Archive for the ‘Long Term Care’ Category

How a Data Dive Makes a Difference in ACO Care Coordination Efficiency

March 30th, 2017 by Patricia Donovan

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UTSACN used data analytics to trim its home health network from more than 1,200 agencies to 20 highly efficient home health providers.

How does UT Southwestern Accountable Care Network (UTSACN) use information to inform and advance care coordination programming? As UT Southwestern's Director of Care Coordination Cathy Bryan explains, a closer look at doctors' attitudes toward a Medicare home health form initiated a retooling of the ACO's home health approach.

We realized our home health spend was two times the national average. When we reviewed just the prior 12 months, we identified more than 1,200 unique agencies that serviced at least one of our patients. With this huge number of disparate home health agencies, it was difficult to get a handle on the problem.

Our primary care doctors told us they found the CMS 485 Home Health Certification and Plan of Care form to be too long. The font on the form is four-point type; it's complex, so they don't understand it. However, because they don't want a family member or patient to call them because they took away their home care, they often sign the form without worrying about it.

As we began looking at these findings, we wondered what they really told us. Are some agencies better than others, and how do we begin to create a narrow network or preferred network for home care? We knew we couldn't work with 1,200 agencies efficiently; even 20 agencies is a lot to work with.

We began to analyze the claims. My skilled analyst created an internal efficiency score. She risk-adjusted various pieces of data, like average length of stay. For home health, there were a number of consecutive recertifications. We looked at average spend per recertification, and the number of patients they had on each agency. We risk-adjusted this data, because some agencies may actually get sicker patients because they have higher skill sets within their nursing staff.

We created a risk-adjusted efficiency score based on claims. We narrowed down the list by only looking at agencies with 80 percent or higher efficiency. That left us with about 80 agencies; we then narrowed our search to 90 percent efficiency and above, and still had 44. That was still too many, so we cross-walked these with CMS Star ratings to narrow it even more. Finally, after looking at our geographic distribution for agencies that serviced at least 20 patients, we eliminated those with one and two patients. We sought agencies that had some population moving through them.

Ultimately, we reduced our final home health network to about 20 agencies that were not creating a lot of additional spend, and not holding patients on service for an incredibly long period of time.

Source: Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives

advanced care coordination

During Advanced Care Coordination: Bridging the Gap Between Appropriate Levels of Care and Care Plan Adherence for ACO Attributed Lives, a 2016 webinar available for replay, Cathy Bryan, director, care coordination at UT Southwestern, shares how her organization’s care coordination model manages utilization while achieving its mission of bridging the gap from where patients are to where they need to be to adhere to their care plan.

UPMC: INTERACT Tools Boost Provider Communication in RAVEN Project to Reduce Long-Term Care Hospitalizations

September 6th, 2016 by Patricia Donovan
UPMC reduces long-term care hospitalizations

Even custodial or housekeeping staff can use the INTERACT Stop and Watch tool to record subtle changes in a patient.

The RAVEN (Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents) project by the University of Pittsburgh Medical Center (UPMC), aimed at improving quality of care for people residing in long-term care (LTC) facilities by reducing avoidable hospitalizations, is set to enter phase two in October 2016. Here, April Kane, UPMC's RAVEN project co-director, describes a pair of key resources that have enhanced communication between providers, particularly those at the eighteen nursing homes collaborating with UPMC on the RAVEN project.

Currently INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement project and has been funded through Medicare. It is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities (SNFs). The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. These tools are free online.

INTERACT is used in multiple settings, but in our long-term care setting, we've been primarily encouraging the use of two INTERACT tools. There are a wealth of others. First is the Stop and Watch tool. This is a very easy early detection tool that would be used by members of your nursing home staff, such as nurses aides, custodial or housekeeping staff, and other workers who have a lot of one-on-one engagement with residents.

Using this tool, they may notice subtle changes, such as a patient who isn't as well engaged, who has been eating or drinking a little less, or is not as communicative as they had been before. It's a very easy one-page tool. Sometimes it's a card where they can circle if they're seeing something different, for example, "The resident seems a little different," or "They ate less."

The goal would be to take that tool to either the LPN or the RN in charge of the unit they're working on and say, "You know, I was with Mrs. Smith today. This is what I've been seeing that's a little different with her." That nurse should take that tool, validate its usage and then from there, go in and assess the patient.

