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Winning at Care Coordination Using Data-Driven Partnerships

Session #166, February 22, 2017

Steven Littlehale, MS, GCNS-BC

EVP & Chief Clinical Officer

Idriz Limaj, LNHA, RN

Chief Operating Officer

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Speaker Introduction

Idriz Limaj, LNHA, RN

Chief Operating Officer

LifeBridge Health

Steven Littlehale, MS, GCNS-BC

EVP & Chief Clinical Officer

PointRight Inc.

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Conflict of Interest

Idriz Limaj, LNHA, RN

Has no real or apparent conflicts of interest to report.

Steven Littlehale, MS, GCNS-BC

Has no real or apparent conflicts of interest to report.

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Agenda

• What’s going on in the post-acute world?

• What data is available from post-acute care?

• What are the steps for building and managing a high-performing post-acute provider network?

• How can predictive analytics play a role in managing the network?

• How can this advance population health management?

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Learning Objectives

• Recognize the depth and breadth of available LTPAC data and what it can do for you – public domain data, MDS data, OASIS

• Evaluate the critical components of a data-driven strategy for building and managing a ‘smart’ network of LTPAC providers

• Discuss how predictive analytics can directly impact care coordination, reduce readmissions and optimize placements

• Develop the necessary steps for integrating LTPAC data into population health management programs

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STEPS™ to ValueAn introduction to the benefits realized for the value of Health IT

• The value STEPS™ impacted were:

– Treatment/Clinical

– Patient Engagement & Population Management

– Savings

• Improved the Hospital discharge and admission process

• Improved the Nursing Home to Hospital transfer process

• Reduced overall risk-adjusted rehospitalization rate by 1.06 percentage points

• Improved LifeBridge Quality Score by 6.81%

• Improved overall Five-Star by 4.45%

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What’s Going On in the Post-Acute World? The journey to value-based care

HVBP NewMeasures

SNFVBP

NewMeasures

NewData

HHVBP

NewMeasures

NewData

IMPACT Act

NewMeasures

NewData

Five-Star

NewMeasures

NewData

AffordableCare Act

NewData

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There is an Alignment…

HRRP

NewMeasures

SNFVBP

NewMeasures

NewData

HHVBP

NewMeasures

NewData

IMPACT Act

NewMeasures

NewData

Five-Star

NewMeasures New

Data

NewData

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HHS Payment ReformHHS announced targets to increase the number of payments that are linked to quality outcomes by 2018.

We are setting clear goals – and establishing a clear timeline – for moving from volume to valuein Medicare payments.

“Our first goal is for 30% of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide – and to do it by 2016.Our goal would then be to get to 50% by 2018.”

Our second goal is for virtually all Medicare fee-for-service payments to be tied to quality and value; at least 85% in 2016 and 90% in 2018.- HHS Secretary BurwellJan. 26, 2015

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Focus on Quality

Payment is now aligning with quality.

The Administration has set measurable goals and a

timeline to move the Medicare program, and the

health care system at large, toward paying

providers based on the quality, rather than the

quantity of care they give patients. The final rule

includes policies that advance that vision and

support building a health care system that delivers

better care, spends health care dollars more wisely

and results in healthier people.

CMS 8/3/2015

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Understanding post-acute data

And knowing what it can do for you

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Available Data: Home Health Agencies (HHAs)

• The Outcome and Assessment Information Set (OASIS)

– Home health quality measures (both outcome and process measures)

• Medicare claims

– Medicare claims data is used to calculate certain utilization-based home health quality measures.

• The patient experience of care survey uses the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) instrument.

• Medicare.gov/HomeHealthCompare

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Available Data: Skilled Nursing Facilities (SNFs)

• CMS’s health inspection database

– Nursing home characteristics and health deficiencies issued and data about staffing and penalties

• The Minimum Data Set (MDS)

– Clinical data for quality measures come from the MDS Repository

• Medicare claims

– Medicare claims data is used to calculate certain utilization-based home health quality measures

• Medicare.gov/NursingHomeCompare

• Many states have unique data sets/report cards

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Available Data: Metrics in the Future

• IMPACT Act – QRP Measures and C-CDA files

– Long-Term Care Hospitals (LTCHs): LTCH Care Data Set (LCDS)

– Skilled Nursing Facilities (SNFs): Minimum Data Set (MDS)

– Home Health Agencies (HHAs): OASIS

– Inpatient Rehabilitation Facilities (IRFs): IRF-Patient Assessment Instrument (IRF-PAI)

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The critical components of a data-driven strategyBuilding and managing ‘Smart’ LTPAC provider networks

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Building a Narrow vs. “Smart Network”

NARROW NETWORKS• Efficient

• Geared toward the stakeholderSMART NETWORKS• Customized to fit patients’ needs

• High Performance/Data-driven

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Three Keys to Success

StandardizedTransparent

Operational

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LifeBridge Health OverviewLeading provider of hospital services in northwestern Baltimore and all of Carroll County, Maryland

• $1.8B health system

• 4 hospitals

• 249 nursing home beds (1 free-standing, 1 TCU)

• ~550 employed physicians │~2,000 employed nurses

• 100+ locations

• 22 urgent care sites

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SNF Collaborative – A Preferred Network

The SNF Collaborative was developed to:

• Create a network that is focused on quality and patient experience

• Enhance patient outcomes while reducing the cost of care

• Standardize and share best practices across systems

• Enhance problem-solving and collective navigation within today’s healthcare landscape

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Continuum of Care

PRIMARY

CARE,

PREVENTION,

WELLNESS

AMBULATORY

CARE

ACUTE CARE,

TERTIARY CAREPOST-ACUTE

CARE

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Ongoing Performance MonitoringMetrics

• Quality

• Rehospitalization

• Patient and family satisfaction

Goals

Improve scores by 10% annually if below state average

Improve scores by 20% annually if above state average

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The Collaborative Dashboard

Transparency. Standardization. Operational.

