1

Post Acute Care Integration:Post Acute Care Integration:Post Acute Care Integration:Post Acute Care Integration:Post Acute Care Integration:Post Acute Care Integration:Connecting the Continuum for a Connecting the Continuum for a

ValueValue--Based WorldBased World

Post Acute Care Integration:Post Acute Care Integration:Connecting the Continuum for a Connecting the Continuum for a

ValueValue--Based WorldBased WorldOctober 31, 2013October 31, 2013

Renée Coughlin PT, DPT, MHSRenée Coughlin PT, DPT, MHSCindy Vunovich RN, BSN, MSMCindy Vunovich RN, BSN, MSMShane Woodley RN, MSN, MBAShane Woodley RN, MSN, MBA

ObjectivesObjectivesObjectivesObjectives1.1. Identify three quality standards that Health Identify three quality standards that Health

Systems and Accountable Care Systems and Accountable Care Organizations (ACOs) will be held to under Organizations (ACOs) will be held to under g ( )g ( )the Affordable Care Act (ACA)the Affordable Care Act (ACA)

2.2. Describe how these quality standards aim to Describe how these quality standards aim to align incentives, and the value partnering align incentives, and the value partnering with home health providers brings to the with home health providers brings to the equationequation

3.3. Discuss three key programming Discuss three key programming considerations for home health providers to considerations for home health providers to consider in an effort to redefine themselves consider in an effort to redefine themselves as providers of solutions, rather than as providers of solutions, rather than vendors of visitsvendors of visits

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Cleveland Clinic EnterpriseCleveland Clinic EnterpriseCleveland Clinic EnterpriseCleveland Clinic Enterprise

Since 1921A Unique Model of Care

Since 1921A Unique Model of Care

• Four doctors share a vision- Non-profit, physician-led

group practice

- Collaboration across disciplines

FRANK E. BUNTS, MDFRANK E. BUNTS, MD GEORGE CRILE SR., MDGEORGE CRILE SR., MD

- All physicians are salaried

- Patient-centered mission JOHN PHILLIPS, MDJOHN PHILLIPS, MDWILLIAM E. LOWER, MDWILLIAM E. LOWER, MD

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Cleveland Clinic TodayCleveland Clinic Today

• 44,000 caregivers

• 5 million total visits

• 145,000 hospital admissions

• 3 000 physicians• 3,000 physicians & scientists

• 1,800 residents & fellows

Cleveland Clinic Cleveland Clinic LocationsLocationsCleveland Clinic Cleveland Clinic LocationsLocations

&

9 Hospitals in Northeast Ohio

27 Specialty Institutes

16 Family Health Centers

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2012 Cleveland ClinicU.S.News & World Report2012 Cleveland ClinicU.S.News & World Report

• #1 in Cardiology & Heart Surgery;1 in Cardiology & Heart Surgery; 18th consecutive year

• #1 in Nephrology• #1 in Urology• 10 specialties ranked in Top 3

R k d i 14 i lti• Ranked in 14 specialties• Cleveland Clinic Children’s ranked

in all 10 pediatric specialties

Fully Integrated Home Care Servicesin the Cleveland Clinic Health System

CCFCCFVentures Meridia

CCHCS

MarymountFairview

Lakewood

5

Home Care Services

SCOPE OF OPERATIONS

Transitional Care

Center for Connected CareCenter for Connected Care

Home Care Services

• Medical Care at Home: physician house- call program / IAH

• Home Health Agency• Home Infusion Pharmacy and

Respiratory Therapy

P t A t K l dH i

Transitional Care

• SNF/LTAC ‘ Connected Care Units’• Disease- based transitional care

programs – Heart Care at Home• Relationships with PAC providers

Post Acute Knowledgeand Solutions Center

• Technology: EMR integration• Distance Health• Payor Contracting • Scholarship / Outcomes Research

Hospice

• At-home Hospice• Palliative care• End of Life community care

Center for Connected CareCenter for Connected CareCenter for Connected CareCenter for Connected Care

TODAY’s Census:• 2,152 Home Health• 272 Hospice at Home• 900 Home Infusion Pharmacy• 214 Medical Care at Home (IAH)• 135 IRF and SNF inpatients•>10,000 RT patients

13,523 Patients

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6

A Tale of Home CareA Tale of Home CareA Tale of Home CareA Tale of Home Care

It is theIt is the

Best Best of Times of Times

WorstWorstof Times of Times

The Future of US HealthcareThe Future of US HealthcareThe Future of US HealthcareThe Future of US Healthcare

• Starts with understanding and owning our history…

Click here to play video

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Key PointsKey PointsKey PointsKey Points

•• 50 million uninsured / 25 million under insured50 million uninsured / 25 million under insured50 million uninsured / 25 million under insured50 million uninsured / 25 million under insured•• 40 million > 65y/o40 million > 65y/o•• 80 million seniors in 204080 million seniors in 2040•• 5% of population use 49% of healthcare 5% of population use 49% of healthcare

resourcesresources•• Payment cuts (mediPayment cuts (medi--medi, commercial)medi, commercial)