If appropriate, they should utilize a second INTERACT tool, SBAR (Situation, Background, Assessment, Recommendation), to provide a more thorough assessment of what is going on and determine if this is a true changing condition. The SBAR allows the nurse to provide feedback to physicians in the very structured format physicians are used to reviewing. This allows them to place all the vitals and information in one place.

When they do make that call to the physician, they're well prepared to update them with what is going on with a particular resident. The physician then feels comfortable in deciding whether to provide further treatment on site or if appropriate, to transfer out to the hospital, depending on that resident's need.

Click here for an interview with April Kane on the value of UPMC's onsite enhanced care coordinators in the RAVEN project.

Care Transitions Playbook Sets Transfer Rules for Post-Acute Network Members

July 28th, 2016 by Patricia Donovan

St. Vincent's Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

St. Vincent's Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

A primary tool for Saint Vincent’s Health Partners Post-Acute Network is a playbook documenting more than 140 transitions for patients traveling from one care setting to another, including the elements of each transition and ways network members should hold each other accountable during the move. Here, Colleen Swedberg, MSN, RN, CNL, director of care coordination and integration for St. Vincent’s Health Partners, explains the playbook's data collection process and information storage and describes a typical care transition entry.

The playbook is made up of several sections, including one with current expectations, based on the Michigan Quality Improvement Consortium, which we can review online. From an evidence-based point of view, they’ve listed the evidence for many common conditions patients are seen for in medical management. This is kept up to date. This is an electronic document stored on our Web site that can only be accessed by individuals subscribed to the network. We’ve also put this on flash drives for various partners.

A second section contains actual metrics for any network contracts. The metrics appear in such a way that the highest standard is included. For example, physician providers, as long as they provide the highest level of care in the metric, can be sure they’re meeting all the metrics. Those metrics are based on HEDIS® standards.

The third section is the transition section, laid out in two to three pages. For example, a patient moves from the hospital inpatient setting to a skilled nursing facility, such as Jewish Senior Services. For that transition, the playbook documents all the necessary tools for that patient: a personal health record, a medication list, whatever is needed. Also included is any communication with the primary care physician, if that provider has been identified. Finally, this section identifies the responsibility of the sending setting—in this case, the hospital inpatient staff. What do they need to organize and make sure they’ve done before the patient leaves and starts that transition, and what is the responsibility of the receiving organization?

That framework is the same for every transition: the content and tools change according to the particular transition. A final section of the playbook details all of the tools used for care transitions. For example, in our network, we’re just now working on the use of reviews for acute care transfers, which is an INTERACT (Interventions to Reduce Acute Care Transfers) tool. In fact, many settings, including all of our SNFs, as it turns out historically, have used that tool. This tool is in the playbook, along with the reference and expectation of when that tool would be used.

Source: Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands

http://hin.3dcartstores.com/Post-Acute-Care-Trends-Cross-Setting-Collaborations-to-Align-Clinical-Standards-and-Provider-Demands_p_5149.html

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient's journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

Bundled Payments Opportunity to Practice Proactive Population Management

September 16th, 2014 by Patricia Donovan

Assuming financial risk for the cost of post-acute services not only helps healthcare organizations avoid value-based readmissions penalties but also provides a chance to proactively manage a population, notes Kelsey P. Mellard, vice president of partnership marketing and policy with naviHealth.

We have been called almost a concierge-type service in the way we think about management and engagement with the patient, their family, and their caregivers. We proactively provide a road map to our beneficiaries based on their functional score. Our tools and technology identify their functional abilities upon discharge from the hospital and use that as a driver for identification of a post-acute care setting.

Our functional score is comprised of three domains: basic mobility, applied cognition and daily living skills. Through the assessment of the patient, we identify a patient in our database just like the patient in front of us and say, ‘Patients just like this patient have gone to skilled nursing facilities (SNFs) or home health and have had this level of functional improvement over the course of this length of stay, this many therapy hours per day, and this patient presents with X% of a risk for readmission. Through that prediction, based on historical real patients in our database, we can identify and help target the level of acuity and care this patient actually needs in a post-acute care setting.

