nhpco strategic options ac os final 03 14-11


©2010 Health Dimensions Group 2©2011 Health Dimensions Group

Strategic Options for Hospice and Palliative Care in the Era of Accountable Care OrganizationsNHPCO 26th Annual Management & Leadership Conference

April 2011


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Presenters

Kyle R. Allen, DO, AGSFChief, Division of Geriatric MedicineMedical Director Post Acute & Senior ServicesSumma Health System75 Arch Street, Ste G1, Akron, OH 44303330-375-3747; [email protected]

Jane Gorwin, RN, BSN, LNC, MASenior Home Health and Hospice ConsultantHealth Dimensions Group4400 Baker Rd, Ste 100, Minneapolis, MN 55343760-250-4558; [email protected]

Jade Gong, MBA, RNVice President, Strategic InitiativesHealth Dimensions Group4012 Nelly Custis Drive, Arlington, VA 22207703-243-7391; [email protected]

mailto:[email protected]




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Topics

•Health care reform and its impact on post-acute and aging services providers

•Strategies for hospice and palliative care providers

•PEACE model of care

•PACE as an accountable care organization (ACO) model


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Drivers of Partnerships for Future Success for Post-Acute Providers

• Accountable Care Organizations

• Bundled Payment

• Hospital Readmission Penalties


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Home Health 30-Day Hospital Readmissions by State


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Why Post-Acute Is Key to Managing Health Care Costs


Post-Acute Payments by Venue and Condition

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In ACO-land, expect greater use of subacute skilled nursing and home health

Hospital Condition

PAC Average

OP Rehab

Home Health

SNF IRF LTCH

Stroke $10,680 $569 $2,478 $8,527 $18,923 $22,070

Hip & Femur Procedures for Trauma

$10,392 $1,217 $2,595 $8,761 $16,018 $22,738

Cardiac Bypass with Catheterization

$5,230 $837 $1,778 $5,737 $14,631 $24,526

Heart Failure $4,144 $612 $1,611 $6,462 $14,698 $20,236

Note: Data are preliminary and subject to change. Numbers reflect standardized payment rates and therefore do not reflect provider-specific adjustments such as the area wage index or DSH payment adjustments. Spending captures payments for all PAC services that occur within 30 days of discharge from the hospital.Source: MedPAC analysis of 5% Medicare claims files 2004 to 2006.


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ACOs – One of the Ways Health Care Reform will Bend the Cost Curve

• Payment Changes

– Reimbursement cuts

– Value-based reimbursement

– Bundled payments

• Care Delivery System Changes

– Accountable care organizations

– Medical homes

– Health information exchange


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How ACOs Provide Accountable Care in a New Delivery System

•Capacity to deliver continuum of care, grounded in strong primary care and minimal use of high-cost institutional settings

•Payment rewards slower cost growth so long as combined with improvements in quality

•Reliable measures of a person’s health assure that savings are achievedthrough improvements in care


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Accountable Care Organizations

- Medical Group(s)- Community MDs- Medical Home

Accountable Care Organization

Physician Network

Hospitals Ancillaries

Medicare/Other Payers 5,000+ Medicare

fee-for-service beneficiaries

Accountable for all Medicare Part A and Part B service

Requires integrated provider network; successful chronic care management; comprehensive home-based services

EHR across settings

Continuum of Care

- Outpatient services- Skilled nursing- Home health- Hospice- Geriatric care management- Non-institutional home-based services- Prevention and wellness programs


Medicare ACOs in 2012, But Many ACO Demonstrations Now

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Tucson, AZ

Louisville, KY

Roanoke, VA

3 Medicare Pilot Sites

Many Private Payer Pilots

Medica and Insurers

Torrance, CA

https://www.tmcaz.com/

http://www.nortonhealthcare.com/default.cfm

http://www.nortonhealthcare.com/default.cfm

http://www.carilionclinic.org/Carilion/Home+Page

http://www.carilionclinic.org/Carilion/Home+Page

http://www.advocatehealth.com/default.cfm

http://www.bcbsil.com/index.html


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Medicare ACO Eligibility

Who Can Be An ACO?

