Transcript NAHC Annual Meeting 2012 - Transitions in Care

TALKING POINTS
1. The ingredients of Transitions in Care (TIC)
a. The opportunity for home health
b. Does your hospitalization & readmit rate get you a seat at the table?
c. Does the hospital/health system have significant exposure to the TIC
penalties
d. Does the hospital/health system have significant costs associated
with Emergency Department and Vacated Days for re-hospitalized
patients within 30 days of their discharge?
e. Is data available to analyze?
I. Patient rehospitalizations
II. Post acute referrals, if any
III. Number of vacated days and ED incidents leading to readmissions
IV. Average cost per bed day and ED incident
V. Outcomes and HHCAHPS
TALKING POINTS
2. Identify the services to be included to meet the goals of reduced ED
incidents and re-hospitalizations of the non-post acute referred patients
a. Development of patient identification criteria protocols to be
implemented by the hospital/health system
b. Development of the service components for a 35 day program
a. Skilled nursing assessment
b. Social service component to identify and engage community support
agencies
c. Telehealth for patients with at-risk diagnose
d. Medical Record Requirements
3. Identify the Direct Costs related to the desired services and developing
price points (Gross Profit Margins) for selling these services
TRANSITIONS IN CARE – THE ISSUES
The ACA provisions for Transitions in Care take effect in 2013
 Provides for penalties to hospitals whose re-hospitalization rates
exceed levels as determined by CMS
oRe-admissions are above national average for AMI, Heart Failure
and Pneumonia beginning with discharges on or after Oct. 1, 2012.
oThe penalties are 1%, 2%, and 3% of Medicare payments graduated
from 2013 to 2015
oThe penalties are separate from the lost revenue from vacated days
due to re-hospitalizations within 30 days of discharge
oMany hospitals have an exposure
oCMS has stated that “64% of re-hospitalizations are patients
discharged without a post acute referral”
TRANSITIONS IN CARE – THE HOSPITALS’ ISSUES
Inadequate discharge planning for significant numbers of patients
 Budget constraints – appropriate staffing
o Inability to identify all “at risk” patients, regardless of “homebound
status
o Appropriate clinical and social service staffing components
o Protocols
 Late day discharges by physicians without notification
 Lack of a post acute service component to prevent re-hospitalizations
with 30 days of discharge
o Can not provide free care to a patient using hospital employees
Violation of the “Stark” laws
TRANSITIONS IN CARE – HOME CARE’S OPPORTUNITIES
A non-hospital-based agency can provide services to non-homebound
patients paid for by the hospital
 Who gets a seat at the table?
• Excellent Home Health Compare and HH-CAHPS scores
• Avoidance of Adverse Events (drivers of hospitalization)
• Low re-hospitalization and ED incidents
• Patient transition protocols
• Service plan design, including technology with the right pricing
Getting a Seat at the Table
Does your agency stand out?
DO YOU DESERVE A SEAT AT THE TABLE?
• Excellent Outcomes and Low Hospital and Emergent Care Usage
Compare scores
Source: SHP National Database. Provider: VNA of Cape Cod
DEMONSTRATING SOUND BUSINESS PRACTICES
Source: SHP National Database. Provider: VNA of Cape Cod
DO YOU DESERVE A SEAT AT THE TABLE?
• Demonstrating beneficiary satisfaction (excellent HHCAHPS results
Source: SHP National Database. Provider: VNA of Cape Cod
BRINGING TRANSPARENCY TO THE TABLE
• Hospitals want to see detailed data
• Although it’s helpful to show risk-adjusted scores, they’re
oftentimes more interested in raw numbers
• Hospitals find benchmarks interesting, and local benchmarks even
more interesting
DO YOU DESERVE A SEAT AT THE TABLE?
Source: SHP National Database.
WHEN DO MOST OF YOUR READMISSIONS OCCUR?
WHY RAW COUNTS ARE IMPORTANT
DEMONSTRATING TRENDS
ARE YOU GETTING ADMISSIONS THAT ARE
HIGHLY LIKELY TO RE-HOSPITALIZE?
