RUSK REHABILITATION

1. RUSK REHABILITATION The Triple Aim – How Physiatry and the Rehabilitation Team can improve the patient experience and thrive within healthcare reform and value based medicine Jonathan H. Whiteson, MD, FAAPMR Assistant Professor, Rehabilitation Medicine Medical Director, Cardiac and Pulmonary Rehabilitation Medical Director, Rusk Outreach and Growth RUSK Rehabilitation

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3. Health care reformis…… a general rubric used for discussing major health policy creation or changes — for the most part, governmental policy that affects health care deliveryin a given place. • Health care reform typically attempts to • Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies • Expand the array of health care providers consumers may choose among • Improve the access to health care specialists • Improve the quality of health care • Give more care to citizens • Decrease the cost of health care RUSK REHABILITATION

4. Health reform includes the following key steps…. • Expand Medicaid to allow more people at the lowest income levels to qualify for coverage. • Encourage employers to offer health insurance. • Provide credits to purchase private health insurance coverage to moderate income Americans who do not qualify for Medicaid. • Streamline the purchase of health insurance through the establishment of the Health Insurance Exchange. • Strengthen consumer protections and require transparency. • Impose protections to guard against unreasonable rate increases. • Encourage primary and preventive care. • Require most Americans to purchase health insurance. RUSK REHABILITATION

5. Healthcare reform issues impacting Physical Medicine and Rehabilitation…. • Reinstatement of the 75% rule for Inpatient Rehabilitation? • Site-Neutral Payments restricting access to care based on diagnosis, not patients’ clinical need • Medicare Bundle Payment Proposals creating risk of underservice to patients • Medical Coverage of Outpatient Therapy Services and Therapy Caps • Rehabilitative and Habilitative Services and Devices limiting needed prosthetics and other needed items like power chairsfor patients • RUSK REHABILITATION Presentation Title Goes Here

6. Site Neutral Payments…. The Medicare Payment Advisory Commission (MedPAC), the nonpartisan government agency that advises Congress on Medicare policy, indicated in 2014 it would recommend: • phasing-in site-neutral payments for inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs) • loosening regulatory requirements for IRFs so that they might continue to provide care to Medicare beneficiaries after their Medicare reimbursement rates are reduced. • deleting IRF requirements that physicians see patients at least three times per week and that IRFs provide intensive therapy to patients each day.  RUSK REHABILITATION

7. But… • American Medical Rehabilitation Providers Association Chairman Bruce Gans - MedPAC's recommendation "fails to consider the long-term impact of diverting Medicare beneficiaries into less intensive rehabilitation settings despite their clinical needs.“ • Hospital outpatient departments treat sicker and poorer patients in need of more extensive care and resources than do physician offices and patients treated in outpatient departments have more severe chronic conditions RUSK REHABILITATION

8. Values Based Medicine (and Evidence Based Medicine) • Values-Based Medicine (VBM) is the theory and practice of effective healthcare decision-makingfor situations in which legitimately different (and hence potentially conflicting) value perspectives are in play. • VBM is the values-counterpart of Evidence-Based Medicine, or EBM. • EBM is a response to the growing complexity of the relevant facts • VBM is a response to the growing complexity of the relevant values • VBM emphasizes the importance of good process in the form particularly of improved clinical practice skills RUSK REHABILITATION

9. Value Based Medicine • Value = Quality / Cost • Quality – • evidence-based standards - transfusion criteria, hospital acquired pneumonia, pressure ulcer development, central line associated bacteremia • LOS - observed/expected - UHC data • Patient reported data – HCAHPS / Press-Ganey survey • Cost – laboratory / radiology / drug / LOS-related cost - fixed and direct cost as determined by Finance RUSK REHABILITATION

10. Shifting the paradigm….. The Physiatrist and rehabilitation team can show value by: • Improving the patient experience • Improving patient outcomes • Decreasing hospital length of stay • Reducing hospital costs • Decreasing the need for post acute services • Developing innovative programs that help maximize revenue while creating new career paths for Physiatrists in the face of healthcare reform RUSK REHABILITATION

