Transcript Hospital Med-Par Data

Niche Development
in Nursing Homes
United Methodist Homes of New Jersey
Larry Carlson, President & CEO
Carol McKinley, Vice President of Operations
Sara Ur, Executive Director - Bristol Glen CCRC
UMH Geography
Bristol Glen
PineRidge of Montclair
Bishop Taylor Manor
Covenant Manor
Wesleyan Arms
Francis Asbury Manor
Collingswood Manor
Pitman Manor
The Shores
Wesley by the Bay
Mission & Values
Compassionately serving in community so that
all are free to chose abundant life
Compassion – demonstrating love in our daily interactions
Respect – seeing and valuing sacred worth
Stewardship – faithfully managing the resources entrusted to us
Service – finding joy in caring
UMH Service Product Lines
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Affordable Housing
Independent Living
Assisted Living
Assisted Living +
Assisted Living Hospice
Memory Support Residence
Skilled Nursing including short-term stay
Community Resource Hub
Hospital Partnership Strategy
Develop a value-based relationship using data
and metrics
– Clinical Quality & Integration
– Resident Satisfaction
– DRG Gap Analysis
– Care Transitions
DATA is KING
• Hospital Discharges
• Readmission Penalties
• Measuring clinical and financial results
Data Driven Partnerships
The most important relationship is CEO to CEO,
physician to physician
Understanding and analyzing hospital discharge data –
MEDPAR
Understanding the differences among hospitals is the
springboard for developing specific value-based
relationships with each organization.
Opportunities
• Recognize high variance
• Understand admission rate
• Understand the implied revenue loss based upon
length of stay
• Reduce and control hospital readmissions
Measure and Report Outcomes
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30-day hospital readmission by diagnosis
Rate of discharge to the community
How each utilizes post-acute care: SNF, Home Health
Clinical Outcomes
Hospital Profile
Discharge Disposition
Discharge
Disposition
Total Discharges
Total Patient Days
Average
Length of Stay
Skilled Nursing Facility
1,376
10,457
7.60
Home Health Agency
1,290
9,183
7.12
Inpatient Rehabilitation Facility
597
3,250
5.44
Long Term Acute Care Hospital
122
1,622
12.30
Other
4,073
16,687
4.10
Total
7,458
41,199
5.52
Category
Hospital Percent
National Average
Heart Attack
21.3%
19.9%
Heart Failure
27.7%
24.7%
Pneumonia
19.7%
18.3%
Hospital Med-Par Data
MS-DRG
Version 26
MS-DRG Name
SNF
Medicare
Part A
Discharges
Acute
Hospital
Days
CMS
GMLOS
Days
ALOS at
Hospital
CMS
GMLOS
LOS Over
(Under)
GMLOS
191
Chronic obstructive pulmonary disease w CC
17
116
70
6.82
4.10
2.72
377
G.I. hemorrhage w MCC
17
130
83
7.65
4.90
2.75
690
Kidney & urinary tract infection w/o MCC
17
83
60
4.88
3.50
1.38
194
Simple pneumonia & pleurisy w CC
15
72
66
4.80
4.40
0.40
481
Hip & femur procedures except major joint w CC
15
87
81
5.80
5.40
0.40
177
Respiratory infections & inflammations w MCC
14
130
101
9.29
7.20
2.09
280
Acute myocardial infarction discharged alive w MCC
14
127
81
9.07
5.80
3.27
392
Esophagitis gastroent & misc digest disorders w/o MCC
13
67
36
5.15
2.80
2.35
308
Cardiac arrhythmia & conduction disorders w MCC
12
97
49
8.08
4.10
3.98
378
G.I. hemorrhage w CC
12
100
44
8.33
3.70
4.63
603
Cellulitis w/o MCC
12
60
47
5.00
3.90
1.10
541
4,314
2,823
7.97
5.22
2.76
Total
Hospital Med-Par Data
MS-DRG
Version 26
MS-DRG Name
SNF
Medicare
Part A
Discharges
Acute
Hospital
Days
CMS
GMLOS
Days
ALOS at
Hospital
CMS
GMLOS
LOS Over
(Under)
GMLOS
945
Rehabilitation w CC/MCC
99
1,480
851
14.95
8.60
6.35
470
Major joint replacement or reattachment of lower extremity