Broken System supported by the largest per Broken System supported by the largest per capita health care spending in the worldcapita health care spending in the world

Affordable Care ActAffordable Care ActAffordable Care ActAffordable Care Act

•• Enacted March 23, 2010 Enacted March 23, 2010 Designed to:Designed to:•• Designed to:Designed to:-- Improve Improve accessaccess for 32 million lacking for 32 million lacking

insurance coverageinsurance coverage-- Improve Improve quality quality of Medicare servicesof Medicare services-- Support Support innovationinnovation

Establish neEstablish ne pa ment modelspa ment models-- Establish new Establish new payment modelspayment models-- Align Align payment models with provider costpayment models with provider cost-- Strengthen Strengthen program integrityprogram integrity-- Improve Improve financial footing of Medicare financial footing of Medicare modelmodel

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ACA ACA –– Breaking it DownBreaking it DownACA ACA –– Breaking it DownBreaking it Down

Quality Standards: 4 Key AreasQuality Standards: 4 Key Areas1.1. Patient / Caregiver care Patient / Caregiver care

experience (7 measures)experience (7 measures)2.2. Care coordination / Patient Care coordination / Patient

safety (6 measures)safety (6 measures)3.3. AtAt--risk population / Frail elderlyrisk population / Frail elderly4.4. Preventive health (8 measures)Preventive health (8 measures)

Patient / Caregiver ExperiencePatient / Caregiver ExperiencePatient / Caregiver ExperiencePatient / Caregiver ExperienceHCAHPSHCAHPSHHCAHPSHHCAHPSHHCAHPSHHCAHPS

-- Hospital / Home Health Consumer Hospital / Home Health Consumer Assessment of Healthcare Providers Assessment of Healthcare Providers and Systemsand Systems

Quality Standard 1

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Care Coordination and SafetyCare Coordination and SafetyCare Coordination and SafetyCare Coordination and Safety

•• All Cause ReadmissionsAll Cause Readmissions•• Medication Reconciliation Post Medication Reconciliation Post

Hospital DischargeHospital Discharge•• Falls Risk Assessment Screening Falls Risk Assessment Screening

and Interventionand Intervention

Quality Standard 2

At Risk Population/Frail ElderlyAt Risk Population/Frail ElderlyAt Risk Population/Frail ElderlyAt Risk Population/Frail Elderly

•• Monitoring, screening, educating, Monitoring, screening, educating, d i fl id i fl iand influencingand influencing

-- DiabetesDiabetes-- HypertensionHypertension-- Ischemic Vascular DiseaseIschemic Vascular Disease-- Heart FailureHeart Failure-- Coronary Artery DiseaseCoronary Artery Disease

Quality Standard 3

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Accountable Care OrganizationsAccountable Care OrganizationsAccountable Care OrganizationsAccountable Care Organizations

•• By the end of Jan 2013, a total of 428 By the end of Jan 2013, a total of 428 ACO i i tACO i i tACOs were in existenceACOs were in existence

•• More than 40% are in only 5 statesMore than 40% are in only 5 states•• 9 of 32 Pioneer ACOs (28%) may 9 of 32 Pioneer ACOs (28%) may

leave the programleave the programDon’t wait to see if your referringDon’t wait to see if your referring•• Don’t wait to see if your referring Don’t wait to see if your referring providers will be part of an ACO to providers will be part of an ACO to make changes….becausemake changes….because

All Health Systems, Hospitals and All Health Systems, Hospitals and ACOs are Subject to:ACOs are Subject to:

All Health Systems, Hospitals and All Health Systems, Hospitals and ACOs are Subject to:ACOs are Subject to:

•• ValueValue--Based PurchasingBased PurchasingValueValue Based PurchasingBased Purchasing•• ReadmissionReadmission•• Patient SafetyPatient Safety•• Patient SatisfactionPatient Satisfaction•• Clinical IntegrationClinical Integration•• TechnologyTechnology•• Case ManagementCase Management•• Care TransitionsCare Transitions

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Aligning Incentives…Aligning Incentives…Aligning Incentives…Aligning Incentives…

•• MarketMarket--based Incentivesbased Incentives•• MarketMarket--based Incentivesbased Incentives•• Provider IncentivesProvider Incentives•• Patient IncentivesPatient Incentives

Rewarding Quality Through Rewarding Quality Through MarketMarket--Based IncentivesBased Incentives

Rewarding Quality Through Rewarding Quality Through MarketMarket--Based IncentivesBased Incentives

• Quality reporting• Effective case management• Care coordination• Chronic disease management• Medication and care compliance• Medication and care compliance

initiatives• The medical home model

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Provider IncentivesProvider IncentivesProvider IncentivesProvider Incentives•• Bundled payment strategiesBundled payment strategies

