touch because of high turnover of SNF staff
– For example tenure of nursing staff, will nursing staff know to call hospital?
• Team
– Integration work led by “SNF insider”
• Innovation in the community
– Health New England – SNFs can take care of patients with medical needs such as IV antibiotics, TPN to avoid readmission. HNE takes care of cost of IV Abx and TPN
On the Horizon
• Deciding to create a Tier 2
• Physician Incentive for SNFist from Next Gen ACO
• Embedded ACO Physician in the ED
• Building care coordination teams
– Navigators vs. liaisons
– How to make it scalable and cost-effective?
Questions?
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