Transcript 2 - LeadingAge

Post-Acute Care
Collaborative
Maximizing the Impact of
On-Campus Primary Care
Elevating the Health Care Capabilities of
Senior Living Providers
Jared Landis
Practice Manager
Post-Acute Care Collaborative
Theresa Younis
Chief Operating Officer
Agapé Senior
Janet Dinino
Chief Clinical Officer
Agapé Senior
[email protected]
[email protected]
[email protected]
2
The Advisory Board is Uniquely Positioned to Help
Research and Relationships at the Intersection of a Dynamic Industry
The Advisory Board Difference
Hospitals
Post-Acute and
Long-Term Care
Providers
Physician
Groups
We are …
 Willing to challenge conventional wisdom
 Devoted to exceeding member
expectations at every turn
And we offer …
Insurers
Nursing Leaders
 Unique visibility into provider CXOs’
world – challenges, priorities, vendor
perceptions
 Direct access to over 500 in-house
health care experts
Suppliers
3,000+
200+
1,500+
200+
5,000+
Hospitals and
Health Systems
Independent
Physician Practices
Post-Acute Care
Facilities and
Agencies
Health Care Product
and Service
Companies
CXO Relationships
Across the Care
Continuum
©2014 The Advisory Board Company • advisory.com
2
3
Addressing the Key Questions of Post-Acute Providers
Becoming the Post-Acute
Partner of Choice
Navigating the Future of
Post-Acute Care
Industrywide Relationships Offers Unparalleled Perspective on the ValueBased Post-Acute Environment
Building the Seamless Post-Acute Network
Forging a Sector-Specific Value Proposition
•
• What role should each post-acute sector
assume in a value-based delivery system to
meet evolving delivery system demands?
How can post-acute providers create a
seamless post-discharge solution that
appeals to referrers and payers?
• What partnerships, mergers or affiliations
should be considered to align the right set of
offerings?
• What are the patient populations that should
be prioritized for specialty program
development?
• How do post-acute providers build a care
management infrastructure to manage
patients across settings?
• What services and clinical factors
differentiate an organization from
competitors?
Generating a Consistent Referral Stream
Developing Meaningful Clinical Capabilities
• What are the latest trends with regards to
post-acute network development?
• What are the clinical competencies that best
meet emerging market demands?
• How are hospitals and physician groups
approaching the creation of post-acute
scorecards?
• What quality tracking and information
technology investments are required to build
a best-in-class care infrastructure?
• Where are patients going following
discharge from the hospital setting?
©2014 The Advisory Board Company • advisory.com
• How can we upskill our nursing staff and
engage them in key clinical priorities?
3
4
Road Map
1
The Case for Primary Care
2
Practice Model Evaluation: Finding Your Health Care Identity
3
4
Maximizing Program Impact and Sustainability
©2014 The Advisory Board Company • advisory.com
Lessons from the Field: Profiling Agapé Senior
5
Serving Assisted Living a “Hands-Off” Commitment
Opportunity to Improve Resident Outcomes with Primary Care Access
Physicians Serving Assisted Living, 2008-2010
Assisted Living Hospitalizations
Preventable with Outpatient Care Access
n=165
Florida Medicaid Assisted Living, 2003-2008
Physician On-Campus Visit Frequency
Virtually never
visits assisted
living
8%
48%
19%
Several times
per month
n =7,991 patients over 65
Once per week
or more
22%
24%
Preventable
with outpatient
care
Once per year
to once per month
Assisted Living Care Must Evolve with Resident Acuity
“Higher acuity is here to stay in assisted living. Consumers do not want to ‘transfer’ to another setting
once they have made an assisted living community their home. It is the responsibility of regulators,
providers, advocates, and nurses to work together to continue to adapt the assisted living model of care to
meet the needs and expectations of an increasingly acute resident population.”