• Group practices• Networks of individual practices• Partnerships or JV

arrangements between hospitals and ACO professionals

• Hospitals employing ACO professionals

• Such other groups of providers of services and suppliers as the Secretary determines appropriate

ACO Professionals

• Doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State

• Physician assistant, nurse practitioner, or clinical nurse specialist

• Certified registered nurse anesthetist

• Certified nurse-midwife• Clinical social worker• Clinical psychologist• Registered dietitian or nutrition

professional


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How Do You Qualify as a Medicare ACO?• Become accountable for quality, cost, and overall care

• Formal legal structure to receive and distribute payments for shared savings

• Have enough primary care physicians

• Have a minimum of 5,000 beneficiaries

• Leadership and management structure that includes clinical and administrative systems

• Processes to promote evidence-based medicine and patient engagement, report on quality/cost measures, and coordinate care

• Meet patient-centeredness criteria

• Minimum three-year contract with Medicare


New Payment Model for Medicare ACOs: Shared Savings• Current per-capita spending for assigned patients

determined from claims for past three years• Spending target is determined (Medicare)• If actual spending lower than target, savings are shared• IF quality targets are also achieved

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ActualShared Savings

ACO Launched

Target

Projected

Adapted from Brookings Institute


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Sample ACO Calculation

* Actual costs for “assigned” population are less than pre-set expected costs based on risk-adjusted trends

** PGP demonstration gave groups 80% of savings; actual split for ACOs to be determined

Year 1 Year 2 Year 3

Quality Standards Met?

Yes No Yes

Cost Savings Achieved?

No Yes* Yes*

Medicare FFS Payment

Medicare Fee

Schedule

Medicare Fee

Schedule

Medicare Fee

Schedule

ACO bonus payment that year?

No NoYes

X% of Savings**

An organization must meet

quality standards

AND achieve cost

savings to earn bonus

payments


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Three Strategic Partnership Imperatives for Post-Acute and Aging Services Providers

Partner with hospitals and ACOs to address

biggest concerns:

• Length of stay

• Pendingre-admission penalties

Partner with other providers to enhance

yourpost-acute and

home care continuum

Partner with like providers to create

one-stop chronic care management

Strategy includes care transitions management and electronic health record


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The New Reality for Aging Service Providers: Partnerships with Other Providers• Provide an array of aging services, not just skilled nursing and long-term care; be the navigator or partner for services or venues you do not offer = care management

• Become preferred partner for integrated health systems or ACOs from whence Medicare dollars will flow



Strategies for ACO and Hospice-Palliative Care Relationships

Jane Gorwin, RN, BS, MA

Health Dimensions Group


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How Do Palliative and Hospice CareFit into an ACO Model?

•Laying the foundation for a palliative care framework first


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How Do Palliative and Hospice CareFit into an ACO Model? (continued)

Wellness

Specific Disease Intervention

Chronic Disease Management• Focus still on interventions only

Interventional Palliation• Combination medical treatment, comfort care

Hospice• Focus on comfort, quality of life, symptom control


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What Needs to Change?•The basic way we work with patients, especially in one of these three categories:– Chronic Disease Management

• Need to better identify where a patient is within this trajectory

• Enhance acute to community-based transitional care coordination

– Interventional Palliation

• Educate/enlighten patient and family earlier

• Provide options for patient/family choice

– Hospice Care

• Marketing strategy and partnerships with hospitals and PCP


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What Do ACOs Want from Post-Acute and Aging Services Providers?

