An Up Close Look at a Home Care Led Bundled Payment...
23
Confidential and Proprietary Not for Distribution (except to authorized persons). An Up Close Look at a Home Care Led Bundled Payment Program Amy Weiss VP, Solution Development Visiting Nurse Service of NY The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.
Transcript of An Up Close Look at a Home Care Led Bundled Payment...
Confidential and ProprietaryNot for Distribution (except to authorized persons).
An Up Close Look at a Home Care Led Bundled Payment Program
Amy WeissVP, Solution DevelopmentVisiting Nurse Service of NY
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.
2
Visiting Nurse Service of New York
• The largest not-for-profit homecare agency in the country
• We are more than just nursing− More than 1,535 nurses, 535 rehab therapists, 340 social
workers, 85 other clinicians, 12,370 home health aides, speaking over 50 languages
− Hospice & Palliative Care− Private Duty Services− Utilization Management and Care Management− Population Health Analytics− NY Delivery System Reform Incentive Payment (DSRIP)
Performing Provider System (PPS) support• Participate with 14 PPSs; On Executive Committees with 6
and 53 other workgroups− Health Home and behavioral health transitions− Center for Home Care Policy & Research− CHOICE Health Plan (MA, MLTC, Dual, FIDA, SNP)
• We visit more than 32,000 people each day
3
VNSNY in a Changing Healthcare System
AffordableCare Act
Industry Driven Towards Post-acute Care
Value-Based Arrangements
Population Health
Shared Risk and Bundling
MedicaidRedesign
Ability to Care for High Cost, Complex Patients
New Payment Methodologies
Revenue Compression
PredictiveAnalytics
Triple Aim
4
A Dual Imperative for Home Health Providers
Source: Advisory Board
Traditional Home Care Under
Medicare/Managed Care Fee for
Service
Care Coordination and
Management Outside Core
Patient Population
5
Our Partners
Academic Medical Centers
Academic Medical Centers
Health Technology Companies
Health Technology Companies
Specialty HospitalsSpecialty Hospitals
Non-traditional Community Based
Providers
Non-traditional Community Based
Providers
Sub-acute Care Facilities
Sub-acute Care Facilities
Integrated Delivery Systems
Integrated Delivery Systems
DSRIP Performing Provider SystemsDSRIP Performing Provider Systems
Federal + State Institutions
Federal + State Institutions
National + RegionalInsurance ProvidersNational + RegionalInsurance Providers
PhysiciansPhysicians
Rehabilitation Centers
Rehabilitation Centers
Accountable Care Organizations
6
VNSNY Approach to Value Based Care and Payment
• Medicare and Medicaid Fee for Service is drying up
• Managed Care payers are seeking a cheaper alternative to facility based care
• Utilizing years of data and recent experiences in episode bundles, we began entering into case rates with managed care payers in 2014
• In early 2016 we began entering into performance-based contracts with incentives around a few core quality measures
• Late 2016 we are expanding the in-scope quality measures with a goal of 1/3 of our managed care revenue under some form of value-based arrangement
• Preparing for clinical episode based payments with managed care for 2017 and accountability for additional quality metrics
7
Experience with CMS Bundles
• VNSNY is a risk-bearing provider for a 90-day cardiac post-acute bundle• VNSNY shares in upside and downside risk for all patients admitted to VNSNY
with a recent hospitalization for congestive heart failure or myocardial infarction• Our Population Care Coordinators provide ongoing assessment and care
coordination throughout the 90-day episode• VNSNY has successfully reduced readmission rates and overall episode cost in
preliminary data from our first full risk-bearing year (2015) and achieved almost $1M in NPRA over first two years
• We are a preferred post-acute provider for cardiac and orthopedic bundles at two large health systems in NYC
• Co-designed clinical pathways leveraging our expertise in clinically and socially complex patient care
• Developed a health information exchange for the transfer of clinical visit data between VNSNY and the hospital providers
• Established enhanced communication pathways between VNSNY and hospital care coordinators
• Helped hospitals reduce episode cost through SNF avoidance programs and readmission reduction strategies
• We are a preferred post-acute provider for a top-ranked orthopedic specialty hospital’s joint replacement bundle
• Developed customized home care episode utilization reporting and population analytics
• Achieved the hospital’s targets for timeliness of care, readmissions, and other quality metrics
8
Bundled Payments for Care Improvement Initiative launched (voluntary)
CMS expands the BPCI participant
pool
BPCI participants offered a 2 year
extension
Comprehensive Care for Joint
Replacement (CJR) Bundle goes live
(mandatory in select MSAs3)
Oncology Care Model goes live
(voluntary)
CMS announces 3 new EPMs2 for orthopedic and
cardiac care (mandatory)
2013-2014 20162015
Bundled Payments for Care Improvement…an eye toward the (very near) future
A bundled episode is triggered by a hospitalization coded with one of the 48 MS-DRG groups selected by the BPCI
participant. The episode starts when the patient is admitted to the Episode
Initiating Provider.
