Critical Access Hospitals

1. Critical Access Hospitals Quality Care in Rural West Virginia

2. Introduction

3. Changes to the Rural Healthcare System • Approximately 20% of the nation’s population lives in areas where education, economic services, transportation, and health services are sparse or nonexistent.

4. Changes to the Rural Healthcare System • The rural healthcare system is changing due to changes in healthcare financing, new technology, and the clustering of health services into systems and networks. • Fee for Service Payment replaced by managed care

5. Changes to the Rural Healthcare System • Increase in the development of networks and systems v. private practice • Rural America has 20% of the nation’s population, but less than 11% of it’s physicians • Rural clinician often described as “another breed” willing to cope with professional isolation and independence in rather unusual cases.

6. Changes to the Rural Healthcare System • Rural residents are more often uninsured than urban residents, and more likely to report themselves in fair or poor health. • 1990’s Policy began to focus on resource disparities as well as payment policies for Medicare beneficiaries as well as the supply of healthcare professionals.

7. Changes to the Rural Healthcare System • Starting in the 1980’s rural hospitals began to close their doors. • Most vulnerable hospitals had 25 beds or less and were located more than 35 miles from the next hospital • Some Rural hospitals were able to survive due to a change in discriminatory Medicare Payment Policies.

8. What is a Critical Access Hospital (CAH)?

9. WV CAH Definition • Currently Licensed Facility • Annual Average Service Limit of 96 hours of in-patient service per pt. excluding observation and swing bed • Facility limited to 25 beds (swing or acute)/ May have Distinct Part Unit (DPU) such as LTC • WV Medicare and Medicaid payment received is cost based reimbursement

10. WV CAH Definition Cont. • Rural Health Network: • At least 1 CAH and 1 affiliate hospital: agreements maintained with network hospital may include: • Referral and Transfer, Communications • Agreement with network hospital • PRO or equivalent for: Credentialing, Quality Assurance, Transportation

11. WV CAH Definition Cont. • Flexible Aspects of the Program Include: • Services included (IP, OP, ER, Lab, Radiology, DPU, etc…) • Emergency Services • Medical Staff • Nursing Staff • Hours of Operation

12. How CAHs were Founded • In February 1998, WV became the first state in the nation to receive approval from the Centers for Medicare and Medicaid Services to implement the Medicare Rural Hospital Flexibility Program.

13. How CAHs were Founded • The WV Rural Hospital Flexibility Program (WVRHFP) resulted from a national initiative to strengthen rural healthcare through: • Allowing small hospitals the ability to reconfigure • Offering cost based reimbursement • Encouraging the development of rural health networks • Offering grants to rural hospitals to strengthen their infrastructure

14. CAHs are Different than Other Hospitals… • To be eligible as a CAH, a hospital must: • Be a current participating Medicare Hospital or • Be a hospital that ceased operations on or after 11/29/89 or • A health clinic or health center that previously operated as a hospital before being downsized to a health clinic or health center

15. CAHs are Different than Other Hospitals… • The facility must be located in a rural area of the state that has an established Medicare rural hospital flexibility program. • Facility must be located more than a 35 mile drive from any other hospital or CAH, or be designated a “necessary provider” by the state (15 miles in mountainous terrain or areas with only secondary roads).

16. CAHs are Different than Other Hospitals… • The facility must make available 24-hour emergency care services. • The facility must provide not more than 25 beds for acute (hospital level) inpatient care, or in the case of a CAH with a swing bed agreement, swing beds used for Skilled Nursing Facility (SNF) level of care. • A CAH maintains a length of stay of no longer than 96 hours on average for Acute level of care patients.

17. CAH’s Exceed US Average in Pt. Satisfaction

18. Swing Bed Units

19. What are Swing Beds? • Transitional unit for individuals who require skilled services for a short term following a hospital stay. • Typical LOS 2-3 weeks

20. Medicare Admission Guidelines • No guarantee of payment provision for providers resulting in strict guidelines for admission including: • Determining if pt has met the 3 day qualifying hospital stay and 30-day transfer requirement.

