CJR Data Affinity Group - hhs.gov

CJR Data Affinity Group

Interpreting and Communicating High Cost/Low Quality Drivers: Deep Dive on Post-Acute Care

Provider Data

February 2017

Comprehensive Care for Joint Replacement Model

Welcome

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Isaac Burrows, MPHLearning and Diffusion Group

Center for Medicare & Medicaid Innovation

Laura Maynard, M.Div.CJR Learning System Team

The Lewin Group

Webinar Agenda

• Welcome & Logistics• Presentations:

– SCL Health – St. Francis Medical Center

• Round Robin Group Discussion• Poll Questions• Announcements & Reminders

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Meeting Logistics & Norms

• All telephone lines are muted and will be opened for the discussion portion of the event.

• We encourage comments and reactions via both Chat and phone following the presentation.

• Participate!– Chat– Polls– Telephone Line (during open discussion)– Post-Event Survey

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Reminders & Resources Available

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• Closed Captioning is Available – use the Media Viewer or the link posted in Chat

• Chat to “All Participants”o If you are experiencing technical issues, chat to “All Panelists”

and someone will assist you

Let’s Test Out Group Chat

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Please share in Group Chat now:• Something you hope to

learn about using data to engage with post-acute care providers

When asking/responding to a specific person use “@” to help keep conversations clear! @John – What data elements are

included in your dashboard?

Introductions

• Your Name• Your Organization• What you hope to learn about using data to

engage post-acute care providers

Comprehensive Care for Joint Replacement Model 7

SCL Health Presentation


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Pam Masters, MSN, RN, CNLProgram Manager Accountable Care

St. Francis Health

Post-Acute Care

Collaboration for the CJR Population

Pamela Masters, MSN RN CNL

SCL Health SystemSt. Francis Health• One of 5 hospitals in CJR

for SCLHS• 259 bed hospital• Located in Topeka, KS• Population 128,000• 43,000 Medicare

beneficiaries• 200 Medicare CJR patients

annually

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SCL Health System

CJR Project Plan

• Costs exceeded target

• MSSP SNF utilization

• Nurse Navigator

• Best Practice Implementation

• Provider engagement

• Objective Discharge Criteria

• Plan B Safety Net

• Engagement with post-acute care providers

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CJR Project Plan

• 2 Inpatient Rehab Facilities (IRF), 11 Skilled Nursing Facilities (SNF),

and 5 Skilled Home Health Agencies (HH) located in Topeka

• We chose to align with 4 SNFs and 3 HH partners

• Partners were chosen based on quality indicators including star

rating, readmission rate, referral conversion rate, ED visit rate

Post-Acute Care Impact

**pre CJR data

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Post-Acute Care Impact

Post-Acute Care Collaboration

• Engagement of PAC• CMS Innovations start in acute care but move to PAC• Referrals due to preferred provider status• Change culture for FFS patients to managed care• Therapies- within 24 hours and frontloading• Nurse Navigator communication and visits

• Transitions of Care Council• Alignment agreement• Monthly meetings with aligned partners• Share best practices• Share quarterly data

• SNF: Star ratings, LOS, readmissions, ED utilization, fall rates, staffing, therapies within 24 hours

• HH: Star ratings, LOS, readmissions, patient experience, ED utilization, therapies first 5 days

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Post-Acute Care Collaboration

Outcomes

**Baseline data 2015CJR started in Q2 2016

0%

5%

10%

15%

20%

25%

30%

35%

Baseline Q2 Q3 Q 4 Year 1

DC to Rehab

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Outcomes

Outcomes (Cont.)

3.89

2.77

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12.6

15.913.9

0

5

10

15

20

25

Baseline Q2 Q3 Q4 Year 1

Days

CJR Length of Stay Acute LOS

SNF LOS

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Outcomes (Cont.)

Thank you for the opportunity to present our CJR work!

Questions?

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Reactions & Insights

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• Tell us using Phone or Chat!– What questions do you have for SCL Health?– Are you using similar methods to SCL Health?

@Jane – Thanks for sharing!

St. Francis Medical Center Presentation


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Hailey Hill, MHABundled Payment Program Coordinator

Engaging Post-Acute Providers in Bundled Payments

Hailey Hill, MHABundled Payment Coordinator

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St. Francis Medical CenterFranciscan Missionaries of Our Lady Health System

• Located in Monroe, LA• 504 licensed beds• Volume FY16 439 (DRG 469 & 470)

• 56% of volume is CJR• Hospital owned SNF & IRF• Non-Employed

Orthopedic Surgeons

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CJR Governance Structure

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Dissecting the Total Joint Pathway

Pre-OperativeJoint Boot CampPre-Admit Clinic

Anchor HospitalizationSurgery: ASU, OR Holding, OR, PACUOrthopedic Unit & Physical Therapy

Case Management & Discharge Planning

Post Hospitalization (90 Days)Post-Acute Care Coordination

Readmission PreventionPatient Follow-up

Opportunities

• Improve patient expectations

• Improve patient optimization criteria

• Reduce LOS• Improve discharge

planning process

• Communication with PAC providers

• Implement pathways• Implement a follow-up

process

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Results & Solutionsfrom Pathway Analysis

Collaboration

Problem: 1. Lack of communication between the hospital and post-acute care2. No care coordination to support a 90 day episode

Solution: Clinical Pathways,

Communication Platform, Improved Discharge Planning

Quarterly MeetingsGroup 1: Home Health, Hospice, DMEGroup 2: Nursing Home, SNF, IRF, LTAC

Post-Acute Community MeetingsSenior Services InitiativesAre You Ready to Bundle? Quality Presentation from AttendeesIndustry Expert EducationQ&A Open Forum

ParticipationGroup 1: 25 attendees representing 13 providersGroup 2: 40 attendees representing 21 facilities

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Engaging Post-Acute Providers“Are You Ready to Bundle?”