HOME HEALTH NEEDS TO IMPROVE
INTERVENTIONS TO KEEP HIGH RISK PATIENTS
FROM READMITTING
Communities that have a high hospital utilization rate
also have higher readmit rates.
THE TRANSITIONS IN CARE SERVICE PROGRAM
THE “TRANSITIONS IN CARE”
SERVICE PROGRAM
• Pure transitions patients – are not Medicare eligible
• May not be homebound
• May not have Medicare benefits
• May not meet Medicare qualifying criteria
• Always validate the criteria before enrollment!
• Create a separate “transitions” service/program within your
organization
• The patient is an agency patient/client – not in certified home care
program.
• This patient/client becomes part of the “Transitions Program or
Transitions Service Line
WRITTEN CONTRACT
• Must have a written agreement with hospital
•
Include written purpose and scope of transitions program
• Specific responsibilities of both the hospital and the agency
• Responsible parties
• Contact information
• Hours of availability
• Agreed upon payment rates
• Include rates for all functions with inclusion of differentials and
mileage (if indicted)
WRITTEN CONTRACT
• Basic requirements of participation in the program
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Physician participation and orders required
Clients must be willing and able to participate
Specify inclusion of Tele-monitoring or Telephone contact
Frequency and type of contact – focus of care is “contact” not in-home
visit
• Specify (few) circumstances that may require in-home visit
• Patient/client education materials/teaching/follow-up
• Agreement must specify that the program is for a minimum patient service
period of 35 days from hospital discharge at no charge to the patient
TRANSITIONS IN CARE
• Must include complete referral information;
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Patient name
Address
Telephone and emergency contact
Hospital diagnoses
History and physical
Signed patient consent and willingness to participate
Responsible physician and transition services agreement
(participation in transitions program)
NURSING ASSESSMENT VISIT
• Non-OASIS clinical assessment RN visit
• Complete necessary intake and clinical assessment information to
manage (and monitor) the patient
• Identify social service needs and safety issues that may require a
PT, OT or Social Work evaluation
• Perform a complete/thorough Medication reconciliation
• Verify current medication orders
• Schedule a physician follow-up appointment if not already
scheduled
• Verify vital sign parameters and when to notify physician
• Review disease management education with patient/client
• Reaffirm willingness of patient/client to participate in program
THE “TRANSITIONS IN CARE”
SERVICE PROGRAM – TELE-MONITORING
• Monitoring via ongoing remote monitoring of vital signs via telehealth, as ordered
• Must have a process for monitor removal
• Performance of necessary telephone contact with patient and
attending physician
• Vital sign alerts
• Other signs or symptoms indicating a potential problem
• Follow-up visit(s) not anticipated unless specifically ordered by attending
physician and included in written contract
• Transitions program must be included in agency’s quality and performance
improvement process
THE “TRANSITIONS IN CARE”
SERVICE PROGRAM – TELEPHONE CONTACT
• Performance of necessary telephone contact with patient and
attending physician
Establish appropriate frequency for contacts
Set goals for each call
May include teaching patient to take and record vital signs daily
Identification of other signs or symptoms indicating a potential
problem
• Review of medications, response and potential side effects
• Follow-up visit(s) not anticipated unless specifically ordered by attending
physician and included in written contract
• Transitions program must be included in agency’s quality and
performance
improvement process
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THE “TRANSITIONS IN CARE”
SERVICE PROGRAM
• Identify patient enrollment exclusions:
• Strong history of non-compliance with meds, diet and physician
appointments
• Evidence of unsafe/inadequate home environment – patient not safe at
home
• Attending physician must agree to manage the patient care with
shared goals:
• To maintain and improve patients health
• To prevent unnecessary re-hospitalizations and emergency room visits
• To provide patient education ands support/mentoring regarding
symptom and medication management
• To promote compliance with appropriate disease management principles
• Teach self care and independence to patients and families/caregivers
PRICE POINT DEVELOPMENT
PRICE POINT DEVELOPMENT
Visit Pricing to be developed:
1. Nursing visits- initial and follow up
2. Physical Therapy
3. Occupational Therapy
4. Social Work
PRICE POINT DEVELOPMENT
Consideration---
Should you price at full cost including allocated overhead or do you default to
managed care visit prices?