Josh Allen, American Assisted Living Nurses Association
©2014 The Advisory Board Company • advisory.com
Source: Sloane et al., “Physician Perspectives on Medical Care Delivery in Assisted Living,” Journal of the American Geriatrics Society, 2011,
available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3752597; Allen, J. “Higher acuity in assisted living is here to stay,” Geriatric Nursing, 2011,
available at: www.ncbi.nlm.nih.gov/pubmed/21387580; Becker, Marion et al., “Predictors of Avoidable Hospitalizations Among Assisted Living
Residents,” Journal of the American Medical Directors Association; Post-Acute Care Collaborative interviews and analysis.
6
Primary Care An Asset for Competitive Positioning
CCRC1 Health Services Rated Important
Family Members of Residents Living in CCRCs
n=3,647 family members at 221 CCRCs
77%
66%
62%
61%
51%
Assisted living
Health clinic
services
Skilled nursing Physician and
care
professional
services
Home health
care
48%
47%
Respite care
Physical,
occupational,
speech therapy
41%
Memory
support
program
Competitors Raising Baseline Standards
Seeking to Impact Health Costs
“Over time [primary care] is going to be an
expectation. If you’re going to play in the space
of caring for sicker residents, you have to be
able to elevate the competency of your staff.”
“It’s emergency department visits,
hospitalizations, and keeping people in
independent settings….that’s where the big
buckets of money are.”
VP of Health Care, Senior Living Organization
1) Continuing Care Retirement Community.
©2014 The Advisory Board Company • advisory.com
Chief Medical Officer, Senior Living Organization
Source: Mather Lifeways, “National Survey of Family Members of Residents in CCRCs,” 2011, available at:
www.matherlifewaysinstituteonaging.com/senior-living-providers/national-survey-of-family-members-of-residents-in-ccrcs;
Post-Acute Care Collaborative interviews and analysis.
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With Partnership Options, Few Economic Limitations
Revenue Potential Complements Resident Care Benefits
Business Development Opportunity, On-Campus Primary Care
Shared Savings,
Preferred Contracts
• Timely access to
home health, hospice,
therapy, DME
Facility
Appeal
Partnership
Often Free
• Contracting leverage
from physician practice
alignment
• Timely care plan
updates for necessary
service additions
• Existing resident
retention
• New resident attraction
Cost
Savings
©2014 The Advisory Board Company • advisory.com
•
Transportation costs
•
Regulatory compliance
•
Pharmacy costs
•
Relative ancillary business
marketing costs
Potential Opportunity
• Shared savings from
reduced acute
episodes, transfers to
skilled nursing
Service
Revenue
Source: Post-Acute Care Collaborative interviews and analysis.
8
Road Map
1
The Case for Primary Care
2
Practice Model Evaluation: Finding Your Health Care Identity
3
4
Maximizing Program Impact and Sustainability
©2014 The Advisory Board Company • advisory.com
Lessons from the Field: Profiling Agapé Senior
9
Health Care Strategy Drives Model Choice
Primary Care Model Options
by Health Care Identity, Referrer Neutrality
Employed
Collaborating Clinicians
3
Neutrality
with
External
Providers
(Referrers)
Partner-Provided
Collaborating Clinicians
Partner-Provided
Full Practice
1
Residential & Long-Term
Care Identity
4
2
External Provider
Partnership Models
Employed Primary
Care Practice
Senior LivingEmployed Models
Post-Acute & Long-Term
Care Identity
5
Employed Practice,
Affiliated Health Plan
Whole Senior
Health Identity
Control, Health Care Premium Dollar
©2014 The Advisory Board Company • advisory.com
Source: Post-Acute Care Collaborative interviews and analysis.
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A “Baseline Model” for On-Campus Primary Care
Foundation of On-Campus Practice Models
Team-Based Care
1 MD1, 1-2 APNs2,
1-2 non-clinical support
staff (MAs3)
•
•
Team commonly sees
between 400-600 patients
(small-panel practices a
facility loss-leader)
•
•
Interviewees identify
•
14-17 patients per day
as provider breakeven point
•
1)
2)
3)
4)
5)
Visiting Practice4
Medical Doctor.
Advance Practice Nurses (e.g. nurse practitioners, physician assistant).
Medical Assistants.
Less common for very large facilities, see next slide
Identified as a regulatory grey area in research.