Sh d i k/ h d iSh d i k/ h d i-- Shared risk/shared savingsShared risk/shared savings•• Penalties/RewardsPenalties/Rewards

-- Pay for Performance bonusesPay for Performance bonuses-- Readmission penaltiesReadmission penalties-- Bonus for Health IT implementationBonus for Health IT implementation

•• Reference pricing (fixedReference pricing (fixed--dollar dollar coverage)coverage)

Patient IncentivesPatient IncentivesPatient IncentivesPatient Incentives•• Choose highChoose high--performing physicians and performing physicians and

hospitalshospitalspp•• CoCo--pay/copay/co--insurance reductions for using insurance reductions for using

decisiondecision--support system for elective support system for elective proceduresprocedures

•• Participation in care management or Participation in care management or coaching to reduce health riskscoaching to reduce health riskscoaching to reduce health riskscoaching to reduce health risks

•• Preventive screening compliancePreventive screening compliance•• ConditionCondition--specific incentives to reduce specific incentives to reduce

financial barriers to medication adherence financial barriers to medication adherence and encourage condition managementand encourage condition management

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The Future is HereThe Future is HereThe Future is HereThe Future is Here

•• Health System success will be Health System success will be defined by those who attain the Triple defined by those who attain the Triple AimAim

Improve the Improve the Health of Health of

the Populationthe Population

Improve Improve AffordabilityAffordability

(Reducing Costs)(Reducing Costs)

Improve Improve the Experiencethe Experienceof the Individualof the Individual

Care / Health / CostCare / Health / CostCare / Health / CostCare / Health / Cost

ChoicesChoicesChoicesChoices

•• Home Health providers are faced with Home Health providers are faced with two posttwo post acute business strategies:acute business strategies:two posttwo post--acute business strategies:acute business strategies:-- Vendor of ServicesVendor of Services-- Specialized solutions providerSpecialized solutions provider

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Post-Acute Care Value ContinuumVendor to those accountable for patients’ costs

Provider partnering to solve the problems of the costliest

patients

Goal: Shift to the Right

Valuation:3X - 5X EBIDA

Valuation:5X-13X EBIDA

Wyatt and Matas, Consultants, 2012

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Center:Center: Specialized Solution Specialized Solution ProviderProvider

Center:Center: Specialized Solution Specialized Solution ProviderProvider

•• BrandingBrandingC T iti / C di ti / I tiC T iti / C di ti / I ti•• Care Transitions / Coordination / InnovationCare Transitions / Coordination / Innovation-- Heart Care @ HomeHeart Care @ Home-- Connected CareConnected Care-- Go Right HomeGo Right Home-- Care Path DevelopmentCare Path Development

Care Delivery / Compensation ModelsCare Delivery / Compensation Models-- Care Delivery / Compensation ModelsCare Delivery / Compensation Models-- Bundled PaymentsBundled Payments

Triple AimResponseACA Quality Standards

Center for Connected CareCenter for Connected CareCenter for Connected CareCenter for Connected CareA new center focused on value-based home, transitional and post-acute care

HOSPITAL HOME FACILITY

home, transitional and post acute care

Disease-based transitional care programs

Excellence in home-based care: nursing, rehab, physician, pharmacy,

Innovative SNF and LTAC programs

Novel relationships ith local andp y,

respiratory, hospice and palliative medicine

with local and national providers

Reporting to the Chief of Medical Operations, the Center aims to be a resource and partner for Institutes and Hospitals as they carry out ‘connected’ care throughout the continuum

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Center for Connected CareCenter for Connected CareCenter for Connected CareCenter for Connected Care

•• The mission of the Center forThe mission of the Center for•• The mission of the Center for The mission of the Center for Connected Care is tConnected Care is to provide o provide worldworld--class transitional care class transitional care services, connecting patients services, connecting patients to care at home and atto care at home and atto care at home and at to care at home and at communitycommunity--based postbased post--acute acute facilitiesfacilities

PatientPatient--Centered VisionCentered VisionPatientPatient--Centered VisionCentered Vision

Cl l d Cli i ill iCl l d Cli i ill i•• Cleveland Clinic will remain at Cleveland Clinic will remain at your side as you transition from your side as you transition from the hospital back to the the hospital back to the community (home or facility) community (home or facility) ––safer faster and with fewersafer faster and with fewersafer, faster, and with fewer safer, faster, and with fewer complications.complications.

