The Health System of the Future: Effectively Managing Bundled Care Payment in the ACO y g g y

Environment

Josh Luke, Ph.D., FACHEFounder, National Readmission Prevention Collaborative

Interim CEO, Memorial Hospital of Gardena

Executive Faculty, CSULB Healthcare Administration Department

Author, Readmission Prevention: Solutions Across The Provider ContinuumAuthor, Readmission Prevention: Solutions Across The Provider Continuum

Josh Luke, PhD., FACHE

• Hospital CEO• Hospital CEO • Memorial Hospital of Gardena• Western Medical Center Anaheim• Anaheim General Hospital

• VP, Post Acute at Torrance Memorial Health System • Home Health and Hospice oversight

Developed award winning Post Acute Network• Developed award winning Post Acute Network

• CEO for HealthSouth Las Vegas Rehab Hospital

• SNF Administrator/ALF Executive Director• Home Kindred• Windsor/SNF Management• California Friends Homes

Health Administration PressAmerican College of Healthcare Executives

Presentation ObjectivesPresentation Objectives

• The delivery model of the future: “Discharge Home”

• Bundled payments• Bundled payments

Let’s get off the starting line and skate to where the puck will be!

Its time to innovate and transform!

1998…….It was a very good y gyear

1998 It d1998…….It was a very good year

Grandma BelvaGrandma BelvaMarch 1920 – July  2002

Congestive Heart FailureCongestive Heart FailureThe Summer of 2002

Home $0Hemet Valley Medical CenterLTACHNursing HomeHome ith Home Health

$$48,000$52,000$12,000$4 000Home with Home Health

* Hemet Valley Medical CenterNursing HomeAssisted Living with Home Health

$4,000$36,000$18,000$4,000

*Hemet Valley Medical CenterNursing Home*Hemet Valley Medical Center

$42,000$24,000$58,000

* Readmission  $298,000

Who got paid?Who got paid?

We must coordinate care

The Affordable Care Act is not a request, but a mandate with significant penalties if we do not.

Wh t d thi f th t h it l t ?What does this mean for the acute hospital sector?

Are you Ready for the truth?

The goal is to find a better way for individuals to• The goal is to find a better way for individuals to age and heal at home.

Th t th i th t j b i t t t h h t• The truth is that my job is not to teach you how to prevent re-admissions, its to teach you to prevent….Admissions.

• Welcome to the world of…

ADMISSION PREVENTIONADMISSION PREVENTION

What does this mean for you?

• Hospitals = Last resort

• SNF = Second to last resort; increase capability to handle med surg level patients

• Home health = Networks will be narrowed

• Patients will be directed to lower levels of care and care paid privately (ALF, home care, remote monitoring)

Winning!Winning!

S h i i i ?• So who is winning? • Home Care• Private duty nursingPrivate duty nursing• Assisted living

• Who can position for success?• Who can position for success?• Health systems designed so that hospital is truly the

last resort• SNF’s who are willing to push for shorter LOS

Tommy Olmstead v LCUS Supreme Court Decision, June 1999

Th US S C l d dThe US Supreme Court concluded:

“Patients in an acute hospital have the right to be discharged to the least restrictive environment when the care team determines that community placement is appropriate and the patient does not oppose to the pp p p pptransfer.”

“Continued institutionalization of patients who may p ybe placed in less restrictive environments often constitutes discrimination based on disability.”

Tommy Olmstead v LCUS Supreme Court Decision, June 1999

Th US S C l d dThe US Supreme Court concluded:

-Operationally, this means that both physicians and fhospital case managers must first rule-out the least

restrictive environment as a safe discharge before considering institutionalizing a patient for post acute g g p pservices.”

- What do you think CMS would say about this? y yMSPB?

Transitional Care Wellness & Revenue StreamsTransitional Care, Wellness & Revenue Streams

Everyone is being incentivized to avoid the hospital

• Direct to SNF transfers from the ED Homefrom the ED

• Remote monitoring at home and in SNF

Home

• Home visits

• Expansion of Home H lth t A b l t

Dr. Office

SNF

Health to Ambulatory case managers

Home Health

Obama AlaskaHypothetical New City

Health System

Home

Doctors officeyof the Future

Wellness clinic/gym

OP/Ancillary Services

Assisted Living

SNF

Hospital

Obama AlaskaTh S t f Old Th F F S i F fThe System of Old – The Fee-For-Service Free-for-

All

Home

Doctors office

HospitalWellness clinic/gym

OP/Ancillary Services

Assisted Living

SNF

Insert Hospital Here!