©2014 The Advisory Board Company • advisory.com
Clinicians visit facilities
for full days or half days
(by volume)
Travel in full teams or as
individual providers,
ensuring balance of MD
visits (typically 2-3 APN
visits to 1 MD)
Residential Care Billing
Medicare
Billing Codes
Senior Living
Setting
Home Services
• Private
Residences
Domiciliary,
Rest Home, or
Custodial Care
Services
• Assisted
Living,
• Independent
Living w/
Shared
Services5
Nursing Facility
Services
• Skilled
Nursing
While assisted living
targeted, may also see
independent living or
skilled nursing patients.
Source: Post-Acute Care Collaborative interviews and analysis.
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Building Size Dictates Visit Patterns
An Unsettled Debate Between Room Visits and Informal Clinics
Large Buildings (~400+ patients)
Full-Time On-Campus Clinic
Dedicated Clinic Space
Small-Medium Buildings
Multi-Facility Visiting Practice
1
Multi-Purpose Clinic Space
Description:
Description: Facility designates
room for informal clinic hours for
visiting physicians
Clinic space on campus with exam table(s),
ideally co-located with campus pharmacy
services; room visit service often available
for patients with limited mobility
Rationale: Difficult to leave patient
rooms quickly, limits physician
travel/set-up time, select partner
PCPs strongly prefer clinic model
Rationale:
•
•
•
Facilitates provider communication,
resident familiarity with services
Protects home feel for independent living
residents
Houses EMR technology
©2014 The Advisory Board Company • advisory.com
2
Room-to-Room Practice
Description: Clinicians travel
directly to patient rooms
Rationale: Does not require PCPs
to lease space, avoids lost time
ushering patients to clinic; avoids
lost resident opportunity
Source: Post-Acute Care Collaborative interviews and analysis.
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Addressing On-Campus Clinician Liability
Documentation Key to Minimizing Legal Risk
Managing Liability
Broadly
Managing Liability
in a Partnership
Managing Liability
During Ownership
•
Speak to facility’s liability
insurer before launching
an onsite primary care
program
•
Be aware the SLF will face some
liability risk, even if the onsite
MD is not an employee
•
Be aware that the SLF is liable
for care provided by the onsite
physicians it employs
•
•
Ensure that all clinicians
onsite are fully licensed, in
accordance with state laws
•
Carefully document all care
Take care when marketing onsite •
physician- liability depends in
part on how SLF presented this
clinician (i.e. Was the MD
endorsed? Did the facility clearly
separate the two entities?)
Thoroughly vet all potential
employees, taking into account
not only “fit” within the
organization, but also clinical
capability and licensure
Select Steps to Protect Against Litigation for Onsite Clinical Care
Document ED1
Transport Offers
Add Clinical Detail to
Admission Agreement
Communicate to Create
Clinical Alignment
Thoroughly document
each instance in which
transportation is offered,
yet declined by the resident
Include details of onsite
services availability and
scope, as well as facility’s ED
transfer protocols
Have onsite MD and facility
staff work together to agree
on facility-wide protocols for
medical care
1) Emergency Department.
©2014 The Advisory Board Company • advisory.com
Source: Post-Acute Care Collaborative interviews and analysis.
13
Will Residents Pick ACOs or Medicare Advantage?
Choices Ahead for Providers as Risk-Bearers Seek Partners
Private Health Plans
Fee-For-Service Risk-Bearers
ACOs, Bundled Payment participants
• Preferred Resident Mix:
High proportion of fee-or-service
Medicare patients
• Partnership Value:
Referrals for post-acute services,
resident acute and specialty care access,
gainsharing opportunity, clinical support
• Model Considerations:
Employed physicians may compete with
health systems and/or void ACO attribution
• Additional Considerations:
ACOs, health systems may become
insurers in the future, necessitating
preserved relationships
©2014 The Advisory Board Company • advisory.com
Medicare Advantage, duals plans
• Preferred Resident Mix:
High proportion of residents with
health plan’s product
• Partnership Value:
Preferred reimbursement, bonus
payments for clinical quality performance,
new payment model innovation
• Model Considerations:
Long-term risk contracts are most
commonly executed at physician group
level, warranting narrow physician
alignment or employment
• Additional Considerations:
Health plans require substantial resident
volume to justify developing risk contracts
Source: Post-Acute Care Collaborative interviews and analysis.
