Hospitals, Clinics, Health Systems and Home Care

Cathy Barr CEO Bethesda Hospital

Vice President Community Based Services HealthEast Care System

New England Home Care Conference

May 31st,2012

Background ◦ Who is HealthEast Care System ◦ Health Care Reform and Market Landscape Government Payers Health Systems

◦ Health East Care System-Positioning for the Future Art of the Middle Game The Critical Few How Community Vitality plays into our Roadmap

◦ Home Health Care Opportunities Market Pressures Consideration of Labor Needs Alignment with Payers, Health Systems, Hospitals and Clinics

HealthEast Care System - St. Paul, Minnesota

HealthEast Care System

• 3 STAC, 1 LTAC Hospitals • 14 Primary Care Clinics • More than 35 specialty services • Home Care & Hospice • Medical Transportation

Some Statistics

Licensed Beds 925 Employees 7,300 Volunteers 1,200 Credentialed Physicians 1,400

Woodwinds

Health Campus

St. Joseph’s Hospital St. John’s Hospital Bethesda Hospital

Visits: 65,000

AVG LOS: 41 days

Patients Served:

7,000 +

Employees: 100+

Disciplines

• Skilled Nursing

• Rehab (PT, PTA, OT, SP)

• Home Health Aide

• Nutrition Services

• Medical Social Work

• Chaplain

Specialty Programs

• Ortho Team

• Perinatal

• Palliative Care

• Wound Management

• Infusion Therapy Nursing & Pharmacy

• Health Alert Personal Response

• Cardiac Care Team

The Pressures Hospitals and

Health Systems are Under!

ACA

ACO

HITECH

VBP

PMPM

Bend the Cost Curve

Value or

Volume

Medical Home

Doc Fix

Primary Care Attribution

Insurance Exchanges

Gang of Six Doughnut Holes

Co-ops

Care Transitions Total

Cost of Care

PMPM

?

Planning & Positioning

2010 – 2013 2014 – 2017

The Prelude Market Expansion

Regulation and Restructuring

2018 – 2020

Constitutionality challenge? Insurance expansion rollbacks? State insurance exchanges? Presidential Election!

Significant increase in insured population

Addressing the realities of affordability

Key Issues:

• Arguments before the Court lasted for three days.

March 26, 2012 thru March 28th The Courts decision is likely at the end of June.

• Court is divided along ideological lines

4 justices – record of conservative opinions (Scalia, Alito, Roberts, Thomas)

4 justices – record of liberal opinions (Sotomayor, Ginsberg, Kagan, Breyer)

1 swing vote - Kennedy

• The outcome of the case is unpredictable, and predictions are largely guess-work.

Moving to Population Health Management

Moving to Total Cost of Care Models

Piloting Risk Sharing/Gain Sharing reimbursement programs

Looking for Innovation

◦ Home Health Falls Prevention Programs

◦ Palliative Care

◦ Diabetes Management

◦ Cognitive Disorders

Dual Eligible Care Management

BCBS-Mass,

Boston, MA:

Alternative quality

contract

CaroMont,

Gastonia, NC:

Bundled payment

for knee

arthroplasty

Source: Sg2 Interviews, 2011.

HealthEast,

Saint Paul, MN:

Incentives tied to

total cost of care

target.

10 Sole Community

Providers in

Maryland:

Prospective annual

budget—total patient

revenue

Aligning Hospitals, Health System, Physicians, and, Post Acute Care Services ◦ Developing Infa-structure-ACO, Care Management ◦ Focusing on Clinical Integration-Standardization of Care

Improve Care Transitions ◦ Improve Patient Outcomes Across the Care Continuum

Reduce the Total Cost of Care

Today’s Market

Disease-Centered System of CARE Production-Model Health System

Patient Training/Education may take more of a front seat for home health with reform

Retail Pharmacy

Wellness and Fitness Center

Diagnostic/ Imaging Center

Urgent Care Center

Home

Physician Clinics

Ambulatory Procedure Center

IP Rehab

Hospital

Home Care

Acuity

Community-Based Care Acute Care

Recovery & Rehab Care

SNF

OP Rehab

ACO Formation –clinical integration

Value Based Improvement with focus on: ◦ Care Transitions (Home Care is a key stakeholder)

◦ Superior Patient Care Experience

◦ Elimination of unnecessary waste

◦ Highly engaged staff and physicians

Electronic Health Record ◦ Engage patients thru medical record

◦ Analytics

Future Focus on primary and post-acute care partnerships

Home Care is integral in providing best care, best value

5%–10%

10%–15%

15%–20%

Incremental Change Incremental ideas that do not significantly disrupt the organization

Operational Improvement Departmental improvement ideas that reorganize activities; moderate impact on other departments Redesign Care Delivery Model Cross-departmental functioning and program elimination ideas; greatest potential to be disruptive Not silo redesign but redesign across the full continuum

% C

ost

Red

ucti

on

Consolidate roles and responsibilities

Invest in productivity

Leverage technology

Care transitions

Great opportunity for home care to be involved.