Story TimeyOnce Upon a time…

Old Hospital = 290 bedsOld Hospital = 290 bedsNew Hospital =

249 bedsHospital Bed

Capacity

The Fee For Service Post ACA Era

Free-for-All Era

Seven Reasons to Coordinate CareSeven Reasons to Coordinate Care

1. ACO’s (MSSP incentive)

2. Bundled Payment Initiatives

3. Value based Initiatives

4. Readmission Penalties

5. RAC Audits

6. MSPB

7. HHS Announcement January 2015• 30% ACO by 2016; 50% by 2018• 90% of FFS reimbursement tied to quality

Connectivity and Care PlanningConnectivity and Care Planning

• Hospitals must be connected to their post acute providers and innovate• Risk stratification software & post acute connectivityRisk stratification software & post acute connectivity • Remote monitoring units

• Formalize relationships for Care Planning support• Formalize relationships for Care Planning support to reduce workload and provide ambulatory case management services• Care Patrol Community Integration Model: Designed

Specifically to Assist Hospitals with MSPB• Care Centrix HomeStar: Home Health managementCare Centrix HomeStar: Home Health management

IMPACTHere Comes Reason #7 to Coordinate Care

Improving Medicare Post-Acute Transformation Act of 2014

IMPACT Act of 2014 takes a crucial step toward the modernization of Medicare payments to post-acute care (PAC) providers

Who wins? Maybe no one: It appears to be more documentation to prove medical necessity

Post Acute ExpectationsPost Acute Expectations

1. POLST2. SBAR3 S d W h3. Stop and Watch4. Return to Acute Log (Emergency Dept)5 Return to ED Root Cause Analysis5. Return to ED Root Cause Analysis6. Predictive software/electronic quality data ** Only tactic requiring investment; small price to pay

to be preferred provider

Four examples of Value-Added Innovation

• Risk Stratification in acute and post acute connectivity• Software such as RightCare Solutions (UPenn) identifies &

connects• Vree Health Population Health management

• Care Management • Community Integration Model

• Home Based Transition programs • Home Instead transition program• Home Instead transition program

• Predictive software (Coms Interactive and Medline) in SNF’s:• Trains nurses when red flags arise and how to react toTrains nurses when red flags arise and how to react to

warning signs

Bundled Payment ModelsBundled Payment Models

Early Learnings• Must have semi-sophisticated EMR to identify those p y

in bundle early in the admission• Must “rule-out home” as an option before considering

LTACH IRF or SNFLTACH, IRF or SNF• Must have post acute providers with leadership not

incentivized to extend length of stay• Risk stratification software

Bundled Payment ModelsBundled Payment Models

Early Learnings• “Graying” of home based servicesy g

• Home health• Home care/private duty

Wellness efforts• Wellness efforts• Support services in the home are key

• Telehealth• Remote monitoring

• Narrowing of Post Acute Network

A Bundle Key - The Super SNFA Bundle Key - The Super SNF

• Stop looking at competitors within the SNF industry for the answers and start innovating

H it l b d SNF’ ithi il f f ilit• Hospital based SNF’s within a mile of your facility get paid $800-$1100 a day for SNF patients; why don’t you?

Post Acute Bundle ConvenersPost Acute Bundle Conveners

• Signature Healthcare• 113 Communities• 9 states• 21 SNF’s (in Kentucky alone)• 1 Critical Access hospital

Key Action ItemsKey Action Items

I t d Diff ti t• Innovate and Differentiate• Readmission Tool Kits

• Providers Must Become Certified to Stand Out• Providers Must Become Certified to Stand Out• Fellow in Readmission Prevention• Certified Readmission Prevention Partner program

• Outreach to your referral partners consistently • On the 15th of each month: Share the tools above!

My Legacy: Going Purple for My Mom

Values

• PassionPassion

• Empathy

• Fight

• Use your giftsy g

• Legacy

Go Purple to fight Alzheimer’s Disease!

Josh Luke, Ph.D., FACHE• Founder, National Readmission Prevention Collaborative• Interim CEO, Memorial Hospital of GardenaC O, p G• Executive Faculty, CSU Long Beach• Author: Readmission Prevention: Solutions Across the Provider

ContinuumJoshLuke@NationalReadmissionPrevention.com

NationalReadmissionPrevention.com