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Connected CareConnected CareConnected CareConnected Care

Heart Care at HomeHeart Care at HomeTransitional Care ModelTransitional Care Model

Heart Care at HomeHeart Care at HomeTransitional Care ModelTransitional Care Model

Transitional • Identifies patient • Nurse Practitioner Transitional Coach

(Inpatient)

p• Introduces program• Begins coaching

Installer

• Visits at home• Coaches• Installs tele-health

equipment

oversight

• Outcomes tracking

• Physician input

equipment

Transitional Coach

(Outpatient)

• Monitoring• Telephonic coaching• Care coordination• Tracks outcomes

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•• CCHS discharges CCHS discharges ~22 000 patients~22 000 patients

Connected Care UnitsConnected Care UnitsConnected Care UnitsConnected Care Units

22,000 patients 22,000 patients annually to over 800 annually to over 800 different SNFsdifferent SNFs

•• Less than 10% go to Less than 10% go to CCHS SNFs CCHS SNFs (Euclid, (Euclid, Lakewood, Fairview)Lakewood, Fairview)

“Trap Door” Reality“Trap Door” Reality“Trap Door” Reality“Trap Door” Reality

•• 40% of patients 40% of patients experience multiple experience multiple care transitionscare transitions

Why focus on SNF?Why focus on SNF?Why focus on SNF?Why focus on SNF?

•• Variable Quality: 25Variable Quality: 25--30%+ re30%+ re--admit ratesadmit ratesVariable Quality: 25Variable Quality: 25 30% re30% re admit ratesadmit rates

•• Fragmented: over 12,400 SNF beds in Fragmented: over 12,400 SNF beds in Cuyahoga County (overCuyahoga County (over--bedded by 1,800)bedded by 1,800)

•• Costly: estimated $175M in SNF cost annually Costly: estimated $175M in SNF cost annually t f CCHS tt f CCHS t t ti tt ti tto payors for CCHS postto payors for CCHS post--acute patientsacute patients

•• ValueValue--based Post Acute model targets based Post Acute model targets significant improvement in SNF quality / costsignificant improvement in SNF quality / cost

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Connected Care UnitsConnected Care UnitsConnected Care UnitsConnected Care UnitsCC Staff

Physicians (0.5 FTE) and Mid-

CC CCU“Virtual Unit”

at SNF(20-30 beds)

EPIC Medical Record

Integration

)Levels (1.0

FTE)

Disease-specific care

paths and ‘Distance Health’Health

Accountable for readmits,

outcomes, and VALUE

Joint Quality Committee

What is Difference Between CCF What is Difference Between CCF CCU Model and Usual SNF Care?CCU Model and Usual SNF Care?What is Difference Between CCF What is Difference Between CCF CCU Model and Usual SNF Care?CCU Model and Usual SNF Care?Usual SNF Care Today

F t d d i blF t d d i blCCU Model for TomorrowT t l l t i i t tiT t l l t i i t ti•• Fragmented and variable Fragmented and variable

documentationdocumentation

•• Physician business based Physician business based on volume of visits and on volume of visits and stipends / facility business stipends / facility business based on volume of per based on volume of per diem paymentsdiem payments

•• Total electronic integration Total electronic integration of documentation across of documentation across venuesvenues

•• Practice and facility Practice and facility business based on value business based on value to patient / payersto patient / payers

•• Technology increasesTechnology increases•• Often disconnected from Often disconnected from

subsub--specialty care teams specialty care teams in hospitalin hospital

•• Variation in clinical Variation in clinical practice and incentivespractice and incentives

•• Technology increases Technology increases access to subaccess to sub--specialistsspecialists

•• Reduced variability, Reduced variability, increased care path increased care path adherence, aligned adherence, aligned incentives across venuesincentives across venues

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CCU RelationshipCCU RelationshipCCU RelationshipCCU Relationship

•• Shared ResponsibilityShared Responsibility•• Shared ResponsibilityShared Responsibility•• Joint Quality CommitteeJoint Quality Committee

-- Administrative & Clinical Administrative & Clinical RepresentationRepresentation

•• Collaborative Review of OutcomesCollaborative Review of Outcomes•• Education and Implementation of Education and Implementation of

EvidenceEvidence--based Practicebased Practice

L dh t M f i ld

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 90I 90I 90I 90I 90I 90I 90I 90I 90