Lean process design

Six Sigma

Vendor and supply consolidation

Clinical Quality Patient Experience +

Cost Effectiveness

TCU/IRF/SNF

Health Alert

HOME CARE

Acu

ity/C

ost

Primary and

Specialty

Clinics Self

Community-Based Care

POST ACUTE CARE

Acute Care

Primary

Clinics

Specialty

Clinics

Based upon SG2 2010

Community Health

Worker, Parish Nursing,

Pathways for Better

Health

The Continuum of Care

LTACH

STACH

TRANSITION COACH

Self

Home Care

Do you have the clinical programs and personnel to serve the institutions patients?

Quality

Cost

Efficiency

Hospital/Health System Concerns

◦ Your programs and results

Readmission rate

Medication reconciliation

Functional Improvement

Pain Management

◦ Hospital Benchmarks and your agency’s performance = improved results and focus.

◦ Clinic Community Measures and your agency’s performance = improved results and focus.

Emergency Room-Hospital at Home Programs

quality

cost

efficiency

Hospital/Health System Concerns – Reduce Length of Stay

• Hospital national and regional benchmarks

–Value Based Purchasing Implications

• Reduce Readmission Costs and Future Penalties

• Core Measures

– Reduce Primary Care Cost after Acute Care Event and Maintain Patient in Community Longer

• Signs/symptoms

• Follow-up within 7 days

• Make it easy for Primary Care to use home health!

cost

Hospital/Health System Concerns

◦ Ease to Do Business With?

◦ Proactively Support Care Transition Processes

History and physical

Communication patterns and protocols

Hand-off’s smooth

Care paths or standards

◦ Focus on “ongoing” communication across the continuum.

efficiency

FY 2012 Year-To-Date Opportunity

Benchmark* STACH

Patients

STACH Patients Discharged to Home

Health Care % to Home

Health

2011 % To Home Health

Additional Cases Discharge to Home Health Care at

benchmark

Hosp A 14% 4,938 843 19.4% 16.8%

Hosp B 14% 9,427 820 9.9% 7.7%

11% 158

12% 300

13% 442

14% 585

Hosp C 14% 8,482 570 7.6% 6.6%

9% 181

10% 309

11% 438

12% 566

13% 695

14% 824

•Source: Fazzi Associates, Inc. Benchmark to Home Health Care is 14% •**home health projected growth rate – 3-5 % per year •***home health’s annual spend is expected to increase 10 percent per year

Collaboration with Acute Care Hospitals

Metric Hospital A Hospital B Hospital C

# Cases FY11 Annualized 240 203 690

Average Age of Patients 64.8 66.4 63.3

Patient Satisfaction – Overall Hospital Rating

65.7% 75% 76.6%

Patient Satisfaction - Pain Score Composite

65.6% 59.4% 74.4%

Inpatient LOS 3.1 3.3 2.8

Implant Cost $3,308 $3,375 $3,277

SCIP – ABX All or None 94.8 95.9 97.1

Discharged to SNF/TCU 40% 36% 18%

Readmission Rate 3.5% 5.7% 2.5%

Infection Rate 0.81% 0.84% 0.81%

Home Health Referrals 50.0% 48 % 72 %

Improve Care Transitions

HealthEast Care Navigation

• Help me through my care experience.

• Connect me to the right resources.

• Communicate with me in ways I understand.

• Patient Centered – patient/family partnership

• Effective - impact clinical quality measures.

• Safe - close care gaps, reduce complications

PATIENT CENTERED

GUIDING PRINCIPLES

Vision Promise: Care for patients within an integrated and patient centered model of care that leverages all components of the HealthEast Care System delivering a coordinated and positive care experience.