11. Rehabilitation Medicine is a major ‘player’ in every aspect of patient care…. • ICU early mobilization • Bundle Payment Initiative • Rehab Continuum RUSK REHABILITATION

12. ICU early mobilization RUSK REHABILITATION

13. ICU care – where were we…? • What was the coordination of clinical care? • Management of Delirium - Sleep / wake cycles – Sedation – Pain? • What was the clinical care culture? • What was the culture of mobilization? • Frequency and duration of rehabilitation treatments? • Longitudinal perspective and VBM considerations? RUSK REHABILITATION

14. Review of the literature… Early Physical Medicine and Rehabilitation for Patients With Acute Respiratory Failure: A Quality Improvement Project. Archives PM&R Volume 91, Issue 4, Pages 536–542 ICU Early Physical Rehab Program • CCM • Volume 41 • Number 3 • March 2013 PT for the Critically Ill in the ICU • CCM • Volume 41 • Number 6 • June 2013 • Decreased Length of Stay: ICU Floor Bed • Improved Functional Independence • More Discharges to Home • Fewer Vent Days • Less ill Effects of Bed Rest- e.g., Strength and ROM • Lower Incidence and Duration of Delirium • Less frequent Use of Sedation/Medications • Lower Average Direct Costs (e.g., medical surgical supplies, pharmaceutical supplies, housekeeping, food expenses, RN salaries) RUSK REHABILITATION

15. Rusk Rehabilitation ICU early mobilization – changes… • Create a collaborative team – driven by PM&R • Reduce deep sedation and delirium in patients in the ICU, reintroduce ‘normal’ sleep / wake cycles, adequately manage pain – all to support more effective and earlier mobilization • Establish a clinical care culture beyond survival • Establish a mobility culture beyond the bed and rehabilitation team • Establish the culture of early mobilization • Create a ‘beyond the horizon’ perspective and support VBM initiatives RUSK REHABILITATION

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17. Early Rehabilitation in the ICU – A Performance Improvement Project • Comparison Group – consisted of 123 ICU patients • Pilot Group – consisted of 160 similar ICU patients • Intervention – Provided average of 60 minutes of interdisciplinary therapy per day to include PT, OT, SLP. • Services were offered to Medical ICU and Surgical ICU at NYU Langone Medical Center Presentation Title Goes Here

18. The value and outcomes from early rehabilitation in the ICU RUSK REHABILITATION

19. Clinical Outcomes for Early Rehabilitation in ICU • Patients discharged home with or without services increased from 59% to 76% (up by 16%) • Patients discharged home without services increased from 18% to 40% (up by 22%) • Patients discharged to post-acute care decreased from 6% to 1% (down by 20%) Presentation Title Goes Here

20. Estimated Cost Savings from Early Rehabilitation in ICU $1.4M Annually (540 patients) when pilot group was compared to the comparison group after inclusion of rehabilitation labor costs using avg. costs per day *This excludes additional hospital revenue with backfill of ICU beds resulting from reduced LOS and improved throughput RUSK REHABILITATION

21. ICU early mobilization next steps… • Administration approved conversion of pilot staff to permanent positions • Academic Presentation – Poster and Podium presentation: Early Mobilization in the Medical and Surgical Intensive Care Units: A Performance Improvement Project. Johns Hopkins Critical Care Rehabilitation Conference • Academic Publication - Early Rehabilitation in the Medical and Surgical Intensive Care Units for Patients With and Without Mechanical Ventilation: An Inter-professional Performance Improvement Project – submitted, pending acceptance • Development of rehabilitation pilot on Medicine floors comparing daily rehab care with current model • UHC Conference Presentation - upcoming RUSK REHABILITATION

22. Bundled Payment Initiative RUSK REHABILITATION

23. Bundled Payment Initiative… • AKA: episode-based payment, episode payment, episode-of-care payment, case rate, evidence-based case rate, global bundled payment, global payment, package pricing, or packaged pricing • …defined as: the reimbursement of health care providers (such as hospitals and physicians) "on the basis of expected costs for clinically-defined episodes of care." "a middle ground" between fee-for-service reimbursement (in which providers are paid for each service rendered to a patient) and capitation (in which providers are paid a "lump sum" per patient regardless of how many services the patient receives). RUSK REHABILITATION

