rusk rehabilitation the triple aim – how physiatry and the rehabilitation team can improve the...

RUSK REHABILITATION

The Triple Aim – How Physiatry and the Rehabilitation Team can improve the patient experience and thrive within healthcare reform and value based medicine

Jonathan H. Whiteson, MD, FAAPMRAssistant Professor, Rehabilitation MedicineMedical Director, Cardiac and Pulmonary RehabilitationMedical Director, Rusk Outreach and GrowthRUSK Rehabilitation

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What is the Tripple Aim?

Improved health

Improved Quality of Care

Reduced Costs


Health Care Reform is….Change….. enforced upon us by government agencies

this is HARD!!!!

for…Health Care Systems / Networks / Institutions

Departments

Individual Practitioners

Health Care Consumers

Don’t forget the Medical Students and Residents…

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The journey of Health Care Reform….

Government agencies set the tone of our industry

Industry viewpoint: expensive / variable outomces / high compliction rate / inptient-centric

Hospital System must: improve efficiencies / work with industry and departments

Departments: embrace grass roots change / clinician training / consumer education

Practitioner: whats your journey – past / present / future?

Have to play an active role in defining HCR ,not just participating in it

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Health care reform is……

a general rubric used for discussing major health policy creation or changes — for the most part, governmental policy that affects health care delivery in a given place.

•Health care reform typically attempts to•Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies•Expand the array of health care providers consumers may choose among• Improve the access to health care specialists• Improve the quality of health care•Give more care to citizens•Decrease the cost of health care

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Health Care Reform means…

Different things to different people / settings in the continuum of care

Conflicting needs / perspectives een within a Department

Allignement critical within the Hospital System

Communication is the key: be at the table

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Health reform includes the following key steps….

•Expand Medicaid to allow more people at the lowest income levels to qualify for coverage.•Encourage employers to offer health insurance.•Provide credits to purchase private health insurance coverage to moderate income Americans who do not qualify for Medicaid.•Streamline the purchase of health insurance through the establishment of the Health Insurance Exchange.•Strengthen consumer protections and require transparency.• Impose protections to guard against unreasonable rate increases.•Encourage primary and preventive care.•Require most Americans to purchase health insurance.

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What does the Consumer want from Health Care Reform?

Care that is:

Available

Affordable

Effective

Excellent

Easy to negotiate

Affable


Healthcare reform issues impacting Physical Medicine and Rehabilitation….

• Reinstatement of the 75% rule for Inpatient Rehabilitation?

• Site-Neutral Payments restricting access to care based on diagnosis, not patients’ clinical need

• Medicare Bundle Payment Proposals creating risk of underservice to patients

• Medical Coverage of Outpatient Therapy Services and Therapy Caps

• Rehabilitative and Habilitative Services and Devices limiting needed prosthetics and other needed items like power chairs for patients

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Site Neutral Payments….

The Medicare Payment Advisory Commission (MedPAC), the nonpartisan government agency that advises Congress on Medicare policy, indicated in 2014 it would recommend:

(1) phasing-in site-neutral payments for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs)

(2) loosening regulatory requirements for IRFs so that they might continue to provide care to Medicare beneficiaries after their Medicare reimbursement rates are reduced.

(3) deleting IRF requirements that physicians see patients at least three times per week and that IRFs provide intensive therapy to patients each day.

i.e. eliminate acuteInpatient rehab!!!!

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But…

•American Medical Rehabilitation Providers Association Chairman Bruce Gans - MedPAC's recommendation "fails to consider the long-term impact of diverting Medicare beneficiaries into less intensive rehabilitation settings despite their clinical needs.“

•Hospital outpatient departments treat sicker and poorer patients in need of more extensive care and resources than do physician offices and patients treated in outpatient departments have more severe chronic conditions

• Consider at SAR: readmissions / LOS / patient experience

MUST plase patients in appropriate settings: home / AR / SAR…

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Values Based Medicine (and Evidence Based Medicine)

• Values-Based Medicine (VBM) is the theory and practice of effective healthcare decision-making for situations in which legitimately different (and hence potentially conflicting) value perspectives are in play.

• VBM is the values-counterpart of Evidence-Based Medicine, or EBM.

• EBM is a response to the growing complexity of the relevant facts

• VBM is a response to the growing complexity of the relevant values

• VBM emphasizes the importance of good process in the form particularly of improved clinical practice skills

CONFLICTS – cost vs patient experience- perception / journey- cinical outcomes

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Value Based Medicine

•Value = Quality / Cost

•Quality: •evidence-based standards - transfusion criteria, hospital acquired pneumonia, pressure ulcer development, central line associated bacteremia

•LOS - observed/expected - UHC data •Patient reported data – HCAHPS / Press-Ganey survey

•Cost – laboratory / radiology / drug / LOS-related cost - fixed and direct cost as determined by Finance

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Value Based Medicine

Value = Quality / Cost

•Goal – highest quality / lowest cost

• Industry holds you PUBLICLY ACCOUNTABLE

•Don’t lose sight of the patient…

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Shifting the paradigm…..

