The Playbook for Partnering with Hospitals in an Era of Outcomes-

Based Payment Reform

Kenneth H. Cohn, M.D., MBA, Facilitator CEO, HealthcareCollaboration.com

ken.cohn@healthcarecollaboration.com http://healthcarecollaboration.com

978-834-6089

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Overview

• What hospitals look for in long-term care partners

• Minimizing readmissions (an introduction)

• Optimizing ecosystem management

• A ten-step guide for partnering with hospitals

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I. What Hospitals Seek in Long-Term Care Providers

• Aligned mission, vision, and values

• Commitment to quality and patient safety

• Customized, patient-focused experiences

• Risk-sharing that improves patient care

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Aligned Mission, Vision, and Values

• Find ways to participate in joint conferences and strategic planning retreats

• Use social media to build bridges

• Use more traditional types of social networking to open up doors (Board member, spouse contacts)

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Customized, Patient-Focused Experiences

• Demonstrate timely, seamless transitions

• Deliver on promises

• Target your services to hospitalists and engaged healthcare professionals who understand the value that you provide

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Risk-Sharing that Improves Patient Care

• Move from risk-shifting to sharing via common vision and operational platform

• Use similar vendors (e.g. group purchasing)

• Demonstrate ways that your niche adds value (e.g. cognitive assessment to decrease readmissions)

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Commitment to Quality and Patient Safety

• Demonstrate commitment with results and transparency

• Use stories as well as numerical data

• Measure and showcase improvement in Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) scores, (http://hcahpsonline.org/home.aspx)

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HCAHPS: An Introduction

• Standardized survey in use since 2006 to measure patients’ perspectives of hospital care to permit hospital comparisons

• Increases transparency http://www.medicare.gov/hospitalcompare/search.aspx

• Creates incentives for hospitals to improve care

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The Three HCAHPS Categories

• Composite: Nursing (1-3), Physician (5-7), Responsiveness (4,11), Pain Management (13,14), Medicines (16,17), Discharge (19,20)

• Individual: Cleanliness (8), Noise (9)

• Global: Overall Rating (21), Willingness to Recommend (22)

http://hcahpsonline.org/surveyinstrument.aspx

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II. Dealing with Re-admissions

Caveats:

• What drives 30-day readmissions may be outside of providers’ control. Track day 3-7 readmission rate

• There are better ways to improve discharge planning and care coordination than focusing on readmissions e.g. Geisinger warrantees following cardiac/ ortho surgery

• Focus on decreasing readmissions can worsen outcomes if too narrowly focused Maintain quality and safety improvement programs, especially those that build a culture of quality & safety

Joynt, KE, Jha AK. 30-day Readmissions: Truth and Consequences. [nejm.org, downloaded 4/1/12]

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Rationale for Improving Care Transitions

• 17.6% of Medicare admissions are readmissions • Estimated cost $15 billion • 80% of readmission costs deemed potentially

preventable

Moral: The setting in which care occurs is largely irrelevant for patients and their families.

The clinical outcomes matter to all of us. Patient Handoffs: Effectively Managing Care Transitions. 2009.

Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 6.

Hackbarth GM et al. 2007. Report to the Congress: Medicare Payment Policy. Washington: Medicare Payment Advisory Commission.

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Context

• Statewide 30-day hospital readmission rates vary from 13% (VT) to 24% (LA)

• Nationwide analysis of Medicare claims found that half of patients readmitted to the hospital within 30 days following discharge had no intervening physician visit

• 70% of surgical patients readmitted to the hospital within 30 days following discharge were readmitted with a medical diagnosis

• Up to 70% of patients have problems with medications within the 1st week of discharge

Naylor M et al. 2005. Opportunities for improving post-hospital home medical management among older adults. Home Healthcare Services Quarterly. 24(1):101-122.