1st Post-Acute Community Meeting

- Overview of CJR- Data Transparency

‘12-14 Variance to TargetReadmissionsDischarge Disposition

- Offered providers an audit of the patients they cared for during the historical period and how they performed to target

April 2016 July 2016 October 2016 January 2017

2nd Post-Acute Community Meeting

- No Current Financial Data- Review of CJR- Discharge Disposition –

2016Q2 47% of Electives were discharged home

- Readmissions- Implemented LOS

Expectations- Implemented LOS

Notifications- Patient Expectations Tool- Home Health Pathways

to Begin on 8/1/16

3rd Post-Acute Community Meeting

- No Completed Episodes- Changes to Historical

Data Impact Past Performance

- Goal: 2017Q3 80% of Electives DC Home

- Discharge Disposition –2016Q3 50% of Electives were discharged home

- Readmissions

4th Post-Acute Community Meeting

- Announce New Bundles- Overall Performance of

16 Completed Episodes- Auditing of patients that

exceed target- New Patient Choice List- Discharge Disposition –

2016Q4 70% of Electives were discharged home

- Readmissions- SNF 3 Day Waiver

ONQ + Multimodal Program Begins

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CJR Bundled Payment Program• Home Health Pathways:

reduced the average home health cost by $1,071

• Changed Patient Expectations• Reduced LOS: Q3 ALOS for

Electives was 3.44, Q4 was 3.12• Changed Physician Discharge

Habits: Elective Joints Discharged Home - Oct 64%, November 63%, December 93%, January 90%

Hospital & Community Wide• Patients sent from NH to Hospital

that expired decreased by 42%• Readmissions decreased by 13%• Reduce referral acceptance time

from 4 hours to 2 (new goal 30 minutes)

• Transportation Issues

Community Meeting Impact

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Reactions & Insights

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• Tell us using Phone or Chat!– What questions do you have for St. Francis Medical Center?– Are you using similar methods to St. Francis Medical Center?

@Jane – Thanks for sharing!

Poll Question 1

As a result of participating in and learning from the CJR Data Affinity Group, my hospital has: [select all that apply]

a. Taken actionb. Changed the way we do some thingsc. Improved our processesd. Discussed new possibilities or new directionse. Reached out to other hospitals to share ideas or toolsf. Not done anything


Round Robin Discussion

As a result of participating in the Data Affinity Group, what has your hospital done or learned?

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Poll Question 2

How well have we achieved these goals?[select one option]

a. Very wellb. Somewhat wellc. Not very welld. Not well at all


Goals of the Data Affinity Group– Increase CJR hospital participant interaction and mutual support– Identify and discuss common drivers of both low quality and high cost– Increase use of dashboards to encourage and monitor improvement

Poll Question 3

Based on a scale of 1-10 (with 1 being the lowest and 10 being the highest), how would you rate your level of expertise in analyzing data to implement the CJR model?


Action Groups

• Differences between affinity groups and action groups. – In action groups:

• Participants agree to work together to test or implement a specific change• Expectation for action, reporting progress to group, sharing tools and

processes• Closed group, new people cannot join once it begins, to develop trust and

transparency

• Goals for action groups– Implement or test a change– Support each other in various ways to approach a single action or change

• Increase sharing of ideas and strategies


Poll Question 4

Are you interested in participating in an action group, working together to test or implement a data-related change?[select one option]

a. Yesb. Noc. Maybe


Poll Question 5

Which of the following topics is of most interest to you for an action group?[select one option]

a. Using data to engage physiciansb. Using data to develop partnerships with PAC providersc. Other (please type into chat)


Announcements & Reminders


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Continue Discussion on CJR Connect

• You have been added to your own private group on CJR Connect called “Data Affinity Group”

• To post a comment or share a resource:o Go to the “Groups” tab on CJR Connecto Click on “Data Affinity Group”o Post your comment in the group

• Or, just respond to others• To request a CJR Connect account, go to:

https://app.innovation.cms.gov/CJRConnect/CommunityLogin and click “New User? Click Here”

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https://app.innovation.cms.gov/CJRConnect/CommunityLogin

Upcoming CJR Events

If you have any questions, send an email to [email protected]


mailto:[email protected]

Reminders

• Send any questions to [email protected]

• Please take a few minutes to respond to the Post-Event Survey

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mailto:[email protected]

CJR Data Affinity Group - hhs.gov

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