Do your managed care prices per visit constitute a floor for pricing of this model?
Should you use the visit costs that your Medicare cost report show on Worksheet C
Part I? Is a specific cost finding more appropriate?
PRICE POINT DEVELOPMENT
Calculation of cost of an initial and follow up nursing visit:
Direct cost per RN visit averages $77.76 per visit overall.
Total visits were 9,249. Total direct costs were $719,202.
Here is how to isolate the cost per type of RN visit:
RN visits Time Visit Weight
%
Direct cost Per Visit
Admissions
1,214
1.60
1942.40
18.9% $135,881
Discharges
1,214
1.25
1517.50
14.8
Follow up
6,821
1.00
6821.00
66.3
$112
106,157
87
477,164
70
Using 120% of direct cost to in order to account for overhead, your visit price would
be $135 Initial Visit , $84 Follow Up Visit and $21 for a Telephone Follow-up.
PRICE POINT DEVELOPMENT
What cost do you use for pricing an RN visit?
Medicare cost report: $138
Specific cost finding: Initial $ 135
Follow up $84 Telephone Follow-up $21
Largest managed care contract rate: $119
Is this your lowest price?
PRICE POINT DEVELOPMENT
Calculation of PT/OT Visit costs:
Using fully allocated costs per cost report, since all visits are equal:
PT
$132
OT
$133
Use $135 per visit.
Note: costs include employees and contracted staff combined and are derived from
Worksheet C Part I of the cost report modified to reflect managed care division
costs.
PRICE POINT DEVELOPMENT
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Calculation of Cost for a Social Work Visit:
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Social work costs from the cost report are greatly distorted due to fewer actual
visit being made--- much of the cost reflects telephone time.
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Need to do a cost finding on actual cost per visit:
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We looked at our hospice data due to larger staff and more in-person visits.
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We estimated that 60% of total direct costs relate to in-person visits.
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Total direct costs were $493,781. Visits were 3,096.
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As a result, direct costs were $97 per visit. Indirect costs were $58 per visit.
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Overall cost per visit is $155.
PRICE POINT DEVELOPMENT
Estimate for Telemonitoring costs:
All monitoring equipment is fully depreciated at this point.
Costs involve person assigned to pick up and deliver devices to the home and to on
call charges for weekend monitoring of results
Based upon total monthly costs divided by average number of monitors in use, we
have a monthly charge of $70.
Applying 120% of direct cost formula to account for overhead, we arrive at a monthly
charge of $84.
PRICE POINT DEVELOPMENT
Recap of per visit costs:
Nursing—Initial
$135
Nursing ---Follow up
84
PT
135
OT
135
MSW
155
Telemonitoring- per month
84
PRICE POINT DEVELOPMENT
Real life example of implementation:
Large Medicare Advantage plan contract provides for a bonus to reduce
readmissions:
Base line readmission rate of 22%
Bonus based upon savings in hospital costs at $8,000 per admission times the
difference between actual readmissions and the base line readmissions (22% of
hospital discharges assigned to us).
Bonus equals cost of hospital readmissions avoided times:
15% if readmission rate drops by 11 to 20%
25% if readmission rate drops by 21 to 30%
30% if readmission rate drops by over 30%
COST / BENEFIT TO THE HOSPITAL
COST / BENEFIT TO THE HOSPITAL
•
Large 500 bed teaching hospital in the Philadelphia metropolitan area
 Total of 4,627 Medicare Fee for Service discharges in fiscal year 2011
 1,074 (23.21%) discharged patients referred to Homecare
 1,079 (23.32%) discharged patients referred to other post acute settings
 162 (3.50%) discharged patients expired
 2,312 (49.97%) discharged patients not referred to any post acute settings !
