The Big PuzzleEvolving the Continuum of Care

Agenda

• Goal• Pre Acute Care• Intra Hospital Care• Post Hospital Care• Grading the Value of Post Acute Providers• Medicare Spending Per Beneficiary (Opportunity)• Focused Efforts with Major Joints and Pneumonia

patients• Implementation Strategy• Recommendations on Next Steps

Goal

• To provide excellence (quality/cost = value) in health care services for our community across the continuum of health care providers

Excellence in Care

Pre Hospital Care

• Provide a solid foundation of patient’s expectation of the care to be delivered Physician’s Office Joint Camp (3 day stay, with possible use of post-acute providers) Pre-admission evaluation and education (Reduce the potential

for SSI) HbgA1C MRSA screening Antibiotic use Obstructive Sleep Apnea Smoking Cessation Personal Hygiene

ER case manager assigning the patient status on all patients Readmission prevention process

Intra Hospital Care

• Foster a transparent flow of information exchange to coordinate care/discharge planning among hospital departments Case management/supportive/rehab

assessment/stratification of patients Develop plan for discharge or identify barriers Set consistent expectations for patient and family along

with clinical providers Seamless information from post-acute providers regarding

DAILY availability of beds, clinical ability, insurance coverage restrictions

Population Health / Chronic Disease

Post Hospital Care

• Supportive Care/Heart Failure Clinic (Advanced Illness Management)• Supportive Care – Post Discharge Navigator (phone calls):

• Patient population defining as high risk (LACE >11 Heart Failure, COPD, Diabetes, Stroke)

• Disease Prognosis is defined and communicated to patient/family prior to discharge

• Post discharge medication reconciliation• Heart Failure Clinic

• Provide follow up care prior to patients first visit to specialist (Heart Failure, COPD, Diabetes, Stroke)

• Contact Specialist/PCP/APN to coordinate intervention• Visits are made to LTACH/SNF facilities to complete the Heart Failure clinic

process to decrease readmissions• Education provided to diabetic/Heart Failure patients on managing

disease• Provide 30 day Diabetic Supply Kit to uninsured patients

Post Hospital Care

• Case Management Impact• Ensure patients have means of transportation• Provide medication assistance as needed• Ensure every patient has a follow up appointment with

PCP• Establish PCP for patients without a PCP• Follow up phone call for disease specific patients to ensure

appropriate use of medicine and follow up appointments• New onset cancer• Cardiac with LACE score <11• New respiratory conditions

• Follow up with Post Acute Agencies related to readmission to improve care

Post Hospital Care

• Create a network of health care providers which optimize the value to our patients and the care continuum Ensure patients receive the appropriate level of care Provide quality outcomes (metrics) Provide excellent patient satisfaction Maintain cost within US averages

Measures of Success with Our Community Partners• Objectives- Ensure Post-Acute Providers assist in

development of and ensure consistent application of clinical pathways to promote excellence in care across the continuum• Scoring will be based on nationally available data• Scorecards will be updated quarterly• Scorecards will be used to elevate the consistency of

care• Scorecards will be used to enhance public opinion of

post-acute providers• Scorecards will be utilized to educate patients,

families, and providers on outcomes• Goal is to be inclusive of all willing participants

LOSCost of

Care per Patient

Overall Rating

Re-admissions

Quality of Care

Skilled Nursing Home Scoring

Cost LOS

Overall Care from the HHA

(Patient Perception)

Re-admissions

% Better with

Functional Mobility

Home Health Scoring

Cost

Medicare Spending Per Beneficiary (Opportunity)• United Regional’s Post Acute Utilization versus US Average

(overall $6.0 million more)• Ortho related procedure ($2.8 million) Inpatient Rehab• Renal Failure ($704K) Inpatient Rehab• Stroke ($690K) Inpatient Rehab• Urinary Tract Infection ($348K) Inpatient Rehab• Pneumonia and Respiratory infection ($416K) Inpatient Rehab &

($492K) Skilled Nursing Facility• Cardiac Arrhythmia ($339K) inpatient Rehab ($361K) Skilled

Nursing Facility• Amputation ($808K) Long Term Acute Care

Focus Efforts on Specific Patient Populations• Selected Groups

• Major Joint Surgery (procedural)• Pneumonia (medical)

• Opportunities• Length of Stay

• Major Joints (4.0 actual vs. 3.1 Medicare GMLOS)• Pneumonia (3.5 actual vs. 3.0 Medicare GMLOS)

• Post-Acute Utilization• Major Joints

• ($2.8 m higher than US Average for Inpatient Rehab case)• Pneumonia

• ($416K higher than US Average for Inpatient Rehab)• ($492K higher than US Average for Skilled Nursing Facility)

Building Value with Major Joint Surgery DRG 470 – Major joint replacement of lower limb

URHCS National Average

Building Value with PneumoniaDRG 177, 178, 179, 193, 194, 195

URHCS National Average

Implementation Strategy

Physician Collaboration

Care Coordination

Management of Patient

Expectations

Quality Metrics

Implementation Strategy (Physician Collaboration)

Educate/Communicate with physicians the need for change

Ensure confidence in care being provided to their patients (outside of the Inpatient Rehab)

Provide quality metrics as a measurement for care (not “one offs”) to measure care

Enlist a physician champion on Joint Procedures and Pneumonia

Implementation Strategy (Care Coordination)

Stage 3 & 4 diagnosis, End of Life, Not able to self manage independently

Need assistance with self management, Post acute care resource to assist with maximizing health post acute

Self managed patients, Low acuity, able to independently care for self

Patients with no needs

Implementation Strategy (Management of Patient Expectations)

Physician’s Office Joint Camp Pre-Admission evaluation and education ER case manager assigning patient status Readmission Prevention Process (to be more

focused with the addition of 4 fte’s)

Implementation Strategy (Quality Metrics)

Patient Satisfaction (After changing referral patterns – Joint and Pneumonia)

Medicare Spending Per Beneficiary (Placement of patients – Reduction of Inpatient Rehab referrals)

Readmission Length of Stay (inpatient and observation) Scorecard of Post Acute Providers (grading)

Common Goal:Getting everyone to work as a TEAM!

Thank you