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Care Team Expansion with Medicare Advantage Plan
Erickson Living Integrates Mental Health within Medical Group
Employed Interdisciplinary Care Team
Narrow Acute Care Partnerships
PCPs
(MD/NP)
Network fills
specialist, acute
care gaps
Social Workers
Mental Health
Clinical Nurse
Specialists
Health
Plan Care
Coordinators
Podiatrists
Home
Health &
Hospice
Team Serves
Single CCRC
Campus
Medical group
supports
transitions
Erickson Advantage1 2014 Star Ratings
4.5/5
1) Erickson Living’s Medicare Advantage plan.
©2014 The Advisory Board Company • advisory.com
Overall performance
(Parts C & D)
5/5
Health plan services
(Part C)
Source: Erickson Advantage, “2014 Medicare Ratings,” 2014, available at: www.ericksonadvantage.com/2014/pdf/English_star_rating_2014PlanRating_H5652_E.pdf;
Centers for Medicare & Medicaid Services, Evaluation of the Erickson Advantage Continuing Care Retirement Community Demonstration,” available at:
www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/Ptaszek-2008.pdf; 2008; Erickson Living; Post-Acute Care
Collaborative interviews and analysis.
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Road Map
1
The Case for Primary Care
2
Practice Model Evaluation: Finding Your Health Care Identity
3 Maximizing Program Impact and Sustainability
4
Lessons from the Field: Profiling Agapé Senior
©2014 The Advisory Board Company • advisory.com
17
Two Factors Imperative for Program Success
Economic Viability
Program
Success
Drivers of Economic Viability
Clinician Alignment
Drivers of Clinician Alignment
1
Overhead Control
1
Organization-Level Alignment
2
Primary Care Provider Efficiency
2
High-Quality Campus Nursing
3
Entrepreneurial Spirit
3
Commitment to Communication
Productivity Critical for Success
Physician Presence Not Enough
“A flat salary model can be tough…
you pay the doctor the same amount
whether they see 6 people or 20.”
“What we need to produce high quality
care is a real partnership [between
facility staff and PCP].”
CMO, Senior Living Organization
©2014 The Advisory Board Company • advisory.com
Medical Director, Geriatrics Group
Source: Post-Acute Care Collaborative interviews and analysis.
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Economic Viability Driver #1: Overhead Control
Low Fixed Costs Yield Sustainable Practice
Model In Brief
Drivers of Economic Sustainability
Bluestone Physician Services
Bluestone Physician Services
Team Structure:
1 MD, 1-2 NPs, 2 nonclinical team coordinators
1
Visit Pattern:
Entire teams visit
multiple AL facilities1
for full or half days.
Sample Support Beyond Visits:
Teams communicate with AL staff, patients,
families, ancillary providers and complete orders
through home-grown physician portal, design
clinical protocols to enhance AL care delivery.
$26,000
FFS2 Revenue
exceeds costs
Annual Dual Eligible
Patient Savings
z
No Office Overhead
2
Fully visiting practice
model avoids medical
office building expenses;
team travel limits
transportation costs
3
z Attention
Productivity
Compensation tied to
collections prevents losses;
practice helps efficiency by
streamlining administrative
tasks through patient portal
Health Planz Alignment
Practice contracts will all
area payers, participates in
coordination programs (e.g.
medical home) with
additional revenue streams
4
z
Team Coordinators
Non-clinical support staff
schedule patients, support
documentation, coordinate
data submission for
federal/state programs
1) Teams operating this model only visit assisted living residents.
2) Fee-for-service.
©2014 The Advisory Board Company • advisory.com
Source: Bluestone Physician Services, Post-Acute Care Collaborative interviews and analysis.