Che

Gates Mills

Wicklif f e

Bratenahl

Collinwood

East Clev eland

Euclid

South Euclid

Noble

Richmond Hts

Connected Care Units

Garf ield Hts

Ly ndhurst-May f ield

I 480I 480I 480I 480I 480I 480I 480I 480I 480

I 71I 71I 71I 71I 71I 71I 71I 71I 71

I 90I 90I 90I 90I 90I 90I 90I 90I 90 I 77I 77I 77I 77I 77I 77I 77I 77I 77

I 480I 480I 480I 480I 480I 480I 480I 480I 480

US Hwy 422

US Hwy 422

US Hwy 422

US Hwy 422

US Hwy 422

US Hwy 422

US Hwy 422

US Hwy 422

US Hwy 422

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 271

Chagrin Falls

North Olmsted

No

Clev eland

Newburgh/Willow

Univ ersity Cir

Lakewood

Rocky Riv er

Clev eland Hts

Shaker Hts Beachwood

Fairv iew Park Warrensv ille Hts

Parma Hts Parma

Maple Heights

Bay Village

Brook Park

Brookly n

Westlake

B df d

Villa St. Joseph

Kindred FairhillLakewood SNF Menorah Park

Wellington Place

Bradley Bay Montefiore

Aurora

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 271

I 77I 77I 77I 77I 77I 77I 77I 77I 77I 7

1I 7

1I 7

1I 7

1I 7

1I 7

1I 7

1I 7

1I 7

1Berea

Columbia Station

MacedoniaNorthf ield

Twinsburg

Parma Hts

Middleburg HtsIndependence

North Roy alton

Parma

Strongsv ille

Olmsted Falls

Solon

Brecksv ille

Bedf ord

Broadv iew Heights

Specific Facilities Being Engaged Based on Quality, Interest, Current Collaboration with CCF, Practitioner Availability, Strategic Factors

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Target Patients for CCUTarget Patients for CCUTarget Patients for CCUTarget Patients for CCU•• Post acute Main Campus SNF patients without a Post acute Main Campus SNF patients without a

community PCP who provides SNF carecommunity PCP who provides SNF care

•• Key institute service lines:Key institute service lines:-- Heart Failure and Heart SurgeryHeart Failure and Heart Surgery-- Pneumonia and COPDPneumonia and COPD-- Stroke and NeurosurgeryStroke and Neurosurgery-- Joint Replacement / Hip FractureJoint Replacement / Hip Fracture

•• PayorPayor--driven models with ‘shared savings’driven models with ‘shared savings’-- Traditional Medicare Readmission RiskTraditional Medicare Readmission Risk-- Employee Health PlanEmployee Health Plan-- Medicare Advantage Risk ContractsMedicare Advantage Risk Contracts

ReadmissionsReadmissionsReadmissionsReadmissions

Source: ECIN/Readmission Report, Jan-June 2013 top 50 placed providers

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Care Delivery ModelCare Delivery ModelCare Delivery ModelCare Delivery Model

Care Delivery ModelCare Delivery ModelHow did we get started?How did we get started?

Care Delivery ModelCare Delivery ModelHow did we get started?How did we get started?

•• Industry ChallengesIndustry Challenges-- Reimbursement changes & recovery auditsReimbursement changes & recovery auditsReimbursement changes & recovery auditsReimbursement changes & recovery audits-- Regulatory changes Regulatory changes -- Call for transitional and disease management care Call for transitional and disease management care -- FragmentationFragmentation-- Accountability for value, outcomes, cost reductionAccountability for value, outcomes, cost reduction-- Increasing consumers / decreasing providersIncreasing consumers / decreasing providers

•• Center ChallengesCenter Challenges-- Limited direct care accountability for outcomesLimited direct care accountability for outcomes-- Capacity managementCapacity management-- Ability to monitor and maintain performance while Ability to monitor and maintain performance while

building quality and reducing costbuilding quality and reducing cost-- Employee engagementEmployee engagement

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Current ChallengesCurrent ChallengesBottom LineBottom Line

Current ChallengesCurrent ChallengesBottom LineBottom Line

Th h ll i H C th tTh h ll i H C th tThere are challenges in Home Care that can There are challenges in Home Care that can negatively impact patient care, financial & negatively impact patient care, financial & clinical outcomes, job satisfaction, clinical outcomes, job satisfaction, effectiveness of staff.effectiveness of staff.

Change was essential

Fundamentally transform the system to make it more Fundamentally transform the system to make it more accountable, sustainable, and patient care focusedaccountable, sustainable, and patient care focused

Measuring SuccessMeasuring SuccessMeasuring SuccessMeasuring Success

•• Demonstrate improved quality of work Demonstrate improved quality of work life and effectiveness of care managerslife and effectiveness of care managers-- Allow more time for care planning and Allow more time for care planning and

coordination activities. Focus on performance coordination activities. Focus on performance rather than visitsrather than visits

-- Provide staff with increased authority and Provide staff with increased authority and accountability for achieving optimal patientaccountability for achieving optimal patientaccountability for achieving optimal patient, accountability for achieving optimal patient, quality, and financial outcomesquality, and financial outcomes

-- Improve communication & collaborationImprove communication & collaboration-- Decrease unpredictability in the dayDecrease unpredictability in the day-- Improve employee engagementImprove employee engagement

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Measuring SuccessMeasuring SuccessMeasuring SuccessMeasuring Success

•• Demonstrate optimal financial and Demonstrate optimal financial and ppquality outcomesquality outcomes-- Ensure effective care planning Ensure effective care planning -- Ensure accurate and timely completion of Ensure accurate and timely completion of

documentation (OASIS)documentation (OASIS)-- Ensure productivity standardsEnsure productivity standards-- Ensure patient satisfaction Ensure patient satisfaction –– high service high service

standardsstandards-- Eliminate unnecessary and duplicative workEliminate unnecessary and duplicative work

Where Did We Need to Go?Where Did We Need to Go?Where Did We Need to Go?Where Did We Need to Go?