Often we discharge patients to a higher level of acuity and care than they actually need. This gives us a tool. It’s not a rule. It’s not the be-all, end-all in our hospital partner settings, but it does create another piece of information based on real patients to help inform the discharge planning process.

We see the level of excitement and engagement our hospital partners exhibit on the ground floor, because right now they’re discharging based on community knowledge or because a case manager really likes one facility or they’re financially interested, from an organizational standpoint, in one facility. This negates all of those conversations and says this is an evidence-based model we’re going to be able to deliver at the bedside.

Source: Bundled Payments: Opportunities in Effective Retrospective Acute and Post Acute Care Bundles

Bundled Payments


Bundled Payments: Opportunities in Effective Retrospective Acute and Post Acute Care Bundles
First quarter experiences from these pilot programs, along with the current bundled payment opportunities for organizations not yet participating in CMMI's pilot program.

Measuring Outcomes Between Hospitals and Long-Term Care Facilities

August 5th, 2014 by Patricia Donovan

As part of its efforts to construct a care coordination network of skilled nursing facilities (SNFs), Summa Health System evaluated outcomes between its hospitals and the long-term care (LTC) facilities it works with, explains Carolyn Holder, manager of transitional care for Summa Health System.

To measure outcomes between hospitals and LTC facilities, we utilized data sent from the Summa Health System database. We found data outcome measures through our own database about these facilities that are working with us. We do limit by group differences. They are depicted by greater than one standard deviation. If they do have low admissions, we did not include them in the comparison. We have many members who don’t have a significant number of admissions to the hospitals, but are still participating in the care coordination network, which is very profound. It shows the dedication to the work regarding improving quality.

Other data that we will include in this measure is the comparison of readmissions, average length of stay (ALOS), percent of admissions and discharges. We have 31-day readmits and a number of one- to seven-day readmissions. We look at the case mix index for the patients we get from these facilities. This data is blinded; there are codes on the report card chosen by the facilities so we could do a comparison but not have that information shared among the competing agencies themselves.

We do the report twice a year because it is an intensive one for our quality department to prepare. The facilities are listed with the number of admissions to Summa, and the number of discharges to that facility for skilled and intermediate care facilities (ICF) level of care. We did an average so that we could compare it to the group itself. If they are doing well, they are better than the mean. If they are in that target area, they are lower in this area in comparison to the large group.

Since we began this initiative in 2003, the ALOS has fluctuated over time. It was still at 7.2 for the full year. Since we do not own these facilities, all we have provided the facilities so far is this data set. We do not have data coming back from the facilities to us with some of these measures, but that is the next task for the group to work on.

Excerpted from Accountable Care Strategies to Improve Hospital-SNF Care Transitions.

Snapshot of CMS Bundled Payment Care Initiative

July 1st, 2014 by Patricia Donovan

From both transparency and best processes standpoints across the entire nation, post-acute care presents an incredible opportunity to streamline not only the staging but also the quality of care provided to Medicare beneficiaries, notes Kelsey Mellard, vice president of partnership marketing and policy for naviHealth, a convener for Models 2 and 3 of the CMS Bundled Payment Care Initiative (BPCI).

Bundled payments touch four opportunities to engage providers in various settings. Model 1 is for retrospective acute care episodes, which focus only on the acute hospital stay. Model 2, which is where naviHealth is most engaged to date, is retrospective acute care hospitals plus the post-acute care. Our goal is building alignment—not only financial alignment but also quality alignment across both the hospital and the post-acute care settings, regardless of whether it’s a home health agency, a skilled nursing facility (SNF), an inpatient rehabilitation facility (IRF) or a long-term care hospital (LTCH). With model 3, we just have the episode focused on the retrospective post-acute care only. Finally, model 4 is for acute care hospital stays only.

Within these four models to date, we’ve seen over 300 organizations sign up and be active in phase 2, which means that they are in the risk-bearing phase. They are financially bearing risks for an episode based on the target sites that CMS has generated. Primarily, the 300 are split between Model 2 and Model 3. The first model, retrospective acute, is most active in the New Jersey market, model 4 has a few hospitals that are scattered throughout the country.

NaviHealth went live focusing on model 2 for a couple of reasons in January 2014, with 11 hospitals in five states. We will expand again in October and will further expand starting January 1, 2015, given the time frame that CMS has allowed us to continue our expansion and our partnerships as an awardee convener.