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St. Lukes Hospital, Cedar Rapids: Case Report

Used variety of techniques to decrease readmission rate for patients with congestive heart failure (CHF), including:

– Involving family caregivers and community providers in predicting home-going needs

– Reconciling medications for discharge

– Scheduling a home-care or office visit within 48 hours of discharge

– Using Teach-Back to assess the patient’s and family’s understanding of self-care expectations

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Teach-Back

• Method to present information, requesting patients and caregivers to restate instructions in their own words as heard

• Questions used for patients with CHF included

– What is the name of your water pill?

– What amount of weight gain should you report to your doctor?

– What foods and condiments should you avoid?

– What symptoms should you report to your doctor?

Patient Handoffs: Effectively Managing Care Transitions. 2009. Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 9.

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Lessons Learned

• Interventions decreased readmission rate from 12% to 3-9% per month

• Widespread variation resulted from patients near end of life but unwilling to discuss palliative care options

• Has stimulated care team to discuss end-of-life options proactively

• Palliative care practitioners included as ongoing members of care team

• Need to address cognitive issues in caregivers as well as patients

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Stop and Watch

If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift:

• Seems different than usual

• Talks or communicates less than usual

• Overall needs more help than usual

• Participated in activities less than usual

• Ate less than usual (Not because of dislike of food)

• N Drank less than usual

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Stop and Watch, II

• Weight change

• Agitated or nervous more than usual

• Tired, weak, confused, or drowsy

• Change in skin color or condition

• Help with walking, transferring, toileting more than usual

http://interact2.net/docs/Communication%20Tools/Early_Warning_Tool_(StopWatch)c.pdf

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Ten Steps to Decrease Re-admissions

• Early assessment of discharge medications and ability to comprehend discharge instructions

• Enhanced patient and caregiver instruction based on preferred learning style and understanding of condition(s)

• Timely and complete communication among physicians, nurses, and allied healthcare professionals well before date of discharge

• Telephone call from nurse within 24 hours of discharge to assess and confirm understanding of follow-up plan

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Ten Steps, II

• Post-acute follow-up within 72 hours with a nurse and/or physician for all patients at risk for readmission Bisognano M, Boutwell A. 2009. Improving transitions to reduce readmissions. Frontiers of Health Services Management. Chicago: Health Administration Press; 25(3), 7.

• Referral for post-acute care services as soon as likely to be needed (www.Curaspan.com)

• Sensitive, appropriate advanced care discussions and planning with patient and family

• Remote monitoring

• Streamlined, systematized transfer processes between facilities that work together frequently

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Ten Steps, III

• Improved medication management, especially with regard to anticipation, avoidance, and management of drug interactions with prescription and non-prescription medications

Bradley EH, et al. Contemporary Evidence about Hospital

Strategies for Reducing 30-day Readmissions: A National Study. J Am Coll Cardiol. 2012;60(7):607-614. doi:10.1016/j.jacc.2012.03.067.

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Readmission Summary

• Unnecessary readmissions are now seen as defects to be eliminated, much like “Never Events”

• The boundaries between physicians, hospitals, and post-acute care facilities are blurring

• Transcending silos can improve the quality and safety of patient care

• Start now and be proactive to differentiate your clinical outcomes

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III. Ecosystem Management

• If your organization is innovative, but your partners do not share in your success, your organization's success will be short-lived

• When partners in an ecosystem do well, innovation flourishes

• Population health and wellness require viable ecosystems

Adner R. The Wide Lens: A New Strategy for Innovation. NY: Penguin Books. 2012

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Ecosystem Value Blueprint I

• Who needs to adopt the innovation for your organization to be successful?

• What does your organization need to deliver?

• What inputs do you need from suppliers?

• Who stands between your organization and the end-consumer?

Adner R. The Wide Lens: A New Strategy for Innovation. NY: Penguin Books. 2012, 85-87.

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Ecosystem Value Blueprint II

• What needs to happen for your intermediaries to move your innovation to consumers?