• Not likely to be a partner, with “skin in the game”, but rather a contractor

• ACOs will want few PAC provider-contractors who:√ Can demonstrate value (quality and cost reductions) with credible

data

Few 30-day hospital readmissions

High volume of discharges to home

√ Have evidence-based clinical programs for most common SNF-HHA discharges and a care transitions program between venues

√Have facilities/services that are geographically convenient to primary care physicians and hospitals

√ Already have positive relationship with hospitals and PCPs

√ Willing and able to be part of health information exchange


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Hospice: Well Positioned for the Future

•Aging demographics – baby boomers

•Chronic disease “explosion”

•Key offenders:– Congestive Heart Failure

– Diabetes

– Chronic Obstructive Pulmonary Disorder

– Pneumonia

– Parkinson’s – ALS – Dementias

– Depression


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Not-for-Profit Accountable Care Readiness Strategy: Aging Services Provider Partnerships

• Create a not-for-profit consortium within a market that has more value than any organization individually

• Benefits:– One-stop shopping for hospitals and ACOs– Benchmarks for hospital readmissions

and ongoing comparison– Post-acute provider partnerships in

geographic areas creating care continuum with standardized protocols

– Care management projects– Bundling experiments with Medicare Advantage Plans as

we learn to take risks– Apply for grants for demonstration projects


To Be a “Player” in the ACO Arena

• You have to be ahead of the curve in developing relationships with hospitals, primary care physician groups, and even insurers/managed care

• Partnerships must be value-based: what do you bring?

– Hospital readmission reduction

– Cost reductions for post-acute episode of care

– Care coordination across the continuum

– Chronic care management to reduce ED visits and hospitalizations

– Electronic information exchange

– Ability to share payment risk based on outcomes

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Define Your Services: What are You Providing Within the Continuum?

•Palliative Care: interventional and comfort care focus– Palliative care in–patient hospital versus home

health

•Hospice Care: comfort care and quality of life focus – Routine hospice care

– Respite

– Continuous care

– General in patient


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Overarching Strategy of Why You Will Benefit an ACO

•Ability to reduce 30-day (+) hospital readmissions

•Ability to reduce emergency/urgent care visits

•Reduce hospital length of stay

•Potentially decrease in-patient hospital mortality rates

KNOW YOUR DATA AND SHARE IT!


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Critical Elements for a Successful Strategy Implementation

•Evidence-based practice (interventional PC and hospice)– Use of aligned, care protocols

•Patient/family centered—self-care management driven– Coaching: motivational interviewing skills

– Patient/Family self goal-setting

– Medication awareness (PHR)

– Self symptom management and interventions


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Critical Elements for Successful Strategy

•An integrated care management and health system navigator approach

•Effective electronic information exchange– From provider to provider

– Patient/family to provider (tele-health, bio-sensory technology, video-audio interface)

•Real-time data management decision-making


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What are Some of the Current Challenges?

•Current fiscal realities (shrinking margins)– Hospitals

– Home Health

– Hospice

•Regulations and future Medicare payment models are always “behind”– Hospice: limited to 6-month end-of-life prognosis

– Palliative care: not officially recognized

– No specific reimbursement for care management models…..yet


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More Challenges

•Need for highly sophisticated data management information systems that will:– Enhance traditional quality care indicators (pain

management, satisfaction surveys post-death)

– Provide predictive statistical modeling as relates to primary diagnoses and co-morbid conditions

– Help to identify patients’ clinical and social needs within their trajectory (chronic disease management, interventional palliation, hospice)


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Next Steps to Move Your Strategy Forward

•Evaluate your current services– Do you provide what your hospital(s) and PCP(s)

need?

– Do you collect the right data?

•Research your most likely ACO partners– What are their specific needs?

– Get their data: mortality rates, lengths of stay, top chronic diseases causing the readmissions


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Moving Your Strategy Forward

•Develop your presentation to meet with potential ACO partners: hospitals and PCPs– Be specific with your data to show how YOU will be

essential to their accountable care organization

•Explore current funding opportunities:– Shared risk ventures with Medicare Advantage

plans

– Grants

– Demonstration projects

•Be proactive to get a “seat at thetable” and start now!