Excellent Patient Experience

Quality Outcomes

Effective Specialty Programs

Episodic Care

Longitudinal Care Relationship

Steering Team 5/29/08

• Timely - prevent care delays

• Equitable – culturally responsive

• Efficient – best use of resources across continuum

• Help me to manage across episodes.

• Coordinate my whole experience with HealthEast.

Financial Alignment

Right Care Right Time Right Place

0

1

2

3

4

5

6

Jan Feb Mar Apr May Jun July Aug Sep Nov Dec

Ac

uit

y L

eve

l

InPt Visits Outpt Visits Cardiac Rehab Office Visits Home

Meet Bouncing Bob!

Four Pillars

• Medication Management

• Personal Health Record

• Follow-up with PCP

• Education regarding

Red Flags

Prescriptive

Interventions

• Hospital meeting

• Post-Discharge

Home Visit

• Post-Discharge

3 phone calls

Diagnoses:

CHF, CAD, Arrhythmia, PVD, COPD, CVA, Diabetes, Hip Fracture & Joint Replacement

21.5% Medication Discrepancy Addressed

Percent of patients that found program to be helpful/very helpful with

Managing Medications 85%

Better understanding on when to call PCP 89%

Better prepared to work with PCP 85%

Follow-up appointments 69%

Patient using the PHR 70%

Would recommend to family and friends 95% 9.7 % readmission rate 30 days post discharge

(for any level of intervention)

Compared to national average 20-25%

Quality

Patient

Satisfaction Cost

March 2011 - March 2012

1114 persons enrolled

Services Provided per

Episode of Care

Average Visits

per Episode Interventions

Nursing 15 Med Rec, Disease Management/Education

Physical Therapy 3 Gait, Exercises, Strengthening

Occupational Therapy 3 Adaptive Equipment, Energy Conservation

Dietician 1 Nutrition Consult & Education

Medical Social Worker 1-2 Community & Financial Resources

Home Health Aide 6 Bathing & Personal Cares

Patient Data:

75 year old female lives with 80 year old

husband with dementia

Patient Diagnoses:

CHF, HTN, CAD, OA, DM, CRF,

Depression.

• Coordination of Care with the PCP • Case Management • Enhance Patient Experience • Improve Quality

Average Episode cost for CHF= $2,730

Medical

floor

Transition Coach

Pulmonary Navigator

PCP Navigator

P C P

Navigator

Pulmonary

Navigator

Inpatient Navigators

(redesign of roles)

D/C plans care progression flag others

Connect with Hospitalist Coordinator

D/C

Post Acute Care

Palliative Care

Home Care

Transitional Care

0%

5%

10%

15%

20%

25%

Baseline Pilot

22%

10%

30-Day Readmission Rate

0%

1%

2%

3%

4%

5%

Baseline Pilot

5%

0%

7-Day Readmission Rate

31 5 # Readmissions 7 0

24 4 # Patients

Readmitted

6 0

Baseline Pilot

Total Inpt Encounters 143 49

Chronically ill, unstable patient

Desire to stay at home

Services include: physician, nursing, HHA and therapy as needed

Frequency of visits in 24 hour period is dependant upon patient condition

Grant applications?

Escalating costs, require health care systems, acute care hospitals and payers to find alternatives that successfully accommodate the complex needs of acutely ill patients.

Home Health and other Post Acute Care Options can provide a service that is comparable to acute care facilities and allows for a critical mass of patients needed for optimal and cost effective outcomes.

• Focus on primary care clinics

• Focus on wellness/case mgt and community care management in the home – Reimbursement potential in the future

– Innovation i.e. falls assessment, diabetes education in the home, community care mgt post home health episode completion

– Be part of the care delivery redesign process

• Payers

• Health Care Systems

• Hospitals

• SNF’s/TCU’s

• IRF’s and LTACH’s

• Public Health

• Parish Nursing

• Payers & Health Systems – Utilization Review/Care Management

• Hospitals • Social Services Departments

– Directors

– Staff

• Health Plan Contracting – Clinical and Financial Leaders

• SNF/TCU – Admission Lead or DON

TCU/SNF partnerships ◦ Formal written agreements/Informal relationships

Accessibility

Patient types or specialty populations

Quality metrics-readmissions

Analytics

◦ Community Stakeholder Partnership-Stratis Health

Health Care Homes

Home Health Care

MSHO Care Management

Community Health Worker

Volunteer Core

Hospice

Parish Nursing

Senior Companion

Your Plan????

TCU’s SNF”s

Assisted Living Facilities

Questions?