•• Develop a care delivery/ compensationDevelop a care delivery/ compensationDevelop a care delivery/ compensation Develop a care delivery/ compensation model that would model that would successfullysuccessfully address address the needs of patients, management, and the needs of patients, management, and direct care staffdirect care staff

•• Develop an model that would demonstrate Develop an model that would demonstrate improved workflow processes and optimal improved workflow processes and optimal outcomesoutcomesoutcomesoutcomes

•• Develop an model that would Develop an model that would lay the foundation to support lay the foundation to support our futureour future

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Care Delivery ModelCare Delivery ModelCare Delivery ModelCare Delivery Model

Operational ChangesOperational ChangesCompensation ChangesCompensation ChangesCare Delivery ChangesCare Delivery Changes

StructureStructure

Care Delivery ModelCare Delivery ModelCare Delivery ModelCare Delivery Model

•• Operational ChangesOperational Changes-- Divided into smaller interdisciplinary Divided into smaller interdisciplinary

teams teams -- redistrictingredistricting-- Redefined the role of the Senior Redefined the role of the Senior

Clinician / Supervisor (SN, Therapy)Clinician / Supervisor (SN, Therapy)-- Revised scheduling guidelines toRevised scheduling guidelines to-- Revised scheduling guidelines to Revised scheduling guidelines to

give more ownership of schedule to give more ownership of schedule to the care managersthe care managers

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Care Delivery ModelCare Delivery ModelCare Delivery ModelCare Delivery Model

•• Compensation ChangesCompensation Changes-- Transition CM from per visit Transition CM from per visit

compensation to salarycompensation to salary•• Incorporate onIncorporate on--call and weekendscall and weekends•• AddAdd--on compensation for work above on compensation for work above

expected workloadexpected workload-- LPNs and select therapy staff remained LPNs and select therapy staff remained

hourlyhourly-- Weekend Staff remained per visitWeekend Staff remained per visit

Care Delivery ModelCare Delivery ModelCare Delivery ModelCare Delivery Model

•• Care Delivery ChangesCare Delivery Changes-- Increased focus on nonIncreased focus on non--visit based carevisit based care-- Increased focus on nonIncreased focus on non--visit based care visit based care

management / coordinationmanagement / coordination-- Move away from visits and move toward Move away from visits and move toward

more nonmore non--visit based management and visit based management and care plan oversightcare plan oversight

-- Emphasize case conferences / case load Emphasize case conferences / case load reviewreviewreview review

-- Leverage specialty services and Leverage specialty services and interdisciplinary collaborationinterdisciplinary collaboration

-- Develop enhanced performance Develop enhanced performance management, build transparency.management, build transparency.

27

Collaboration, Oversight, and Collaboration, Oversight, and ReviewReview

Collaboration, Oversight, and Collaboration, Oversight, and ReviewReview

•• Weekly Scheduling ConferenceWeekly Scheduling Conference•• Ongoing Scheduling OversightOngoing Scheduling Oversight•• Case Conferences & Case Load ReviewCase Conferences & Case Load Review

-- Clinical Risk Stratification Tool Clinical Risk Stratification Tool -- Financial & Utilization Tool Financial & Utilization Tool -- Tracer Visits & Chart AuditsTracer Visits & Chart Audits

•• Continue to develop key Continue to develop key competencies of effective care competencies of effective care managementmanagement

Maximize the role Maximize the role of the of the

Senior Clinician / Senior Clinician / SupervisorSupervisor

Maximize the role Maximize the role of the of the

Senior Clinician / Senior Clinician / SupervisorSupervisor

Performance ManagementPerformance ManagementPerformance ManagementPerformance Management

•• Employee EngagementEmployee EngagementEmployee EngagementEmployee Engagement•• Patient SatisfactionPatient Satisfaction•• Home Health Compare ScoresHome Health Compare Scores•• Financial OutcomesFinancial Outcomes•• ProductivityProductivity

•• Business DevelopmentBusiness Development•• Operational EfficiencyOperational Efficiency

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Performance ScorecardPerformance ScorecardPerformance ScorecardPerformance Scorecard

•• Patient SatisfactionPatient Satisfaction•• Clinical PerformanceClinical Performance•• Financial PerformanceFinancial Performance

SHPSHPSHPSHPSHPSHPAnalyzerAnalyzerHHCAHPSHHCAHPS

SHPSHPAnalyzerAnalyzerHHCAHPSHHCAHPS

Productivity ScorecardProductivity ScorecardProductivity ScorecardProductivity Scorecard