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If everything seems under control, you're just not going fast enough

Mario Andretti.

Kyle R. Allen, DO*Steven Radwany, MD*

Susan Hazelett, MS, RN*Denise Ertle, MSN, RN, CNS* *

Susan Fosnight, RPh, CGP, BCPS* Pamela Moore, PharmD, BCPS*

Patricia Purcell, MSN, RN, CNS* * *Barbara Palmisano, MA * * * *

Ruth Ludwick, PhD, RN.C, CNS* * * * *

* Summa Health System, Health Services Research and Education Institute * * Area Agency on Aging 10B, Inc. * * * The University of Akron

* * * * Northeastern Ohio Universities Colleges of Medicine and Pharmacy * * * * * Summa Affiliate, Robinson Memorial Hospital

The PEACE Trial is supported by The National Palliative Care Research Center

& the Summa Foundation

Area Agency on Aging, 10B, Inc. | Summa Health System | NEOUCOM Kent State University | The University of Akron

PEACE TRIALPromoting Effective Advanced

Care for Elders

Key Points

A National Palliative Care Research Center-funded trial ($154,000 over 2 years)

Collaboration between The University of Akron, Kent State University, Northeastern Ohio Universities Colleges of Medicine and Pharmacy, the Area Agency on Aging 10B Inc., and Summa Health System

A randomized controlled pilot study

A palliative care case management intervention for PASSPORT consumers

Intervention involves collaborative care between a hospital-based interdisciplinary team, the Area Agency on Aging, and the consumer’s PCP

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The S.A.G.E. Project (Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project: A Successful Health Collaborative(Est. 1995)

Improving Care through Collaboration: Integration of the Aging Network and Acute and Post Acute Medical Care

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SAGE Goal

S.A.G.E. Project is an example of how to partner with a community agency:

Acute hospital and medical care services; and,

A community-based Area Agency on Aging

Goal: To integrate a comprehensive geriatric hospital-based clinical program with the community aging network to improve the health, functional status, and prevent institutionalization of older adults at risk for nursing home placement.

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The SAGE Project

A 15-year collaboration partnership Multiple initiatives, a “cast of thousands”, well maybe 100s,

but you get the point Common goal to improve the health, well being and

functional status of Akron region frail older adult population Identified major gaps in the continuum and care processes

from each partner Searched and defined mutual benefits Shared mutual threats and concerns Built trust Grew and multiplied to other regional systems Communication, communication, communication Vision, Vision, Vision, Vision

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Area Agency on Aging Programs Mission: To provide older adults

and their caregivers long-term care choices, consumer protection and education so they can achieve the highest possible quality of life.

Aging Resource Center PASSPORT Home Care Medicaid Waiver Assisted Living Medicaid Waiver Community Services Division

Care Coordination Alzheimer’s Respite Program Family Caregiver Support

Elder Rights Division

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Who were the partners?Summa Health System

Geriatric Medicine Department

6 Hospital System 2,027 licensed beds 61,800 admissions

Level 1 Trauma 113,059 ED visits

Community Locations 4 outpatient health centers Wellness Institute –

• medically-based fitness

Health Plan 110,000 Covered Lives 16,000 Medicare Risk HMO

Major Teaching Residency and Fellowship Program

Post Acute/Senior Service Line 10 Certified Geriatricians 12 Geriatric Certified APNs

Continuum of Care Acute Care/Acute Rehab/ LTAC/ SNF

Beds Home Care/ Hospice/ Home Infusion/

HME

SummaCare, Inc.

Summa Akron City Hospital Summa St. Thomas Hospital

Summa Western Reserve Hospital

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Summa’sInstitute for Seniors and Post-Acute Care

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Transitions of Care:AD-LIFE, PEACE, and Bridge to Home

Post-discharge care management of low income frail elderly

Advance care planning and palliative care/geriatric syndrome management for low income seniors

Nurse care manager activation of client

Collaboration between a hospital-based interdisciplinary team, Area Agency on Aging, and PCP

Integration of acute and long-term care

Transitional care to reduce readmissions

AD-LIFE trial is supported by the Agency for Healthcare Research and Quality Grant # R01 HS014539. PEACE is funded by the National Palliative Care Research Center. Both are supported by the Summa Foundation.