24. Services that can be included under each model RUSK REHABILITATION

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26. the risks for embracing new payment models as they evolve is worth the opportunity to identify what works and influence future policy “The bleeding edge and cutting edge are the same place” RUSK REHABILITATION

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28. Bundled Payment Initiatives • Dept. of Rehabilitation Medicine involved since earliest planning stages of bundled pilot • Departmental Chairman / Departmental Administration / Physiatry Specialists • Hospital Administration and Finance negotiate bundle model and reimbursement $$$s Preferred providers: home health care agencies acute rehab centers sub-acute rehab centers LTACs RUSK REHABILITATION

29. Bundled Payment Initiatives • Hospital Culture Change staff education patient / family centered language default disposition – home • Care Coordination Team Social Worker Care Management • Rehab Team Physiatrist PT / OT Presentation Title Goes Here

30. Bundled Payment Initiatives • Total joint - elective: 90 day • Pre-surgical PT or OT home visits • Rapid Rehab – POD zero • ‘Front-loaded’ home care services • Sub-acute joint replacement program • Outpatient transition RUSK REHABILITATION

31. Bundled Payment Initiatives • Total joint – emergency / fractures: 90 days • Older / increased comorbidities – poorer outcomes from subacute rehab than acute rehab – LOS / readmissions • Enhanced value (quality/cost) of acute rehab – skill / monitoring / intensity • Spine– New surgical techniques associated with unanticipated increased expenditures • Dropped from bundle – cost increased – unable to achieve targeted savings despite decreases in LOS and readmissions RUSK REHABILITATION

32. Bundled Payment Initiatives • Cardiac Valve: 90 days • ICU early mobilization • implementation of twice daily PT and once daily OT sessions • default disposition - home with services (as indicated) • inpatient acute and sub-acute inpatient cardiac rehab programs • outpatient transition RUSK REHABILITATION

33. The Importance of Care Coordination and the role of the Physiatrist in the Bundled Payment Initiative RUSK REHABILITATION

34. With Bundling, the Physiatrist …. • Enforcesbestpractices /standardizationofpathways,workflows,andordersets • Improvescommunicationbetweensurgical / medical team andthepatient • Ensuresfollow-upaftercaretransitions • OptimizesPatientExpectationsandOutcomes Presentation Title Goes Here

35. Value Based Management – Changing care delivery while improving quality through bundled payment initiatives RUSK REHABILITATION

36. The Rehabilitation Continuum RUSK REHABILITATION

37. The Rehabilitation Continuum • Rehabilitation Medicine • Exemplifies Value Based Medicine • Patient centered collaborative practice method • ICU early mobilization • Bundled payment initiatives (efficiency) • Key role in care transitions • Inpatient rehabilitation remains viable – redefine criteria for acute and sub-acute • Home care agencies open to input • Collaborative outpatient programs potentially offer greatest growth opportunities • Wellness (maintenance) programs to maintain care continuum RUSK REHABILITATION

38. Rehabilitation Medicine – Some lessons learned… • Physiatrists and the rehabilitation team MUST play an important role in care redesign • Enhancingrehabilitationservices (RapidRehab)duringacutehospital phaseis relatedto decreasedLOS • Advancingclinical relationships withpostacutepartnersexpandsinfluencewithcare delivery • Ourpatientsareexperiencingimprovedcarethroughenhanced coordination • Well-coordinatedcareisbetterforourpatientsandresultsinreduced costs Presentation Title Goes Here

39. Rehabilitation Medicine – Some lessons learned… Achieving desired goals of health care reform (triple aim) and providing opportunities of physiatrists to redefine themselves and remain important and viable going forward. Considerations for the Future: expansion of the bundle initiative enhanced rehabilitation intensity throughout acute care hospitalization EBM integrated into VBM growth of ambulatory services RUSK REHABILITATION