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Economic Viability Driver #2: Primary Care Provider Efficiency
Maximizing Care Team Productivity
Support Staff, Financial Incentives Create Efficient Environment
Obstacles and Solutions to Clinician Productivity
PCP Productivity
Visit Efficiency
PCPs Unmotivated
to Grow Practice Volume
PCPs Mired in Unscheduled
Conversations, Patient No-Shows
Solution: Add Volume Incentives
Solution: Manage Visits with Support Staff
Individual
Tie PCP payment to practice productivity via
Challenges collections- or RVU1-based compensation,
incenting greater visit volume
Have support staff field impromptu family
requests by scheduling time; if clinic model,
have support staff usher residents to the clinic
for their appointments; allows physician to
maximize billable time
Physicians Fail to Effectively
Delegate to Advanced Practice Nurses
PCPs Burdened with
Administrative Functions
Solution: Link Performance to Team Visits
Solution: Cut Paperwork with Support Staff
Team
Tie physician bonuses to APN productivity,
Challenges incenting PCPs to grow entire team patient
panel, delegate effectively
Equip support staff to assume all possible
non-clinical tasks for care team members,
freeing clinicians to take more appointments
1) Relative Value Unit.
2) Medical Assistant.
©2014 The Advisory Board Company • advisory.com
Source: Post-Acute Care Collaborative interviews and analysis.
21
Economic Viability Driver #3: Entrepreneurial Spirit
Entrepreneurialism Facilitates Practice Growth
Physician-Led Strategies to Attract New Patients
Scheduled
Meet-and-Greets
•
15 minute, non-billable
appointments with residents
and families
Wellness
Programming
•
Education on healthy living,
led by onsite clinicians for
all residents
Contributions to
Program Success
•
Builds patient trust
•
Reminds residents of
program availability
•
Demonstrates clinician
knowledge, expertise
Admission
Appointments
•
Meeting with clinician during
admission process for new
residents
Transitional
Care Support
•
Billable transitional care
management (TCM) interventions
conducted by new clinicians
Physician Availability Governs Practice Growth
“It’s just making yourself known, available, and when people are sick they
can get a hold of you. All of those things will make a practice grow rapidly.”
CMO, Senior Living Organization
©2014 The Advisory Board Company • advisory.com
Source: Post-Acute Care Collaborative interviews and analysis.
22
Clinician Alignment Driver #1: Organization-Level Alignment
Empowering Residents to Pick Their Providers
Health Services Request for Proposal Creation at Asbury Methodist Village
Resident Stakeholder Group:
• 25 residents recruited from
campus leadership groups
• Includes 3 residents who
are physicians
Resident Group Actions: Health Services
Co-Development with Asbury Leadership
Helped
Structure
Resident
Survey
Informed
RFP
Design
Health Services
Request for Proposal
Sample Needs Identified
•
Board certified physicians
•
Dementia, hospice, palliative care,
and pain management experience
•
Same-day acute appointments
•
Willingness to participate in wellness
programming, care coordination
•
Alignment with Asbury outcomes
tracking, health care reform goals
Full RFP Available
Encouraged
Survey
Participation
(68%)
©2014 The Advisory Board Company • advisory.com
Will
Promote
Practice to
Residents
Access the full Asbury Methodist
Village Health Services RFP here
on advisory.com
Source: Asbury; Post-Acute Care Collaborative interviews and analysis.
24
Clinician Alignment Driver #2: High-Quality Campus Nursing
Not all the Physician’s Responsibility
Nursing Quality, Turnover Plagues Physician-Facility Relationships
Challenges Heard from On-Campus Primary Care Groups1
Turnover:
“If we could get really highly
competent nurses at all of our
assisted living partners, to stay
for more than 6 months, we
would be thrilled.”
Ethics:
“The assisted living facilities
just want doctors who will
sign anything under their
noses.”
Limited Clinical Skill:
“Many senior living facilities
are in over their heads when
it comes to dementia and
chronic disease.”
Limited Patient Knowledge:
“We go to the assisted living staff and
ask about the patient, but they don’t
seem to be able to tell us anything.”