Bridge to Home is funded by SummaCare.

The Primary Care Physician• Medical model

• Limited time with patient

The Center for Senior Health and Senior

Services• Consult and support across the continuum

including outpatient, inpatient, house calls and

skilled/long- term care• Addresses medical and

psychosocial

The Area Agency on Aging • Social service model but now

becoming more integrated

• Care management and services for long-term care

• Limited interaction with PCP

• Addresses functional abilities/geriatric syndromes but challenged with high risk enrollees with multiple chronic illnesses

AD-LIFE, PEACE, &

SummaCare’s Bridge to

Home

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Purpose of the PEACE Pilot Study

This randomized pilot study will determine the feasibility of a fully powered study to test the effectiveness of an in-home interdisciplinary palliative care management intervention to improve the quality of palliative care for consumers of Ohio’s community-based long-term care Medicaid waiver program, PASSPORT

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Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System

Hospitalization prompting advance

care decisions (often by the family)

Community-dwelling chronically ill patient with poor symptom control and

coordination of care whose advance care

wishes are rarely documented

Exacerbation of chronic illness

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Palliative Care and Advance Care Planning

Independent Management HospiceAdvance Care Planning

Symptom Management

Disease Management

Diagnosis Death

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Patient Centered Care

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Frailty

Advanced Organ Failure

Dementia

Chronic Critical Illness

Cancer

Stroke

Well Older Adults

Osteoporosis

Geriatric syndromes

Peri-operative care

Stable chronic dx

Preventive care

Gait DisordersAIDS

Cancer (<65)

TBI

Cystic Fibrosis

Genetic/ Developmental

Disorders

Pediatric Oncology

Morrison, S . National Palliative Care Research Center

Target Population for the PEACE Pilot Study

New PASSPORT enrollees >60 years old with one of the

following diseases and the corresponding level of severity will

be eligible for inclusion:

CHF and being actively treated (AHA class C) COPD and on home O2 or nebulizer treatments

Diabetes with renal disease, neuropathy, visual problems, or CAD End-stage liver disease, cirrhosis Cancer (active, not history of) except skin cancer Renal disease on dialysis ALS with history of aspiration Pulmonary hypertension Parkinson’s disease (stages 3 and 4)

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Enrollment

RN assessors from the AAoA will screen consumers at the time of their initial PASSPORT assessment

RN assessor will obtain HIPAA release

Research nurse will obtain consent and obtain baseline measures

Consumers will be randomized to usual care or the intervention group

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Intervention

Each Care Manager will have approximately 10 consumers

Care Manager will make 2 home visits centered on symptom

assessment & advance care planning

Care Manager will take her assessment findings to an interdisciplinary team

Team produces recommendations for consumer & PCP

Care Manager accompanies consumer to 1 PCP visit to assist consumer in discussing advance care goals with PCP

Care Manager & Palliative Care Nurse supervisor make another home visit to begin implementation of plan of care

Care Manager follows-up with consumer monthly for 1 yr to assure team recommendations are implemented

PEACE Intervention

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OutcomesMeasured at 3, 6, 9 and 12 months

5 Domains Measurements made to determine domain score

1) Symptom management Memorial Symptom Assessment Scale

2) Quality of life/death QUAL-E

3) Relationships Meaning in Life Scale

4) Decision making; care planning; continuity; communication; patient activation

Palliative Outcome Scale, Patient Activation Measure

5) Depression and anxiety Hospital Anxiety and Depression Scale

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Challenges

Getting buy-in from case managers Education and knowledge gaps Changing culture of the AAA Needing to get more top-down support for the

project so AAA CM supported for the project Not over “medicalizing” the care plans

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Successes

Strong working relationship and commitment by the AAoA

A team that has gone from forming to storming, not yet norming

Culture sensitivity and knowledge between aging network and acute care sector—“becoming bilingual”

Outgrowths of other educational projects, additional funding for PC research, and bridging the community network and acute sector

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Additional PEACE Related Projects

A survey of knowledge and attitudes about ACP and PC sent to all area PCPs. Funded by the Summa Foundation.