21. Medicare Admission Guidelines Cont… • Determine if pt. has Medicare Part A benefits. • If no Part A Benefit, the responsibility of payment must be explained to the pt. • Determine if pt. is appropriate medically for admission to a Skilled Nursing Facility level of care.

22. Skilled Nursing Facility (SNF) Level of Services Definition: • Skilled nursing and skilled rehabilitation services are those services furnished based on the orders of a medical professional that: • Require the skills of qualified technical or professional health personnel such as registered nurses, licensed practical nurses, physical therapists, occupational therapists, and speech pathologists or audiologists.

23. Skilled Nursing Facility (SNF) Level of Services Definition Cont… • Services must be provided directly by or under the general supervision of these skilled nursing or skilled rehabilitation personnel to assure the safety of the patient and to achieve the medically desired result.

24. Skilled Nursing Facility (SNF) Level of Services Criteria for determining whether a service is skilled include: • If the complexity of a service prescribed is such that it can only be performed safely and/ or effectively by or under the supervision of skilled nursing or skilled rehabilitation personnel. • The nature of the service and the skills required for a safe and effective delivery of that service. (The patient’s diagnosis or prognosis should never be the sole determinant of whether a service is skilled.)

25. Skilled Nursing Facility (SNF) Level of Services Criteria for determining whether a service is skilled include: • When rehabilitative services are the primary services it is key whether or not the skills of a therapist are needed. (Can the services be carried out in an outpatient setting or by the assistance of non-skilled personnel?)

26. Skilled Nursing Facility (SNF) Level of Services Criteria for determining whether a service is skilled include: • A service that is ordinarily not considered skilled may be considered so in cases where, because of special medical complications skilled nursing or skilled rehabilitation personnel are required to perform or supervise the service or observe the patient. These complications must be documented in the physician’s orders as well as the therapy and/ or nursing notes.

27. Skilled Nursing Facility (SNF) Level of Services Criteria for determining whether a service is skilled include: • To determine whether services provided to Swing-Bed patients are skilled, you must considered whether individual services are skilled or in light of the patient’s total condition skilled management of unskilled services are necessary. (The importance of a particular service to a patient or the frequency with which it must be performed, does not, by itself, make a service skilled.)

28. Skilled Nursing Facility (SNF) Level of Services Criteria for determining whether a service is skilled include: • The possibility of adverse effects from the improper performance of an otherwise unskilled service does not make it a skilled service unless there is documentation to support the need for skilled nursing or skilled rehabilitation personnel. • Teaching and training activities that require skilled personnel to teach a patient how to manage his treatment regimen would constitute skilled services.

29. Case Examples

30. Case Examples • A 70yr old female presents to the ER with mental status changes, following tests she is admitted to acute care to be treated for a UTI. After three days of antibiotics, minimal improvement is seen. She is then admitted to swing bed to receive a 10 day antibiotic circuit.

31. Case Examples • An 82yr old male who resides at home with the assistance of only his elderly and disabled wife. After years of suffering with knee pain due to arthritis he receives a total right knee replacement. Following surgery and a brief recovery he is transferred to swing bed to receive physical therapy for mobility and ambulation to better equip him to go home following discharge.

32. Case Examples • A 67yr old female was treated for a CVA. She is declared medically stable but still struggles with swallowing and speaking. She is transferred to a swing bed unit to receive speech therapy.

33. Payment/ Coverage

34. Medicare Coverage- Part A • Medicare Part A covers skilled services for beneficiaries requiring additional skilled nursing care and/ or rehabilitation services following hospitalization for up to 100 days per course of illness. • Beneficiaries pay nothing for the first 20 days and a daily co-payment of $141.53 (2011) for days 21-100 • This co-payment may be covered by another insurance

35. Increased Post-Acute Access for Medicare Beneficiaries • Improved Quality of Care • Rural hospitals and CAHs that have swing bed approval increase Medicare beneficiary access to post-acute SNF care and maximize the efficiency of operations by meeting unpredictable demands for acute and LTC.