In Models 2 and 3, Medicare A and B payments are grouped into a care
episode for 30/60/90 days and retrospectively reconciled against the
target price. Target price = historical spend – 2-3%
discount
BPCI participants have the option to gainshare with other providers,
incentivizing care coordination and clinical efficiency.
Financial and quality performance including NPRA1 is reported quarterly
followed by a series of true-ups.
BPCI Framework
1NPRA: Net Payment Reconciliation Amount2Episodic Payment Models3MSA: Metropolitan Statistical Area
9
Bundled Payments for Care Improvement…an eye toward the (very near) future
• As of July 1, 2016, the BPCI initiative has 1448 participants in Phase 2 comprised of 305 Awardees and 1143 Episode Initiators
360
658
262
979
0100200300400500600700
Acute CareHospitals
SkilledNursingFacilities
PhysicianGroup
Practices
Home HealthAgencies
InpatientRehab
Facilities
Participants by Provider Type*
*Non-provider Awardees excluded
296
3
1[VALUE]
BPCI in New York State
Skilled Nursing FacilitiesHome Health AgenciesPhysician Group
296
3
1[VALUE]
Model 2
Model 3
Source: Where Innovation is Happening. www.innovation.cms.gov
10
CMS Results in Bundles
11
The VNSNY Bundled Payment Program
Bundled Care
DRGs selected from 48 CMS-designated episodes: congestive heart failure and acute myocardial infarction
Defined episode duration: 90 days
Episode is initiated when VNSNY admits a patient within 30 days of an acute hospitalization for the selected DRG
Medicare Part A and Part B services are bundled, including physician visits, DME, outpatient rehabilitation, and hospital readmissions
Payment Model
A target price is established based on historical performance data; this incorporates a 3% discount to Medicare
Post-acute service claims are paid by Medicare on a fee for service basis
A retrospective review of costs determines if total cost of care in the bundle fell above or below the target price
If costs fell below target, Medicare pays the participant the difference and savings are distributed between contracted partners; if cost is above target, the participant pays Medicare the difference
12
Program Timeline
2012 - 2013
2014 - 2015
Evaluated options for participation in BPCI
Evaluated: Existing capabilities to be
leveraged for this engagement New capabilities needed to meet
intended outcomes Identified the appropriate target diagnosis Highest hospitalization rates Highest health system cost
Identified convening partner Designed 90 day model:
Care components Staffing needs
2015 - 2016
Launched the program in 2014 (non-risk sharing year)
Tweaked risk stratifying tool based on actual BPCI patient data
Adjusted workflows to meet program goals
Continued to streamline transitions Focused on training and
communication improvements with other VNSNY hospital and field based staff
Received preliminary program performance data
Expansion into new MI DRGs in 2015
Leveraging RHIO alert data Exploring data integration
with upstream providers Enhancing our Population
Health Care Management platform
Seeking direct agreement with CMS
13
Care Redesign in a Bundle: Beyond Traditional Home Care
Triggering hospitalization
Traditional home care episode Remainder of 90-day episode
• VNSNY RN on-site hospital liaisons (~40 facilities): shift from intake processing to transitional care
• Additional focus on transitional care & HF/MI home care pathways
• Calculation of acuity score using enhanced risk stratification algorithm (low, rising, high risk)
• Ongoing internal tracking of key outcome metrics, with frequent feedback loop to core clinical operations teams
• Introduction of VNSNY CO•CARE 90 model, anchored by a Nurse Population Care Coordinator who delivers/manages care with other providers beyond traditional home care period of service
• Stratification-driven mix of face-to-face, telehealth, telephonic communication; emphasis on goal-setting via motivational interviewing and behavior activation
• Partnership with community resources to tailor care plans and interventions to cultural/demographic needs
Initial Care Redesign Elements
Goal: Reduced 90-day rehospitalization rates and improved coordination of post-acute care
14
Program Timeline
2012 - 2013
2014 - 2015
Evaluated options for participation in BPCI
Evaluated: Existing capabilities to be
leveraged for this engagement New capabilities needed to meet
intended outcomes Identified the appropriate target diagnosis Highest hospitalization rates Highest health system cost
Identified convening partner Designed 90 day model:
Care components Staffing needs
2015 - 2016
Launched the program in 2014 (non-risk sharing year)
Tweaked risk stratifying tool based on actual BPCI patient data
Adjusted workflows to meet program goals
Continued to streamline transitions Focused on training and
communication improvements with other VNSNY hospital and field based staff
Received preliminary program performance data
Expansion into new MI DRGs in 2015
Leveraging RHIO alert data Exploring data integration
with upstream providers Enhancing our Population
Health Care Management platform
Seeking direct agreement with CMS
15
Population Care Management is Used to Provide Comprehensive and Patient-Centered Care
16
Care Redesign
Triggering hospitalization Traditional home care episode Remainder of 90-day episode
Patient & Family
Hospital‐Based RN Liaison
HomeCareNurse
HomeCare
Therapist