• Identify the risks in your ecosystem that your intermediaries, complementors, and suppliers must bear

• For those partners whose status is not green-lighted, work to understand the reason and to identify a viable solution

• Update your blueprint at least monthly or more rapidly depending on the pace of change

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IV. Ten-Step Approach to Partnering with Hospitals

• Reach out to one (or two) hospital(s) where you have a relationship(s)

• Connect at multiple levels: case mgr./ DC planner, utilization review, hospitalist, nurse mgr., C-suite, Board

• Partner on pilot projects that produce wins for hospital, assisted living community, and residents (e.g. reducing readmissions within the first week after transfer, web-based discharge planning)

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Partnering with Hospitals III

• Make it easy for your strategic partners to know you

– Hotline or designated connection number

– Informative, interactive website: about us, history, awards & recognition, comments from residents and patients (video)

– Thought leadership: blog, newsletter, water-cooler links to your facility that add value, repurposing content

– Social media, esp. LinkedIn

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Partnering with Hospitals III

• Demonstrate support at highest levels at kick-off of new pilot project

– Set stretch goals

– Use plan, do study, act (PDSA) framework

– Limit planning to 30 days, execution to 120-day cycles

– Make deadlines public

– Use a dashboard to highlight barriers to progress (red-green light)

– Summarize goals, actions, learning, and next steps on Intranet to aid others in your organization

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Partnering with Hospitals IV

• Strengthen your network(s) by attending local, regional, and national conferences with hospital leaders (eg. ACHE Congress March 24-27, 2014 or ACHE cluster seminars approved for NAB credit, http://ache.org/NAB )

• Form an interdisciplinary group that meets quarterly to move from us vs. them to we

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Partnering with Hospitals V

• Provide value: V= Quality/ Price – Focus on quality, as measured by people you

serve – Use checklists to improve safety

http://www.nejm.org/doi/pdf/10.1056/NEJMsa0810119 http://www.cdc.gov/ncipc/pub-res/toolkit/Falls_ToolKit/ DesktopPDF/English/booklet_Eng_desktop.pdf

– Eliminate waste Quality = Appropriateness x (Outcome + Service)/ Waste

chris.backous@vmmc.org, www.VirginiaMasonInstitute.org 206-341-1654

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Some Sources of Waste

• Duplicate laboratory testing and imaging

• Time searching for frequently used items

• Rework from not doing something correctly the first time

• Unnecessary patient transfers

• Arbitrary individual caretaker variation

• Fighting fires rather than preventing them

National Priorities Partnership, http://nationalprioritiespartnership.org/aboutnpp.aspx

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Partnering with Hospitals VI

• Give the HCAHPS survey to your residents twice annually and publish results on your Intranet:

(http://hcahpsonline.org/surveyinstrument.aspx)

– After a year, publish the results on your Internet and in your annual report

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Partnering with Hospitals VII

• Celebrate all successes publicly in person and on Intranet and Internet

– Present results at local, regional, and national meetings

– Use abstract deadlines to sustain momentum

– View speed bumps as learning

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Conclusion

• We encounter different perspectives as a result of our training, care models, professional organizations, and the people we serve

• The pace of change and the need to balance the interests of different stakeholders make conflict inevitable

• Well-managed constructive conflict is a challenging but rewarding journey that can be a source of innovative, transformative ideas

• Long-term relationships can become a core competency, with competitive advantage accruing to those who do it well

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Thanks

• Maribeth Bersani, mbersani@alfa.org Senior Vice President Public Policy, ALFA 703-562-1180

• Dr. Jennifer Daley, jenniferdaleymd@gmail.comalfa.org

• Neal Peyser, nealpeyser@att.net President Healthcare Continuum Advisors, 708-829-7054

• Ron Tamol, rtamol@comsllc.com VP Southern Region, COMS Interactive LLC 704-661-150004-661-1500

• Stephanie Handelson, Eric Bartkowiak, Kristie Kronk, Loriann Putzier