CMS is keenly focused on the variation of post-acute care, based on the most recent Institute of Medicine (IOM) report stating that if regional variation in post-acute care did not exist, we would see Medicare spend variations fall by 73 percent.

From a transparency standpoint and from a best processes standpoint across the entire nation, post-acute care has an incredible opportunity to streamline not only the staging, but also the quality of care provided to Medicare beneficiaries.

Excerpted from: Bundled Payments: Opportunities in Effective Retrospective Acute and Post Acute Care Bundles

Infographic: Few States Meet Palliative Care Benchmark

March 3rd, 2014 by Jackie Lyons

Only four states have effective strategies in place to improve access to and knowledge of palliative care services, according to the American Cancer Society Cancer Action Network.

State palliative care services are scored on a 0-6 scale, according to a new infographic from IMNG Medical Media. This infographic shows how each state scores on the scale, which combines grades from the Center to Advance Palliative Care's national palliative care report card with actions on model legislation.

You may also be interested in this related resource: 2014 Healthcare Benchmarks: Palliative Care. Healthcare organizations need to be informed of new technologies and information sources. This 40-page report documents emerging trends in palliative care at more than 200 healthcare organizations, from the timing for initial palliative care consults to individuals on the palliative care team to the impact this specialized care is having on healthcare utilization and the patient experience.


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Infographic: Dementia in the United States

January 23rd, 2014 by Jackie Lyons

In 2013, the cost of dementia for the United States was estimated at $203 billion. It is expected to increase to $1.2 trillion by 2050, according to a new infographic from OpenPlacement.com.

This infographic focuses on Alzheimer's disease, which is the most common form of dementia. The facts and statistics identify prevalence, mortality rates, time and money invested in care, as well as statistics specific to California.

Statistics and Trends of Healthcare in the U.S.

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You may also be interested in this related resource: The Encyclopedia of Elder Care, Third Edition.

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5 Barriers to Optimal Care in the Post-Acute Setting

January 22nd, 2014 by Jessica Fornarotto

Summa Health System's care coordination network of skilled nursing facilities (SNFs) is working to decrease fragmentation, length of stay and unnecessary readmissions while improving outcomes of care. Mike Demagall, administrator of Bath Manor & Windsong Care Center, a participant in this network, identified five barriers to patient care that originated in the acute care setting.

First, we found a lack of quality information received upon transfer from an acute care to a nursing facility and the lag time in identification of post-acute bed availability. The social worker was calling or faxing information to a facility, and the facility took up to 24 hours to respond as to whether a bed was available. That person may have been ready that day; instead it postponed that discharge another day.

We also had barriers to the patient’s acceptance of the need for post-acute care. Social workers and care coordinators at the bedside tell them when it is time for rehabilitation.

The next barrier was family expectations. Does the family feel that they need to go to the nursing home? The hospital staff and the insurers had to spot the appropriate levels of care. One of the concerns we had was, 'Is this going to send a lot of our patients — our referrals — to home healthcare and decrease our referrals by participating in this?' That happened to not be the case at all.

There was still a lack of knowledge and respect toward long-term care (LTC). All the discharge planning individuals, which were the case manager nurses and social workers, were able to tour the facility. Each facility had the opportunity to present their services and what they do. That helped with the overall cohesion of the group, and it moved this project forward.

There was also a lack of quality information received from the nursing facilities on the transfer to an emergency department (ED). That was information that we needed to get back, just as we were asking for information as those residents were coming in.

Excerpted from: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement

Infographic: Is Technology the Key to Aging Well?

January 15th, 2014 by Jackie Lyons

Although 73 percent of boomers and Gen X surveyed want to age in their own home, they believe the aid of technology will present significant barriers to achieving this, according to a new infographic from Philips and the Global Social Enterprise Initiative (GSEI) at Georgetown University’s McDonough School of Business.

In fact, 95 percent believe technology needs to be better developed to help them successfully age at home or in place. This infographic also details what 'aging well' entails, technology comfort levels by generation, healthcare technology security concerns, and much more.

Is Technology the Key to Aging Well?

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You may also be interested in this related resource: 2013 Healthcare Benchmarks: Telehealth & Telemedicine.

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