The Intersection of Clinical Services & Revenue Cycle

1. The Intersection of Clinical Services & Revenue Cycle

2. Strategy to Reduce Readmissions HomeTown Health Spring Conference 2012

3. Presentation Focus • What is the problem? • Reduced reimbursement from Medicare, Medicaid, and commercial payers • Hospitals assuming more risk for discharged patients • What is the solution? • Choosing a proven readmissions solution model • Choosing a solution team • Choosing a solution tool • Where do we go from here? • Next steps

4. What is the Problem? • Reduced reimbursements for avoidable readmissions • Medicare now • Medicaid • Commercial plans • Driven by employers to reduce costs • Hospitals assuming more risks for discharged patients. Examples: • Medicare High Readmission Penalty • Medicare Bundled Payments • Medicare and Medicaid Accountable Care programs

5. Readmission Risks Over Time

6. Medicare Readmission Penalty • Penalty Amount • Adjustments up to 1% will be imposed on hospitals in FY2013 (Oct 2012), related to higher than expected readmission rates • Penalty Basis • Based on high readmission rates for fee for service Medicare enrollees age 65 or older discharged from an acute care hospital with a principle diagnosis of • Acute Myocardial Infarction (AMI) • Heart Failure • Pneumonia

7. Future Medicare • Readmission Penalties • More significant reductions in future years • up to 2% in FY 2014 (Oct 2013) and up to 3% in FY 2015 (Oct 2014) • Additional principle diagnosis conditions could be added such as: • COPD • Cardiovascular surgical procedures • Vascular conditions

8. Penalty Impact on Hospitals • Hospitals in the bottom quartile • Hospitals in the bottom quartile on readmissions will suffer penalties in the hundreds of thousands • The measurement period has already begun. • Four HTH hospitals in bottom quartile • CMS link - http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/CCTP_FourthQuartileHospsbyState.pdf

9. What if you are not on the CMS list? • You could be on the next CMS list • Hospitals in the bottom quartile will work quickly to get off the list • Your readmission rates will be published on a public website (Hospital Compare) • Employers are selecting hospitals to reduce costs • Workers and their families will be steered to hospitals that can prove they deliver quality care. Providers would earn part of their fees for keeping patients as healthy as possible, similar to the "accountable care organizations" in the health care law.

10. Effective Care Transition Barriers • Practitioner Level Barriers • Practitioners often have not practiced in settings where they transfer patients • Sending practitioners may not communicate critical information to receiving practitioners • Practitioners may not know the patient and his or her preferences for care • Practitioners have no accountability Hospitals

11. Effective Care Transition Barriers • Patient Level Barriers • Patients assume that someone is in charge of coordinating care • Patients (and caregivers) are often the only common thread weaving between care sites • Yet they navigate the system with few tools or training to manage in this role

12. Critical Success Factors • Clinical professionals and care coordinators must prepare patients and their caregivers to receive care in the next setting and actively involve them in decisions related to the formulation and execution of the transitional care plan • Bidirectional communication between clinical professionals, care coordinators, and patients is essential to ensuring high quality transition care

13. Case Study 1 • During a patient’s monthly follow-up appointment with the cardiologist, he informed the doctor that he was having trouble with one of his medications. The doctor asked which one. The patient said “The patch, the nurse told me to put on a new one every day and now I’m running out of places to put it!” The physician had him undress and discovered that the man had over a two dozen patches on his body.

14. Case Study 2 • An older man with atrial fibrillation who takes warfarin for stroke prophylaxis was hospitalized for pneumonia. His dose of warfarin was adjusted during the hospital stay and was not reduced to his usual dose prior to discharge. The new dose turned out to be double his usual dose and within two days he was re-hospitalized with uncontrollable bleeding.