A statewide survey of all care managers at all AAoA that will examine knowledge and attitudes regarding ACP and PC. Funded by Northeastern Ohio Universities Colleges of Medicine and Pharmacy.

An educational program to teach AAoA care managers how to bring PC upstream in the disease process. Funded by the First Merit Foundation.

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PACE as an ACO Model of Care

Jade Gong, MBA, RN

Health Dimensions Group


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Comprehensive Services

• Integrates preventive, acute, and long-term care services

•All Medicare and Medicaid services, plus community long-term care services

•No benefit limitations, co-payments,or deductibles

•PACE is the only fully capitated and integrated Medicare and Medicaid program to serve frail nursing home eligibles


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PACE Eligibility Criteria

•55 years of age or older

•Live in a PACE service area

•Be certified as eligible to receivea nursing home level of care

•Be able to live safely in thecommunity at point of enrollment


PACE Enrollees Snapshot

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Mean Age 80

Gender75%

women

Average Number of Basic ADL Deficits 3.5

Cognitive Impairment 63%

Average Life Expectancy4.5

years


PACE Nationally

•79 PACE organizations and growing

•31 states

•20,000 PACEparticipants

•100 to 2,000participantsper program

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HomeCare

Nutrition

PersonalCare

OT/PT Transportation

PrimaryCare

Activities

Pharmacy

SocialServices

Well-functioning IDT Key to PACE Success


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PACE Network

Specialty Care

Medication Supplies

DME

Transportation

Meals

Personal Care

Subacute Care

Hospital Care


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PACE Payment Sources

•Payment features are unique

•Capitated payment system—per member per month (PMPM)

•Combines funding from multiple payor sources to meet all participant needs


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Integrated Financing

Pooled Capitation

(PMPM)

Medicare Part D

Medicare Medicaid

Private Pay


21%

45%

34%

Hospital Home Nursing Home

Place of Death in PACE

53%

20%

Older Americans

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Survival in PACE

Median Survival (years)0

1

2

3

4

5

2.3

3.5

4.2

NH Waiver PACE

•South Carolina

•Two counties

•PACE group same baseline risk as NH group

•PACE group higher baseline risk than Waiver group

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PACE Core Competencies

•Provider-based model

•Tightly controlled care management and utilization systems

•Serves a nursing home-eligible population in the community when enrolled

•Good health care outcomes, high enrollee satisfaction, and low disenrollment rates

•Established existing program with a proven track record



Opportunities for Hospice and PACE Collaboration in the Delivery of Person-Centered Care

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Exploring Common Ground:PACE and Hospice

•Patient centered

•Holistic approach to care

•Utilizes interdisciplinary teams

•Supports caregivers

•Utilizes managed care efficiency

•Receives capitated payment (per diem or per month)


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Why Should Hospice Develop PACE Programs?

•Meet community needs with broader care options for frail seniors at the end of life

•Build upon community awareness of hospice

•Draw upon greater stability of multiple revenue streams

•Greater efficiency through shared allocation of administrative expenses


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PACE with Hospice Opportunities for Collaboration• Each provider can focus on providingpatient-centered care

– Some hospice referrals may be more appropriatefor PACE

– Some PACE referrals may be more appropriatefor hospice

• PACE can utilize hospice expertise through contracting:

– Pain and symptom consultation/pain management

– Use of hospice interdisciplinary team (IDT)

– Training in end-of-life care

– Inpatient hospice facility if needed by participant

nhpco strategic options ac os final 03 14-11

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