•• Direct CareDirect CareDirect CareDirect Care•• Indirect CareIndirect Care•• TravelTravel•• AdministrativeAdministrative•• UnavailableUnavailable

•• Case Load Case Load ActivityActivity

29

Identifying the AtIdentifying the At--Risk HH PatientRisk HH PatientIdentifying the AtIdentifying the At--Risk HH PatientRisk HH Patient

•• Challenge presented by size andChallenge presented by size and•• Challenge presented by size and Challenge presented by size and complexity of our active patient complexity of our active patient populationpopulation

•• 350350--400 Admissions weekly400 Admissions weekly•• ADC > 2100ADC > 2100•• Goal: develop a resource to focus Goal: develop a resource to focus

increased attention to the POC for our increased attention to the POC for our more complex patientsmore complex patients

Risk Stratification ToolRisk Stratification ToolRisk Stratification ToolRisk Stratification Tool

•• Report created to extract dataReport created to extract data•• Report created to extract data Report created to extract data routinely collected at SOC, ROC and routinely collected at SOC, ROC and Recertification from AllscriptsRecertification from Allscripts

•• Available early in the episode Available early in the episode –– 48 48 hours following the visithours following the visit

30

Financial / Utilization ToolFinancial / Utilization ToolFinancial / Utilization ToolFinancial / Utilization Tool

•• Active PatientsActive Patients•• Active PatientsActive Patients•• Length of StayLength of Stay•• Revenue & CostRevenue & Cost•• CMWCMW•• DiagnosisDiagnosis

Analyzer

DiagnosisDiagnosis•• UtilizationUtilization

Demonstrated ResultsDemonstrated ResultsDemonstrated ResultsDemonstrated Results-- Clinical Outcomes ImprovedClinical Outcomes Improved

Clinical Outcomes DeclinedClinical Outcomes Declined-- Clinical Outcomes DeclinedClinical Outcomes Declined-- Acute Care ReAcute Care Re--hospitalizationhospitalization-- Financial Outcome Financial Outcome -- CMWCMW-- LUPALUPA-- Capacity ManagementCapacity Management-- Employee SatisfactionEmployee Satisfaction-- Patient SatisfactionPatient Satisfaction

31

Bundled PaymentsBundled PaymentsBundled PaymentsBundled Payments

Rapid Recovery PostRapid Recovery Post--TJATJARapid Recovery PostRapid Recovery Post--TJATJA

•• CMS Bundled Payment InitiativeCMS Bundled Payment Initiative•• CMS Bundled Payment InitiativeCMS Bundled Payment Initiative-- DRG 469/470 Total Hip and Knee DRG 469/470 Total Hip and Knee

ArthroplastyArthroplasty•• Applicants offer a discount (2 or 3%) to Applicants offer a discount (2 or 3%) to

CMS for Medicare FFS patients onlyCMS for Medicare FFS patients only•• Incentive: If a savings is achieved Incentive: If a savings is achieved

about the proposed discount rate, CMS about the proposed discount rate, CMS retrospectively pays the difference backretrospectively pays the difference back

32

Type of BundleType of BundleType of BundleType of Bundle

•• PostPost acute period of 30 daysacute period of 30 days•• PostPost--acute period of 30 daysacute period of 30 days•• Discount rate of 3%Discount rate of 3%•• Applicable to Medicare FFS Applicable to Medicare FFS

patients as of January 1, 2013patients as of January 1, 2013

Considerations to Reduce CostConsiderations to Reduce CostConsiderations to Reduce CostConsiderations to Reduce Cost•• Reduce discharges to SNFReduce discharges to SNF•• Reduce home care costs for thoseReduce home care costs for thoseReduce home care costs for those Reduce home care costs for those

being discharged first to a SNFbeing discharged first to a SNF•• Reduce readmissionsReduce readmissions•• Shift appropriate home care volume to Shift appropriate home care volume to

Outpatient RehabOutpatient Rehab•• Shift more SNF volume to the hospitalShift more SNF volume to the hospital--

based SNFbased SNF•• Decrease SNF LOSDecrease SNF LOS

33

Rapid Recovery Program GoalsRapid Recovery Program GoalsRapid Recovery Program GoalsRapid Recovery Program Goals•• Early mobilization of postEarly mobilization of post--operative patients operative patients

(Day 0)(Day 0)•• Early return to activities of daily livingEarly return to activities of daily living•• Empower patients to actively participate in Empower patients to actively participate in

their POCtheir POC•• Improve patient experience throughout the Improve patient experience throughout the

continuumcontinuum•• Improved functional outcomes postImproved functional outcomes post--Improved functional outcomes postImproved functional outcomes post

operativelyoperatively•• Patient/caregiver education in the surgical Patient/caregiver education in the surgical

and periand peri--surgical processsurgical process

High Level ProcessHigh Level ProcessHigh Level ProcessHigh Level Process

I. PreI. Pre--OPOP II. AcuteII. Acute III. PostIII. Post--acuteacute

PrePre--op op Surgeon visitSurgeon visit

PrePre--op patient op patient educationeducation

PrePre--op op Surgeon visitSurgeon visit

PrePre--op patient op patient educationeducation

Early Early initiation of initiation of PT and OTPT and OT

Early Early initiation of initiation of PT and OTPT and OT

Home Care: Home Care: start of care start of care date set up date set up preoperativpreoperativelyely