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™

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Pro30™ Rehospitalization for Collaborative

18.6%

19.0% 19.1%

18.6% 18.7%18.3% 18.2% 18.2%

17.5%17.1% 17.3%

17.1%18.1%

18.5% 18.5%

18.1% 18.2%

17.8% 17.8% 17.8%

17.0%16.8% 17.0%

16.8%

15%

16%

17%

18%

19%

20%

Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16

Observed Adjusted

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SNF Outcomes to DateTransparency and data exchange drive change:

– Improved the Hospital discharge and admission process

– Improved the Nursing Home to Hospital transfer process

– Reduced overall adjusted rehospitalization rate by 1.06 percentage points

– Improved quality metrics by 6.81%

– Improved overall Five-Star by 4.45%

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Next Steps for the SNF Collaborative

• Leverage a ‘Smart’ network for discharge planning Discharge patients to the right setting based on outcomes

• Standardized clinical pathways based on best practices CHF, UTI, COPD, Pneumonia, Diabetes

• Reduce costs Monitor length of stay and quality outcomes

• Investigate acute care end of life admissions

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The power of predictive analytics

Knowing what to look for so you can better prepare for what lies ahead

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Choose the Right BenchmarksWhen it comes to using your data, it’s not just about choosing the right outcomes…

it’s about choosing the right benchmarks…

AND proper risk adjustment.

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Risk Adjusted Rehospitalization Rates – Nation

Source: Original PointRight®

Research © 2016

15% and below

15% to 18%

18% and above

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Observed vs. Risk Adjusted Rehospitalization Rates – California

Risk-AdjustedObserved

12% and below

12% to 20%

20% and above

Source: Original PointRight®

Research © 2016

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Predictive Analytics = Better PartnershipsPointRight Post-Acute Grades vs. the CMS Five-Star Ratings

Post-Operative Care (All Procedures)

CMS 5 Star

Ranking

5 4 3 2 1

18.2% 19.1% 20.0% 19.1% 20.0%

PointRight

Grade

A B C D E

14.1% 17.0% 18.4% 20.8% 24.4%

Chronic Obstructive Pulmonary Disease (COPD)

CMS 5 Star

Ranking

5 4 3 2 1

19.0% 19.3% 19.5% 20.0% 21.1%

PointRight

Grade

A B C D E

16.0% 17.3% 19.0% 21.3% 24.9%

2% Points

Difference

9% Points

Difference

2% Points

Difference

10% Points

Difference

1 and 2 Star SNFs Might be Best Choice in Some Markets

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Care Processes at One SNFCARE PROCESSES AND OUTCOMES Measure Group State National

Pain Management: % of Patients 50% 33% 38% 51%

Advanced Directives: % of Patients 2% 20% 20% 59%

Behavior Management Ratio 5% 40% 42% 80%

Diagnosed with Depression: % of Patients 17% 35% 38% 41%

Facility Acquired Contractors: % of Patients 6% 5% 6% 2%

Hospice Care Utilization 8% 5% 5% 4%

Respiratory Therapy: % of Patients 13% 7% 9% 13%

Observed Drug Administration Errors No

Source: Original PointRight ® Research © 2016

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Average Length of Stay (ALOS)

Year State Median

2012 Nation 24

2013 Nation 24

2014 Nation 24

2015 Nation 22

Year State Median

2015 Nation 22

2015 AL 20

2015 FL 22

2015 MD 27

2015 MA 19

2015 MS 29

2015 TX 25

Source: Original PointRight ® Research © 2016

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What Impacts Average Length of Stay?

State Cognitive

Impairment

Median

Nation No 22

Nation Yes 25

State Incontinence Median

Nation No 21

Nation Yes 28

State Depression Median

Nation No 22

Nation Yes 27

State Pain Median

Nation No 22

Nation Yes 24

Source: Original PointRight ® Research © 2016

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What’s next for LTPAC data?

Accelerating population health management

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Performance by Clinical Cohort™

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COPD at One SNF

Source:

Source:

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Summary

Data is abundant; turning

it into action requires an

extra layer of intelligence

DATA

INTELLIGENCE

ACTION

Partnerships are best

achieved through metrics

that are:

TRANSPARENT

STANDARDIZED

OPERATIONAL

Alignment and

communication improve

outcomes

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STEPS™ to ValueA summary of the benefits realized for the value of Health IT

• The value STEPS™ impacted were:

– Treatment/Clinical

– Patient Engagement & Population Management

– Savings

• Improved the Hospital discharge and admission process

• Improved the Nursing Home to Hospital transfer process

• Reduced overall risk-adjusted rehospitalization rate by 1.06 percentage points

• Improved LifeBridge Quality Score by 6.81%

• Improved overall Five-Star by 4.45%

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Questions

Idriz Limaj, LNHA, RN

Chief Operating Officer

ilimaj@lifebridgehealth.org

Steven Littlehale, MS, GCNS-BC

EVP & Chief Clinical Officer

steven.littlehale@pointright.com

@SteveLittlehale