66
264
238
4.00
3.60
0.40
291
Heart failure & shock w MCC
33
281
165
8.52
5.00
3.52
871
Septicemia w/o MV 96+ hours w MCC
33
288
182
8.73
5.50
3.23
292
Heart failure & shock w CC
26
132
107
5.08
4.10
0.98
190
Chronic obstructive pulmonary disease w MCC
24
187
120
7.79
5.00
2.79
193
Simple pneumonia & pleurisy w MCC
22
141
119
6.41
5.40
1.01
057
Degenerative nervous system disorders w/o MCC
21
101
82
4.95
3.90
1.05
689
Kidney & urinary tract infections w MCC
21
143
103
6.81
4.90
1.91
641
Nutritional & misc metabolic disorders w/o MCC
20
85
62
4.25
3.10
1.15
065
Intracranial hemorrhage or cerebral infarction w CC
18
140
77
7.78
4.30
3.48
Partnership Pathway
• Joint Operating Committee
• Develop a specialty clinical niche to match the
hospital’s need
• Extend the hospital clinical pathway into the SNF
• Manage Transitions
• Share medical records through cloud technology
Bristol Glen CCRC
• Located in Newton, Sussex County NJ
• We offer Independent Living, Assisted Living,
Memory Support, Rehabilitation, Long Term
Care
Our Healthcare Neighborhood
– 60 bed community
– Average Medicare Number: 19
– Average Healthcare Census: 59
Hospital Med-Par Data
MS-DRG
Version 26
871
MS-DRG Name
Septicemia w/o MV 96+ hours w MCC
SNF
Medicare
Part A
Discharges
Acute
Hospital
Days
CMS
GMLOS
Days
ALOS at
Hospital
CMS
GMLOS
LOS Over
(Under)
GMLOS
119
952
637
8.00
5.35
2.65
470
Major joint replacement or reattachment of lower extremity
53
251
216
3.98
3.42
0.56
291
Heart failure & shock w MCC
41
226
154
5.51
3.99
1.52
35
234
146
6.69
4.16
2.53
194
Simple pneumonia & pleurisy w MCC
291
Heart failure & shock w CC
32
244
153
7.63
4.77
2.85
190
Chronic obstructive pulmonary disease w MCC
16
120
72
7.50
4.52
2.98
481
Hip &Femur Procedures Except Major Joint w CC
27
150
137
5.56
5.07
0.48
552
Medical Back Problems with W/O MCC
24
125
79
5.21
3.28
1.93
683
Renal Failure W CC
23
131
92
5.70
3.99
1.70
641
Nutritional & misc metabolic disorders w/o MCC
22
114
64
5.18
2.89
2.29
872
Septicemia or Severe Sepsis W/O MV 96+hours W/O MCC
22
147
96
6.68
4.46
2.22
Hospital Med-Par Data
MS-DRG
Version 26
MS-DRG Name
SNF
Medicare
Part A
Discharges
Acute
Hospital
Days
CMS
GMLOS
Days
ALOS at
Hospital
CMS
GMLOS
LOS Over
(Under)
GMLOS
689
Kidney & Urinary Tract Infections W MCC
21
125
98
5.95
4.64
1.31
177
Respiratory Infections and Inflammation W MCC
19
180
129
9.47
6.81
2.67
392
Esophagitis,Gastroent, &Misc Digest Disorders W/O MCC
18
112
50
6.22
2.77
3.45
16
57
48
3.56
3.02
0.54
563
Fx. SPRN,STRN,&DISL, Except Femur,Hip,Pelvis,and Thigh W/O MCC
189
Pulmonary Edema & Respiratory Failure
15
125
65
8.33
4.33
4.00
378
G.I Hemorrhage w CC
15
87
53
5.80
3.52
2.28
280
Acute Myocardial Infarction, Discharged Alive W MCC
14
115
73
8.21
5.22
3.00
TOTAL
593
3,814
2,587
6.43
4.36
2.07
Hospital Med-Par Analysis
• Review of the Hospital Med-Par Analysis to indict
where to focus
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Top MS-DRGs
SNF Medicare Part A Discharges
Review of Hospital LOS versus CMS LOS
LOS Over/Under GMLOS
• Discussions with discharge planners regarding difficult
discharges
• Readmissions Rates
Our Partners
Active Members of the community that we brought together to
review the results of the Med-Par Analysis to develop solutions
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Newton Medical Center
Alliance Rehabilitation
At Home Medical
Ocean Medical
Skyland's Medical Group
Pulmonologist and APN attached to the hospital and
Bristol Glen
Clinical Niche---- COPD
• Disease Management Program
• Who is a good candidate for the COPD
management program?