36. Increased Post-Acute Access for Medicare Beneficiaries • In rural areas where access to services may be limited, patients ready for acute discharge from a facility may need more care and support than can be achieved through a discharge to home with home health services.

37. Benefit to Rural Geriatric Community

38. Proximity of Care • Large Percentage of WV Elderly Reside in Rural Areas • Rural elderly can receive transitional skilled services in a facility closer to home. • Easier for support network to be actively involved in pt. care and discharge planning.

39. Transitional Ease • Psychologically and emotionally, swing bed admissions may be less traumatic and threatening for the patient. Admission to a swing bed feels more like a continued hospital stay to the patient and helps improve continued recovery and a return to independence.

40. Community Centered Care • Employment • CAHs are major employers in rural areas for which they are present. • Provides an opportunity for professionals from rural communities to remain and utilize their skills in the communities from which they originated.

41. Community Centered Care • Community Participation and Support • CAHs sponsor community activities based on wellness • Health Fairs • Blood/ Health Screenings • Advance Directives • Education

42. Boone Memorial Hospital Braxton County Memorial Hospital Broaddus Hospital Grafton City Hospital Grant Memorial Hospital Hampshire Memorial Hospital Jefferson Memorial Hospital Minnie Hamilton Healthcare Center Montgomery General Hospital Morgan County War Memorial Hospital Plateau Medical Center Critical Access Hospitals of WV

43. Pocahontas Memorial Hospital Potomac Valley Hospital Preston Memorial Hospital Corporation Roane General Hospital Sistersville General Hospital Summers County Appalachian Regional Hospital Webster County Memorial Hospital Critical Access Hospitals of WV

44. Questions?

45. References Casey, M., Burlew, M., Moscovice, I., & University of Minnesota Rural Health Research Center. (2010). Critical access hospital year 5 hospital compare participation and quality measure results: Policy review #15. Flex Monitoring Team: Federal Office of Rural Health Policy. Centers for Medicare and Medicaid Services. (2008). Fact sheet: Critical access hospital. American Medical Association. Centers for Medicare and Medicaid Services. (2010). Critical access hospital: Part A. Trailblazer Health Enterprises, LLC.

46. References Chan, L., Hart, L.G., & Goodman, D.C. (2006). Geographic access to health care for rural medicare beneficiaries. National Rural Health Association, 22(2), 140-146. Department of Health and Human Resources Centers for Medicare and Medicaid Services. (2010). Swing bed: Rural health fact sheet series. Medicare Learning Network. Division of Rural Health, West Virginia Department of Health and Human Resources. West Virginia rural hospital flexibility (flex) program. Retrieved from http://www.wvochs.org/orhp/rhfp.aspx

47. References Gale, J.A., Lenardson, J., Race, M., Gregg, W.R., Casey, M., Richardson, I., & Rutledge, S. (2007). State I nitiatives funded by the medicare rural hospital flexibility grant program: Policy review #3. Flex Monitoring Team: Federal Office of Rural Health Policy. Herbert, D. & Davis-Fleming, J. (2009). Boost your critical access hospital bottom line with swing bed designation. Washington Healthcare News, 4(3), 1-3.

48. References Lutfiyya, M.N., Bhat, D.K., Gandhi, S.R., Nguyen, C., Weidenbacher-Hoper, V. & Lipsky, M. (2007). A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States. International Journal for Quality in Health Care, 19(3), 141-149. Ricketts, T. C. (2000). The changing nature of rural health care. Annual Review of Public Health, 21, 639-657. Tai, W.C., Porell, F.W., & Adams, E.K. (2004). Hospital choice of rural medicare beneficiaries: Patient, hospital attributes, and the patient-physician relationship. HSR: Heal Services Research, 39(6), 1903-1922. Yacker, H.G. (2001). Medicare’s Skilled Nursing Facility Benefit. CRS Report for Congress: Congressional Research Service. The Library of Congress.