 Hospital does not track its re-admission data!
 Hospital’s variable cost per Bed Day is $1,130 and likely a $1,950 total cost
 Hospital’s variable cost of an Emergency Room visit is $124.30 and likely a
$ 214.31 total cost
 Hospital’s re-admission rate on Hospital Compare is above the national average
for all reported measured diagnoses!
 Hospital’s H-CAHP scores are all below national averages!
COST / BENEFIT TO THE HOSPITAL
• The Hospital’s 2011 Medicare revenue was $101,000,000.
• If this was 2013, the Hospital’s 1% penalty risk is $1,010,000
• The Vacated Days and ER visits are estimated:
• Assuming an average of 3 re-hospitalized days for each patient and a
50% patient usage of an emergency room visit (actual data unknown)
• Estimated variable cost:
2,312 patients discharged x 23.07% readmission rate = 533 patients
x 3 re-hospitalized days = 1599 days @ $1,130 =
$1,806,870
50% of 533 patient admitted through ER @ 124.30 =
33,126
$1,839,996
COST / BENEFIT TO THE HOSPITAL
VARIATION AND COSTS OF SERVICES FOR 35 DAYS:
Patient
Variation
RN
Assessment
RN
Follow-up
Calls
Social
Service
Visit
OT
VISIT
Tele-health Total Cost
Monitoring Per patient
RN Only
$ 135 (4)
$84
$ 219
Monitoring
$ 135 (4)
$84
(35) $98
$ 317
OT
$ 135 (4)
$84
$ 133 (35) $98
$ 450
Soc. Work
$ 135 (4)
$84
$ 133 (35) $98
$ 605
$ 155
COST / BENEFIT TO THE HOSPITAL
• Assumed cost of Vacated Days and ER Visit Costs
$ 1,839,996
• Cost of Services – 2,312 patients
•
30% RN only
694 @ $219 =
$ 151,986
•
25% RN & Monitoring
578 @ $317 =
183,226
•
20% RN, Monitoring and OT 462 @ $450 =
207,900
•
25% RN, Monitoring OT & SS 578 @ $605 =
349,690
•
Net Savings to Hospital
892,802
$
947,194
HOSPITAL READMISSION STUDY WITHIN
THE 30-DAY DRG PERIOD
HOSPITAL READMISSION STUDY
WITHIN THE 30-DAY DRG PERIOD
Large Regional Medical Center in a Western State
 680 Readmits (single and multiple)of Medicare Patients within
the DRG Period resulted in 8,214 inpatient days for FY 2003
 23.53% re-admission rate (2,890 Medicare discharges)!
 12.08 average days per readmitted patient!
 Loss of $15,072,700 @ $ 1,835 per Bed Day Cost
Not including ER or any other Department Costs
 Only 80 of the Readmitted Patients had ever been Referred to
Home Care
 Tele-health was not available at the Hospital-based Home
Health Agency
HOSPITAL READMISSION STUDY
WITHIN THE 30-DAY DRG PERIOD
External Review of Readmission DRGs
 231 Readmitted Patients (34%) should have been in Home
Care
 Only 34 of the Readmitted patient were referred to home
care
 Potential Savings to Hospital of 2,752 days (33.50%) @
$1,835 = $5,049,900
 Additional Revenue to Home Care Agency = $482,650
 Estimated 197 Episodes @ $2,450
HOSPITAL READMISSION STUDY
WITHIN THE 30-DAY DRG PERIOD
External Review of Readmission DRGs
 449 Readmitted Patients (66%) should not have been referred to
Home Care
 Could have been eligible for a “Transitions in Care” program
 Potential savings of a significant portion of the $10,022,800 in
vacated days cost!
Pat Laff, Managing Principal, Laff Associates
Lynda Laff, Principal, Laff Associates
Walt Borginis, Executive Vice President/CFO, VNA of Philadelphia
Barbara Rosenblum, Founder and CEO of Strategic Healthcare Programs (SHP)