– A patient with a primary or secondary diagnosis of
COPD
– A patient that requires durable medical
equipment
• Bipap,Cpap, Continous oxygen
Objective of the COPD Management Program
• Educate recently diagnosed COPD residents/
families assuring a better quality of life
• Reduce readmission rates.
• Provide proper medical equipment upon
discharge.
Assessment and Planning
• Comprehensive assessment of respiratory
status to determine baseline and criteria for
COPD program.
• Complete medication reconciliation
• Consistently monitoring for cyanosis especially
in therapy
Referral Received
↓
Respiratory Diagnosis
__ COPD
↙
__ Acute
__ Other Respiratory Diagnosis
↘
__ Chronic
__ Multiple Hospitalizations
__ 0² Dependent
__ New to 0²
__ Nebulizer Treatments
__ CPAPP/BIPAPP Treatments
__ Percussion Vest
↓
Refer to Bristol Glen in House COPD Program
__ Stop
Equipment Company → No Equipment Company → Refer to At Home Medical COPD Program
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↘
__ At Home Medical
__ Other Medical Co.
↓
Refer to At Home Medical
COPD Program
↓
Refer to VNA
COPD Program
Assessment Day 14-28
• Interventions to Occur during care period:
• Assess and reconcile all medications. Instruct in purpose, route,
frequency, side effects. Instruct on use of bronchodilator,
mucolytics, expectorants, and nebulizers as ordered.
• Assess respiratory status – lung sounds, respiration rate, depth,
rhythm, use of accessory muscles, etc.
• Assess level of dyspnea with activity and at rest, note change in
status or assessment goal.
• Instruct: to avoid stressors precipitate disease exacerbation of
(including temperature extremes & infection).
• Instruct: S/S infection including temp evaluation, change in sputum
to yellow/green, and increased viscosity.
Therapy Best Practices
• Initial Assessment/Evaluations
– Record Vitals/Monitor BORG and RPE
– Assess ROM of all 4 extremities
– Assess strength of all major muscle groups through
manual muscle testing
– Assess Gait Pattern with or without a device
– Perform the Six Minute Walk Test
– Perform Dynamic Gait Index on patients with
suspected balance dysfunction
Suggested Interdisciplinary Stages for Patients with Cardiopulmonary History/Precautions
(METs and ADL Category)
Stage/MET Level
ADL and Mobility
Exercise Capacity
Recreation
Stage 1
1.0 to 1.4 MET(s)
Bed Mobility
Hands & face washing
Self-Feeding
Transfers required
10 to 15 min/extremity and
deep breathing
Increase sitting tolerance
progressively
Stage II
1.4 to 2.0 MET(s)
Unlimited sitting
Bathing, shaving,
Grooming and dressing
Room ambulation only
Increase extremity # of
Repetitions
No Isometrics
Sitting activities i.e.
Crafts, sewing, knitting
Stage III
2.0 to 3.0 MET(s)
Brief standing for
Hygiene and grooming
Short outside room
Ambulation
Balance and light mat
Activities
Paced ambulation at
comfortable pace
Any form of tolerable
Sitting activities
Stage IV
3.0 to 3.5 MET(s)
Standing : total
Washing and dressing Light
advanced ADL(s) i.e.
cooking, cleaning Unlimited
ambulation
Increase # and speed of
repetitions
Stair climbing, cycling to
5mph and treadmill at 1mph
to 1.5 @ 2%
Driving
Light gardening, ability to
weed and plant
Stage V
3.6 to 4.0 MET(s)
Washing dishes, making
beds, ironing, & hanging
clothes
Increasing the speed and
repetitions of Stage IV.