Home Care: Home Care: start of care start of care date set up date set up preoperativpreoperativelyely

PrePre--op home op home exercisesexercisesPrePre--op home op home exercisesexercises

yyyy

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Predicting Patient Discharge Predicting Patient Discharge DispositionDisposition

Predicting Patient Discharge Predicting Patient Discharge DispositionDisposition

Euclid to CC Home CareEuclid to CC Home CarePopulation Overview Jan Population Overview Jan –– May 3012May 3012Euclid to CC Home CareEuclid to CC Home CarePopulation Overview Jan Population Overview Jan –– May 3012May 3012

•• 140 total joint/Birmingham hip referrals140 total joint/Birmingham hip referrals•• 140 total joint/Birmingham hip referrals 140 total joint/Birmingham hip referrals -- 108 from acute care108 from acute care-- 32 from IRF or SNF32 from IRF or SNF

•• One readmission for Ludwig AnginaOne readmission for Ludwig Angina-- Sent to Outpatient after Hospital DCSent to Outpatient after Hospital DCSent to Outpatient after Hospital DCSent to Outpatient after Hospital DC

35

CC Home Care to OutpatientCC Home Care to OutpatientJan Jan –– May, 2013May, 2013

CC Home Care to OutpatientCC Home Care to OutpatientJan Jan –– May, 2013May, 2013

•• 92 referred directly to OP with CCRST: 66%92 referred directly to OP with CCRST: 66%•• 92 referred directly to OP with CCRST: 66%92 referred directly to OP with CCRST: 66%•• 22 with no OP ordered by surgeon: 15.7%22 with no OP ordered by surgeon: 15.7%•• 12 chose OP outside of CCHS: 8.6%12 chose OP outside of CCHS: 8.6%•• 10 geographic outliers with “unknown” OP 10 geographic outliers with “unknown” OP

facility: 7.1%facility: 7.1%•• 3 refused OP therapy: 2.1%3 refused OP therapy: 2.1%•• Potential OP referrals placed with CCRST: Potential OP referrals placed with CCRST:

87.6%87.6%

Type of ProcedureType of ProcedureType of ProcedureType of Procedure

Birmingham Hip, 6%

Bilat TKA, 10%

THA, 20%

Hip, 6%10%

TKA, 64%

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Home Care ReferralsHome Care ReferralsEuclid Hospital Total, JanEuclid Hospital Total, Jan--MayMayHome Care ReferralsHome Care Referrals

Euclid Hospital Total, JanEuclid Hospital Total, Jan--MayMay

900

1,000 965

Home Care referrals

500

600

700

400

800

900

Cleveland Clinic Home Care

566

751

717

+28%

300

0

200

100

2012 2013

Other agencies185

248

Source: ECIN/Allscripts Care Management Opportunity reports

CC Home Care ReferralsCC Home Care ReferralsEuclid Hospital Total, Monthly TrendEuclid Hospital Total, Monthly Trend

CC Home Care ReferralsCC Home Care ReferralsEuclid Hospital Total, Monthly TrendEuclid Hospital Total, Monthly Trend

180

Cleveland Clinic Home Care referrals

80

160

80

100

120

1402013

2012

Source: ECIN/Allscripts Care Management Opportunity reports

0

60

40

20

AprilMarchFebJan May

37

Home Care ReferralsHome Care ReferralsEuclid Orthopedic Service, Q1Euclid Orthopedic Service, Q1Home Care ReferralsHome Care Referrals

Euclid Orthopedic Service, Q1Euclid Orthopedic Service, Q1

40

Average Home CarePlacements per Month

37

20

15

25

30

35

29

37

Cleveland ClinicHome Care

15

10

15

0

5 7 Other agencies

20132012

4

11

Source: ECIN/Allscripts Care Management Opportunity reports

QuestionsQuestionsQuestionsQuestionsQuestionsQuestionsQuestionsQuestions

Contact InformationContact Information

R é C hli PT DPT MHSR é C hli PT DPT MHS hl @ fhl @ fRenée Coughlin PT, DPT, MHS Renée Coughlin PT, DPT, MHS –– coughlr@ccf.orgcoughlr@ccf.orgCindy Vunovich RN, BSN, MSM Cindy Vunovich RN, BSN, MSM –– vunovic@ccf.orgvunovic@ccf.orgShane Woodley RN, MSN, MBA Shane Woodley RN, MSN, MBA –– woodles@ccf.orgwoodles@ccf.org

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