Lack of Clinical Presence:
“The staff at the centers are not
clinical, so I’m not aware of that
being a communication point for us.”
1) Quotes representative of physician perspectives across
several states, actual locations blinded.
©2014 The Advisory Board Company • advisory.com
Source: Post-Acute Care Collaborative interviews and analysis.
25
Clinician Alignment Driver #3: Commitment to Communication
Streamlining Communication with Family, AL Staff
Bluestone Physicians Services’ Patient Portal: Bluestone Bridge
Sample Communication Features
Care Team
Messaging :
Messaging pane
facilitates and
documents
communication
between PCPs, AL
staff, other
providers (e.g.
home health),
patient, and family
members
Consolidated Patient Orders:
Order queue allows PCPs to manage all order requests
across multiple facilities, communicate with requesting
providers regarding specific orders, complete orders
and bill for services as appropriate
©2014 The Advisory Board Company • advisory.com
Practice Tracks PCP Response Time
15 minutes
2 hours
Average Daytime
Response Time
Average After-Hours
Response Time
Source: Bluestone Physician Services; Post-Acute Care Collaborative interviews and analysis.
27
Looking Far Beyond Readmission Rates
Data Collection Informs Physician Performance Opportunity
Direct Performance Indicators
PCP-Facility Engagement
Care Management
Preventive Care
• Resident satisfaction
• Advance care planning
completion
• Chronic disease management
process indicators (e.g. LDL
testing, measurement of systolic
function)
• Response time to orders, patient
requests
• Transitional care completion
• Participation in campus wellness
programs
• Time between hospital
discharge, follow-up visit
• HEDIS1 measures
• Proportion of residents seeing PCPs
• Resident care plan adherence
• Residents on medications
deemed unsafe for seniors
Indirect Performance Indicators
Adverse Health Outcomes
Facility Quality
• 30-day readmission rate
• 30-day medication error rate
• 30-day ED visit rate
• Falls per month
• Hospitalization rate
• Residents with facilityacquired UTIs
• Residents moving to skilled
nursing care
• Residents with bedsores
1) Healthcare Effectiveness Data and Information Set
©2014 The Advisory Board Company • advisory.com
Source: Post-Acute Care Collaborative interviews and analysis.
28
Road Map
1
The Case for Primary Care
2
Practice Model Evaluation: Finding Your Health Care Identity
3
4
Maximizing Program Impact and Sustainability
©2014 The Advisory Board Company • advisory.com
Lessons from the Field: Profiling Agapé Senior
29
Today’s Speakers
Theresa Younis
Janet Dinino
President, COO
Chief Clinical Officer
• Responsible for organizational
strategy and clinical quality
• Oversees all service line operations
• Oversees employed clinicians,
directs clinical services and
operations
• Provides administrative leadership
and direction for all Agapé Senior
holdings
• Works with senior leadership
to develop clinical standards,
pathways, and practices
Organization in Brief: Agapé Senior
• Integrated post-acute care provider, based in South Carolina
• Offers independent living, assisted living, skilled nursing, rehabilitation,
hospice, durable medical equipment, pharmacy, and primary care services
• Operates three skilled nursing and rehabilitation centers, ten assisted living
facilities, twenty-two hospice sites, two specialty clinics, and ten freestanding
primary care clinics
©2014 The Advisory Board Company • advisory.com
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
30
The Case for Primary Care
Benefits to Agapé of Onsite PCP1
Reasons for AL Resident Discharge
2009
1
Reduced Resident Turnover
Onsite PCP promotes health and
wellness, allowing residents to
remain at AL2 level of care longer
2
Other
Increased Appeal to Hospitals
Added clinical capability, support
attractive to hospitals interested
in reducing readmission rates
3
Health-
47% Related
Integration with Other Providers
Additional Care Coordination
Compared to facility staff, PCP
better able to direct, communicate
with resident’s other doctors
• Residents with multiple specialists may
struggle to coordinate their treatment
• Onsite PCPs serve as central resource, help
reconcile treatment plans and medications
1) Primary Care Physician.
2) Assisted Living.