RNPopulation
CareCoordinator
Social Worker
Health Coach
Nurse Practitioner
Psych Nurse Practitioner
Pharmacist
Referring MD
D/C Planner
Other Care Managers
PrimaryCare
Physician
SpecialistPhysicians
Post‐AcuteFacilities
Community‐Based
Organizations
Hospital‐Based RN Liaison
HomeCareNurse
HomeCare
Therapist
RNPopulation
CareCoordinator
Social Worker
Health Coach
Nurse Practitioner
Psych Nurse Practitioner
Pharmacist
Referring MD
D/C Planner
Other Care Managers
PrimaryCare
Physician
SpecialistPhysicians
Post‐AcuteFacilities
Community‐Based
Organizations
17
Program Timeline
2012 - 2013
2014 - 2015
Evaluated options for participation in BPCI
Evaluated: Existing capabilities to be
leveraged for this engagement New capabilities needed to meet
intended outcomes Identified the appropriate target diagnosis Highest hospitalization rates Highest health system cost
Identified convening partner Designed 90 day model:
Care components Staffing needs
2015 - 2016
Launched the program in 2014 (non-risk sharing year)
Tweaked risk stratifying tool based on actual BPCI patient data
Adjusted workflows to meet program goals
Continued to streamline transitions Focused on training and
communication improvements with other VNSNY hospital and field based staff
Received preliminary program performance data
Expansion into new MI DRGs in 2015
Leveraging RHIO alert data Exploring data integration
with upstream providers Enhancing our Population
Health Care Management platform
Seeking direct agreement with CMS
18
Boosting the Power of VNSNY’s Population Health Through Technology
• Care management platform that provides “real time” decision support tools− Built-in risk stratification algorithm
• Identifying the right patients for the right clinical pathway, and the right level of care
− Status changes and event notifications− Care management clinical pathways and evidence-based
assessment tools− Outcomes reporting for identifying improvement opportunities
and areas of success• Remote patient monitoring
• Data integration with upstream providers
19
Boosting the Power of VNSNY’s Population Health Through Technology
Enhancing our BPCI Bundle:• Leveraging the additional information made available through CMS
− Monthly claims− Reconciliation reporting
• Supporting care management over the 90 day bundle period
− Using home care assessment data− Risk stratification time points− CHHA to post-CHHA workflows − Population Care Coordinator encounters (types and dosing)− Use of evidence based tools and assessments
• Reporting and analytics
− Clinical quality and outcomes− Process performance metrics− Financial performance − External reporting requirements − Building your quality and financial ROI
20
• Challenge: Ensuring that workflows and processes are constantly monitored for relevance and effectiveness
• Solution: Identify dedicated staff that constantly monitors program performance and evaluates processes to identify patterns or trends that must trigger workflow and protocol changes for continued possible program effectiveness-and leverage technology wherever to produce meaningful and actionable program analytics
Challenges and Lessons Learned in BPCI
Identifying and providing care for the right patient cohort
Aligning the risk stratification tool with the target patient population traits and program goals
Focusing on care transition points for improved hand-offs and continuity of care
Ensuring that workflows and processes are revised to incorporate program findings
• Challenge: Hospital “working” DRG is not always aligned with the final DRG, so targeting the right patients was a challenge
• Solution: Develop a predictive model that runs in the background of our EMR to assist with identification of BPCI cases that may have been missed at intake
• Challenge: Adjusting existing tools to stratify patients into a high, rising or low risk bucket that reflects the needs of our program and guides the right set of interventions
• Solution: Used actual BPCI patient data to tweak the algorithm on an ongoing basis so that it is aligned with the program and patient goals
• Challenge: Seamless transitioning from a hospital to a home setting and from a CHHA episode to the remainder of the 90 day episode
• Solution: Provide extensive education on the BPCI program and goals for clinical staff across settings and across VNSNY departments and ensure that guiding principles of our care model are used throughout the 90 day episode of care
21
VNSNY and BPCI: Moving Forward
• In 2016 VNSNY published a report of program performance to date:
• Continued positive performance has facilitated our move to extend our BPCI participation through 2018
• VNSNY is seeking Single Awardee status with CMS for the duration of our participation
22
Value Based Programs with Provider Partners: Challenges
• Early engagement of post-acute care providers is key in developing value-based models across the care continuum
• Lack of EMR integration or even basic clinical information exchange can be a significant hindrance in care coordination efforts
• Hospital systems, ACOs, and physician groups are hesitant to enter into risk sharing arrangements with an independent post-acute care provider
• Alignment between senior leadership across organizations may not trickle down to ground-level clinical staff
23
Questions
• Questions?
• Thank you Amy WeissVP, Solution Development
212-609-4861