Cycling to 8mph (no
resistance) +sitting exercises
Swimming, golfing with cart
and light home repairs
Standing showering in hot
water, raking and mopping
Walking up 4-6% grade hills
and cycling up to
10mph. Also, 10-17 #’s of
resistance for limbs
Slow dancing and light
calisthenics to tolerable
range of motion
Stage VI
4.1 to 5 MET(s)
Light handwork and table
games
Durable Medical Equipment to Home
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Oxygen Testing:
Documentation of Qualifying ABG (P02 of < 55) or pulse oximetry (<88%)
results obtained under the following conditions in the patient’s medical
record (must document testing condition):
ABG or pulse oximetry results within 48 hours of Hospital discharge
ABG or pulse oximetry results within the last 30 days Office/Facility
Resting on room air (if at 88% or below, only this condition needs to be
documented)
Ambulating on room air
Ambulating with oxygen applied
Nocturnal
Nocturnal oximetry must be for a minimum of 2 hours and include 5
cumulative minutes of qualifying saturations
– PO2 of 88% or less will qualify a resident for DME at Home under Medicare
The Home Visit
• Providing clinical follow-up and re-education on DME if
ordered.
• Evaluating patient for an oxygen conserving device PRN.
• Instructing on proper breathing exercises and technique.
• Educating on proper nutrition.
• Discussing shortness of breath scale.
• Reviewing medications and ensuring prescriptions have
been filled.
• Reviewing/instructing on proper MDI and nebulizer usage,
techniques and care.
Resident/Caregiver Outcomes
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(V) Verbalizes (D) Demonstrates
Knowledge of reasons to take medications as ordered with
understanding of route, frequency, purpose and side effects, as
appropriate. (V)
Correct use of 0², nebulizers, inhalers. (D)
Effects of stressors on disease process, breathing and lifestyle. (V)
Coughing and deep breathing exercises; energy conservation. (D)
Correct use of bronchodilators, mucolytics, expectorants,
nebulizers. (D)
Adequate fluid intake to help liquefy secretion. (V)
3 safety issues regarding use of oxygen. (V)
Importance: Consulting with physician before using OTC meds. (V)
The Outcomes
• The communication that was developed
between the partnerships and discussions
from the hospital provided:
– Readmission Rate for the Healthcare Neighborhood for August and
September:
0% Readmission Rate
– Average Medicare COPD Admissions for the last 6 months: 40%
admissions
Next Steps--- Where are we going
• Hiring of a Respiratory Therapist to the team to
enhance the needs of our residents
• Continuing to strengthen the lines of communication
with the hospital for Bundling Payments
• Outpatient Therapy to allow residents to continue
achieving their goals and quality of life.
• Home and Community Based Services – reaching out to
the community, providing services, answering their
needs. Meeting the needs of the community outside
our walls.
The Shores at Wesley Manor
• 190 Apartment Community
– Memory Support
– Hospice
– Assisted Living
– Assisted Living Plus
• 60 Unit Health Care
– 22 Sub-Acute
– 38 Long Term
Hospital Med-Par Analysis
• Community Hospital
• Major care provider
in local area.