©2014 The Advisory Board Company • advisory.com
Source: Assisted Living Federation of America, “2009 Overview of Assisted Living,” 2009,
available at: www.alfa.org; Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
31
Primary Care Extends Beyond Agapé Facilities
PCP Practice Creates Broad Strategic Opportunities
Agapé’s Primary Care Service Development
Clinic Primary Care
and Facility Rounding
Primary Care for
External Communities
Complementary
Support Opportunities
Outpatient Rehab
• Separate revenue source
• New revenue sources
• Early brand awareness
opportunity
– Facility primary care
rounding
• Enhanced quality in
skilled nursing, AL
environments
– In-service support to build
new clinical capabilities
• Reduction in hospital
readmissions
DME1
SNF
– Medical director services
(hourly rate)
Pharmacy
Hospice
1) Durable Medical Equipment.
©2014 The Advisory Board Company • advisory.com
Source: Agapé Senior; Post-Acute Care Collaborative Interviews and analysis.
32
Practice Model Overview
Primary Care Program Staffing Levels1
Compensation Model in Brief
26
Physicians
21
Nurse Practitioners
2
Physician Assistants
MDs assigned to
community clinic
or AL campuses
• In addition to base salary, physicians
receive productivity-based bonus
• Agapé EMR2 automatically
calculates physicians’ bonuses
• Productivity formula considers billing
and collections, not RVUs3
• Collections less affected than RVUs
by factors beyond physician control
Two Areas of Operation for Agapé Primary Care Clinicians
1
Visit AL campuses
in MD4–NP5 teams
2
Operate community
practices
1) Staffing levels reflective of
September, 2014.
2) Electronic Medical Record.
3) Relative Value Units.
4) Medical Doctor.
5) Nurse Practitioner.
©2014 The Advisory Board Company • advisory.com
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
33
Onsite Operations Overview
Agapé Minimizes Burden on Physicians, Focuses on Efficiency
Onsite Care Team Model
Physician
Provides primary care services, works directly with
patient to assess and address health issues
Keys to Efficiency
Administrative Support
Medical assistants handle
administrative tasks, allowing
MD to see additional patients
Nurse Practitioner
Provides direct care, updates physician on patient
progress, each onsite team includes 3 NPs
Medical Assistant
Travels with physician, triages ad hoc patient and
family questions, manages administrative tasks
Physicians travel with PT/INR1 kit,
pulse oximeter, blood pressure cuff,
stethoscope, staple remover kit,
laceration kit, to provide immediate
service when possible
Strong NP Presence
NPs address common patient
needs so MD can focus on
higher acuity cases
Home-Based Appointments
Clinicians visit patients in their
residences to reduce time
between appointments
1) Prothrombrin Time/ Internal Normalized Ratio.
©2014 The Advisory Board Company • advisory.com
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
34
Building Upstream Brand Recognition
Agapé Directly Employs Primary Care Physicians
Senior’s Trajectory from Community To Senior Living
Patient joins
community practice
Patient experiencing
functional decline
PCP Impact:
PCP Impact:
Patient ready to
transition to SL
PCP Impact:
Introduce Agapé
Senior brand
Knowledgably
discuss SL1 options
Provide referral
to Agapé facility
Additional consumer contact
made possible via primary
care practice ownership
Repositioning Agapé Senior’s Image
“We wanted to introduce Agapé Senior to the community at a point
where health and wellness was the question, not institutionalization.”
1) Senior Living.