15. What’s the Solution? • Key Goals • Identify issues and barriers to transitions across the continuum of care • Evaluate appropriate referral criteria between levels of care • Assess available technology, evidence based guidelines, medication reconciliation, and adherence gaps

16. What’s the Solution cont’d? • Focus on the root cause of readmissions • Patient non compliance • With medications • With physician follow-up • With nutrition (meals) • With physical therapy • Barriers to patient compliance • Lack of transportation • Lack of help at home • Home environmental barriers • Heating and cooling • Changing bed sheets • Reducing fall related risks • Cultural, mental, and language barriers

17. Solution Components • Select a proven care transitions model • National models include • Eric Coleman CTI model • Mary Naylor model • Project RED • Boost • Guided Care • Select care coordinators – options include: • Hospital staff (legal review required) • Local area agency on aging • Home health agency • FQHC • Outsource to case management company

18. Solution Components cont’d • Engage patients and caregivers • Obtaining consent for participation • Orientation and education • Engage care transition team members • Patient Physicians • Patient Pharmacists • Skilled Nursing Facilities • Home health care agencies • Community resources • Area agency on aging • United Way agencies • Churches

19. Solution Components cont’d • Select Care Transitions Tool for: • Collecting hospital discharge data • Conducting risk assessments • Building transitions care plan • Selecting and scheduling referrals • Medical • Non medical • Tracking care plan compliance • Capturing and analyzing results

20. Care Transition System

21. Patient Management Action Plans

22. Real Healthcare Reform Hospitals Safety Net Clinics Area Agency On Aging Health Departments Local government agencies Churches Home Health Agencies United Way Agencies

23. My patient’s most pressing health issue was a broken carburetor “Months later, before a pending well-child visit, I called the school to get an update on his development. I was shocked to learn that it had been weeks since he had last attended. When he and his mother came in for their appointment, I learned her car had broken down. She was saving money for a fix, but had no one to rely on for her son’s transportation and hadn’t known where to turn for help. . . . This was a crystallizing moment for me. The long-term health and well being of a developmentally delayed childwhom I had helped coax through recovery from prolonged hospitalizations and multiple complicated surgeries hinged not on the quality of my medical care but on a taxi voucher and a broken carburetor.” Dr. Douglas Jutte, MD, UC Berkeley Medical Program - 12/7/2011

24. Gaps with EMR Technology “Today’s EMR technology was not developed to support role-based access to information for team care. Instead, it was developed to support a traditional fee-for-service, visit-based reimbursement model, with the focus on documentation requirements to support a billing function. That technology is inadequate to the transformational activities required for new health care models. Anchoring the electronic health record (EMR) in the traditional visit-based care delivery model limits the potential of the medical home to generate paradigm-shifting care delivery transformation and the positive outcomes it promises.” Source: Cyberinfrastructure Patient-Centered Medical Home: Current and Future Landscape - Zayas-Caban, Finkelstein ,Kothari, Quinn, Nace, 2011

25. Where do we go from here? • The clock is ticking • Oct 2012 will be here soon • Hospital Compare site already up • Act now to manage “forced” risk • Engage with Home Town Health • E.g., CMS Community Care Transitions Grant • Engage Home Town Health Partners • CivicHealth - Care Transitions Tool • Other HTH partners as appropriate • Consultants • Personal telemonitoring

26. Questions and Answers • Richard Taylor • CivicHealth • rtaylor@civichealth.com 615 482 3600 • Lou Semrad • HomeTown Health • lsemrad@gmail.com 706 474 0434

27. Additional Slides

28. Care Transitions Team Interactions Family Patient Physician Provider and Social Services Network CareCoordinators Hospital (Discharge Plan) Health advisors and coaches

29. A Comprehensive Patient Management Solution Process Function Uses/Data Patient Intake Patient Eligibility Patient Referrals Patient Management Patient assessments and demographics, medical history Patient community Database Eligibility Rules (e.g.,CHIP, Medicaid); community resources database Eligibility and Community Resources Set up and schedule Referrals – social and Clinical (transportation meals, home services) Referral Coordination Manage patient Compliance (goals, alerts Follow-up interventions) Case Management/ Disease Management Outcomes Reporting/ Analytics

30. Patient Management Applications • Care Transitions • Managing patients after discharge • ER Room Redirection • Reducing uncompensated care by redirecting uninsured patients to safety net clinics • Accountable Care Programs • E.g., chronic Disease management • Community Health Improvement programs • E.g., reducing community obesity • Prenatal and Maternal/Child health programs • Coordinating care for pregnant mothers • Senior Citizen Health Management • Coordinating programs for seniors