The Physiatrist and rehabilitation team can show value by:

•Improving the patient experience

•Improving patient outcomes

•Decreasing hospital length of stay and readmissions

•Reducing hospital costs

•Decreasing the need for post acute services

•Developing innovative programs that help maximize revenue while creating new career paths for Physiatrists in the face of healthcare reform

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Shifting the paradigm…..

Improved Health


Reduced Costs

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Rehabilitation Medicine is a major ‘player’ in every aspect of patient care….

• ICU early mobilization

•Bundle Payment Initiative

•Rehab Continuum

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ICU early mobilization

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ICU care – where were we…?

•What was the coordination of clinical care?

•Management of Delirium - Sleep / wake cycles – Sedation – Pain?

•What was the clinical care culture?

•What was the culture of mobilization?

•Frequency and duration of rehabilitation treatments?

•Longitudinal perspective and VBM considerations?

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Review of the literature…

Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project. Archives PM&R 2010, Volume 91, Issue 4, Pages 536–542

ICU Early Physical Rehab Program • CCM • Volume 41 • Number 3 • March 2013

PT for the Critically Ill in the ICU • CCM • Volume 41 • Number 6 • June 2013

• Decreased Length of Stay:

ICU Floor Bed

• Improved Functional Independence• More Discharges to Home• Fewer Vent Days• Less ill Effects of Bed Rest- e.g., Strength and ROM • Lower Incidence and Duration of Delirium• Less frequent Use of Sedation/Medications• Lower Average Direct Costs (e.g., medical surgical supplies, pharmaceutical

supplies, housekeeping, food expenses, RN salaries)

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Rusk Rehabilitation ICU early mobilization – changes…•Create a collaborative team – driven by PM&R

•Reduce deep sedation and delirium in patients in the ICU, reintroduce ‘normal’ sleep / wake cycles, adequately manage pain – all to support more effective and earlier mobilization

•Establish a clinical care culture beyond survival

•Establish a mobility culture beyond the bed and rehabilitation team

•Establish the culture of early mobilization

•Create a ‘beyond the horizon’ perspective and support VBM initiatives

•Administration buy-in

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Early Rehabilitation in the ICU – A Performance Improvement Project

• Comparison Group – consisted of 123 ICU patients

• Pilot Group – consisted of 160 similar ICU patients

• Intervention – Provided average of 60 minutes of interdisciplinary therapy per day to include PT, OT, SLP.

• Services were offered to Medical ICU and Surgical ICU at NYU Langone Medical Center

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The value and outcomes from early rehabilitation in the ICU

LOS

• Reduced ICU length of stay by 0.93 days – 20%

LOS

• Reduced Med-Surg bed length of stay by 1.9 days – 30%

$

• Reduced average direct cost per day by 12%

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Clinical Outcomes for Early Rehabilitation in ICU

• Patients discharged home with or without services increased from 59% to 76% (up by 17%)

• Patients discharged home without services increased from 18% to 40% (up by 22%)

• Patients discharged to:• Acute rehab decreased from 24% to 13%• Sub-acute decreased from 6% to 1%• Nursing home decreased from

10% to 6%

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Estimated Cost Savings from Early Rehabilitation in ICU

$1.4M Annually (540 patients) when pilot group was compared to the comparison group after inclusion of rehabilitation labor costs using avg. costs per day

*This excludes additional hospital revenue with backfill of ICU beds resulting from reduced LOS and improved throughput

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ICU early mobilization next steps…

•Administration approved conversion of pilot staff to permanent positions

•Academic Presentation – Poster and Podium presentation: Early Mobilization in the Medical and Surgical Intensive Care Units: A Performance Improvement Project. Johns Hopkins Critical Care Rehabilitation Conference

•Academic Publication - Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Inter-professional Performance Improvement Project – submitted, pending acceptance

•Development of rehabilitation pilot on Medicine floors comparing daily rehab care with current model

•UHC Conference Presentation - upcoming

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Bundled Payment Initiative

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Where we were NOT Value Based Medicine!

everyone gets paidpiece-mealduplicationpoor efficiencyhigh costpoor outcomeslimited accountabiltylitte attention to patient experience

Where we need to be Value Based Medicine

one payment for episode of carecoordinatedlean careexcellent outcomesfull accountability

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Bundled Payment Initiative…

•AKA: episode-based payment, episode payment, episode-of-care payment, case rate, evidence-based case rate, global bundled payment, global payment, package pricing, or packaged pricing

•…defined as: the reimbursement of health care providers (such as hospitals and physicians) "on the basis of expected costs for clinically-defined episodes of care."