• Affiliations with
Philadelphia
Hospitals
• 296 Acute Beds
• 30% Skilled Nursing
Discharge
Dispositions
Hospital Med-Par Analysis
Hospital Med-Par Data
MS-DRG
Version 26
MS-DRG Name
SNF
Medicare
Part A
Discharges
Acute
Hospital
Days
CMS
GMLOS
Days
ALOS at
Hospital
CMS
GMLOS
LOS Over
(Under)
GMLOS
945
Rehabilitation w CC/MCC
99
1,480
851
14.95
8.60
6.35
470
Major joint replacement or reattachment of lower extremity
66
264
238
4.00
3.60
0.40
291
Heart failure & shock w MCC
33
281
165
8.52
5.00
3.52
871
Septicemia w/o MV 96+ hours w MCC
33
288
182
8.73
5.50
3.23
292
Heart failure & shock w CC
26
132
107
5.08
4.10
0.98
190
Chronic obstructive pulmonary disease w MCC
24
187
120
7.79
5.00
2.79
193
Simple pneumonia & pleurisy w MCC
22
141
119
6.41
5.40
1.01
057
Degenerative nervous system disorders w/o MCC
21
101
82
4.95
3.90
1.05
689
Kidney & urinary tract infections w MCC
21
143
103
6.81
4.90
1.91
641
Nutritional & misc metabolic disorders w/o MCC
20
85
62
4.25
3.10
1.15
065
Intracranial hemorrhage or cerebral infarction w CC
18
140
77
7.78
4.30
3.48
Hospital Med-Par Data
Hospital Med-Par Data
Heart Failure
• LOS 4.57
Initial Discussions for Cardiac Niche
• CEO
• Selected Hospital Leaders (CMO; CNO)
• Cardiology Group
Partnerships
• Determined partnerships based on like
philosophies and outcomes:
– Non-profit backgrounds
– High standards of care
– Collaborative in nature
– Person-centered in service
– Invested in process
Original Partnerships
Mainland Heart
Consultants
Protocols
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Collaborative Effort
Care Pathways
Training
Equipment
Telehealth
Staffing
Goal of Program
• Overall agreed goal of program:
To provide the highest level of care to residents with
the condition of CHF and to improve their quality of
life, prevent exacerbations and re-hospitalizations
Care Pathways Examples
• Who should be in program: CHF; cardiomyopathy;
Ejection fraction < 40%; Hx of significant valvular
disease
• Established Care Guide Initiatives that include:
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Vital signs q shift/prn
Orthostatic BP q week sitting/standing 1 minute
Pulse Oximetry q shift
Measure intake/output q 8 hrs
Daily weight at same time q day; same type of clothing
and on same scale. Follow set reporting parameters for
weight gain
Care Pathway Examples
• Obtain baseline laboratory and diagnostics: CBC;
complete Metabolic panel; Urinalysis; microalbuminuria,
fasting lipid profile, albumin, TSH, chest x-ray, and EKG.
• Peripheral Edema Management Protocols/Parameters
• Observation for signs and symptoms of CHF:
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Unexplained weight gain > 3lbs in 24 hours, or 5 lbs in 3 days
New edema
New dyspnea
New abdominal symptoms
Education
• Appropriate staff members received CHF
training
• Telehealth training
Equipment Needs
• Telehealth – weigh scale – provided by home
health agency
• Portable Cardiac Monitor
• EMR reflection of protocols/orders
• Disease Managed Assessment Software
(COMS)
Staffing
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Registered Nurses
Cardiac nurses
Utilized NPs of Cardiology Group
Therapists
Adding RT
Moving to 12 hour nursing shifts subacute
Physicians
• Utilized their requested standing orders for
Heart Failure
• Adjusted as requested by MD
Outcomes
• In last six months – 37 admissions (50%) for CHF
from the hospital
• 25 were discharged to home
• 6 discharged to assisted living
• 4 to long term care
• 2 readmissions for end stage failure due to lack of
DNH/DNR
• Robust census
• 0% readmission in last quarter.
Issues
• Changing Environment
– Change in hospital leadership
– Mergers/affiliations of physicians and cardiac
groups
– Shortages of cardiac physicians
– Changes of personnel in physician groups ie NP or
PA
Potential Concerns
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Multiple hospitals serve you/selection
Multiple DRG/LOS issues
Speaking to the right person
Competition (Super PACS; Developed
Programs for sale)
Conclusion
• Health Care Environment Changing
• SNFs are at risk
• ACOs, Hospital Systems, Insurance Carriers are
driving the conversation
• Being Creative and Assertive is Essential
• Determine the Value You Bring to the
Relationship
“Our real problem, then, is not our
strength today; it is rather the vital
necessity of action today to ensure
our strength tomorrow.”
~ Dwight D. Eisenhower -
Questions??????