"a middle ground" between fee-for-service reimbursement (in which providers are paid for each service rendered to a patient) and capitation (in which providers are paid a "lump sum" per patient regardless of how many services the patient receives).

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Services that can be included under each model

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the risks for embracing new payment models as theyevolve is worth the opportunity to identify what works and influence future policy

“The bleeding edge and cutting edge are the sameplace”

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Bundled Payment Initiatives

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•Dept. of Rehabilitation Medicine involved since earliest planning stages of bundled pilot

•Departmental Chairman / Departmental Administration / Physiatry Specialists

•Hospital Administration and Finance negotiate bundle model and reimbursement $$$s

Preferred providers:

home health care agencies

acute rehab centers

sub-acute rehab centers

LTACs

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•Hospital Culture Changestaff educationpatient / family centered languagedefault disposition – home

•Care Coordination TeamSocial WorkerCare Management

•Rehab TeamPhysiatristPT / OT

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•Total joint - elective: 90 day

•Pre-surgical PT or OT home visits

•Rapid Rehab – POD zero

• ‘Front-loaded’ home care services

•Sub-acute joint replacement program

•Outpatient transition

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•Total joint – emergency / fractures: 90 days

•Older / increased comorbidities – poorer outcomes from subacute rehab than acute rehab – LOS / readmissions

•Enhanced value (quality/cost) of acute rehab – skill / monitoring / intensity

•Spine – New surgical techniques associated with unanticipated increased expenditures

•Dropped from bundle – cost increased – unable to achieve targeted savings despite decreases in LOS and readmissions

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•Cardiac Valve: 90 days

• ICU early mobilization

• implementation of twice daily PT and once daily OT sessions

•default disposition - home with services (as indicated)

• inpatient acute and sub-acute inpatient cardiac rehab programs

•outpatient transition

•Change for TAVR… separate DRG created

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The Importance of Care Coordination and the role of the Physiatrist in the Bundled Payment Initiative

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With Bundling, the Physiatrist ….

Enforces best practices / standardization of pathways, workflows, and order sets

Improves communication between surgical / medical team and the patient

Ensures follow-up after care transitions

Optimizes Patient Expectations and Outcomes

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Value Based Management – Changing care delivery while improving quality through bundled payment initiatives

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Bundled Payment Initiatives – what’s new…

Comprehensive Care for Joint Replacement Model (CCJR)

• 2013 400,000 Medicare THR / TKR

• Significant variation in care:• Infection• Implant failure• Expense ranged $16K - $33K

• DRG 469/470 90 day 5 year demonstrationmandatory

• 75 metropolitan areas with urban population > 50,000

• Evaluated annually with repayments to M’care or additional payments from M’care

• Submission date September 8th 2015



•What else…?

• Inflexibility of DRGs•Myriad of rules•Communication / feedback with Medicare•Gain sharing

•Whats next…?

•Medical DRGs•CABG 10/1•Cancer

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The Rehabilitation Continuum

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The Rehabilitation Continuum

•Rehabilitation Medicine

•Exemplifies Value Based Medicine•Patient centered collaborative practice method• ICU early mobilization•Bundled payment initiatives (efficiency)•Key role in care transitions• Inpatient rehabilitation remains viable – redefine criteria for acute and sub-acute•Home care agencies open to input•Collaborative outpatient programs potentially offer greatest growth opportunities – value in prevention of readmissions•Wellness (maintenance) programs to maintain care continuum

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Rehabilitation Medicine – Some lessons learned…

•Physiatrists and the rehabilitation team MUST play an important role in care redesign

•Enhancing rehabilitation services (Rapid Rehab) during acute hospital phase is related to decreased LOS

•Advancing clinical relationships with post acute partners expands influence with care delivery

•Our patients are experiencing improved care through enhanced coordination

•Well-coordinated care is better for our patients and results in reduced costs

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Rehabilitation Medicine – Some lessons learned…

Achieving desired goals of health care reform (triple aim) and providing opportunities for physiatrists to redefine themselves and remain important and viable going forward.

Considerations for the Future:

expansion of the bundle initiative

enhanced rehabilitation intensity throughout acute care hospitalization

EBM integrated into VBM e.g. the science of readmissions

growth of ambulatory services

wellness programs in community

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The Triple Aim

Improved Health


Reduced CostsThank you!!!

rusk rehabilitation the triple aim – how physiatry and the rehabilitation team can improve the...

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