©2014 The Advisory Board Company • advisory.com
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
35
Employment Model Ensures Physician Presence
Non-Employed PCP Time Allocation
Employed PCP Time Allocation
PCP must balance multiple patient
groups and care settings
Agapé sets PCP schedule, PCP devotes
all time to Agapé patients
Community
Practice
Hospital
Agapé
Facilities
Senior Living:
PCPs onsite 2-3
days per week,
4 hours per day
Agapé
Facilities
Skilled Nursing:
PCPs onsite 5
days per week,
8 hours per day
Benefits of Frequent Onsite Physician Presence
Slows
deterioration
Decreases
resident turnover
©2014 The Advisory Board Company • advisory.com
Reduces
hospitalization
Enables higheracuity admissions
Lengthens resident
stay in SL facility
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
36
Building Patient Base Key to Practice Growth
Steps to Build Primary Care Program
1 Acquire
Community Practices
2
• Purchase existing community
practices with older patient base
• Defrays initial costs, ensures
sufficient patient volume
3
Agapé Senior
Primary Care
Hire
Additional MDs
• Embrace opportunity to employ
new physicians, expand staff
• Minimize Medicare credentialing
lag with dedicated employee
Develop
Onsite Patient Base
• 30-day onboarding plan
for new facilities
• MDs meet with administrators,
facility staff, and residents
• Share information on MD
backgrounds, program success
Patients Drawn to Convenience
of Agapé senior
94% Percentage
living residents enrolled in
Agapé Senior primary care
Medicare credentialing for new MDs
can take up to 6 months, dedicated
staff member streamlines process
©2014 The Advisory Board Company • advisory.com
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
37
Primary Care Opens Additional Revenue Streams
Expanding Practice to External Providers Yields Alignment Opportunity
Linkage Potential for Primary Care Practices at Agapé Senior
Services for Hospitals
Services for External
Senior Living Facilities
Hospice
• Transitional care
management
• Physician practice
management
• SNF physician staffing
• Outpatient palliative care
PCP
Practice
DME1
• Primary care visits
• Clinical programming
• Assistance with new staff
competencies
• Medical director services
Rehab
Pharmacy
A Foot in the Door for Strategic Conversations
“When you look at how our expertise with having a primary care
practice really helps us, it allows us to sit and have conversations with
a health system C-suite that no independent organization can have.”
©2014 The Advisory Board Company • advisory.com
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
38
Agapé Physicians Help Make the Case for Hospice
Agapé Hospice’s Hospital Engagement Points
VPs of Hospital Relations Engage C-Suite
Menu of Hospice Benefits
Tailored to Each Stakeholder’s Interests
Economic
Agapé MDs Engage Key Physicians
Clinical
(Quality,
Satisfaction)
•
•
•
•
•
Reducing readmissions
Decreasing mortality rates
Managing length of stay
GIP contract revenue
New source of care funding for the patient
•
•
Extending life for the patient
Comfortable end-of-life care tailored to
patient preferences
Family support resources
Organization-specific quality
Satisfaction with hospice-provided
transitional services increases hospital
satisfaction and word-of-mouth marketing
•
•
•
•
Liaisons Engage Case Managers
Operational
•
•
•
©2014 The Advisory Board Company • advisory.com
Additional staffing support through GIP
relationship
Timely, effective transitional care
Hospital/SNF staff training programs for
awareness of referral appropriateness
Fundraiser support
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
39
Hardwiring Hospice Utilization Through Integration
General Inpatient Contract Implementation Instills Hospice Champions
Hospital C-Suite
Designates Physician Champion
Hospital
Champion
Development
Champion identifies
stakeholders for
educational engagement,
advocates for hospice
General Inpatient
Contract Signed
Agapé Assigns
Implementation Team
Agapé
Service
Integration
©2014 The Advisory Board Company • advisory.com
Regional president, VP of
strategic partnership, director
of clinical services, patient care
coordinator, and hospice RN
serve hospital
Champion Supports
Multi-Stakeholder Education
Agapé delivers inservices
with physicians, nurses, care
managers, chaplains, to
explain value of hospice; walk
through referral scenarios
Implementation Team Integrates
with Hospital Culture
Agapé team receives
recommended hospital orientation
to ensure alignment with hospital
culture, priorities, mission
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis.
40
Primary Care Service Revenues Only the Beginning
Primary Care Practice Delivers Range of Unexpected Benefits
Marketing Asset for Agapé ALFs
Link to Other Providers
Greater brand
recognition in
the community
Ancillary service
agreements with
non-Agapé ALFs
Selling point
for potential
residents
Support for
inpatient
hospice offering
Benefits of
Primary Care
Ownership
Direct Revenue Generator
Revenue from
community-based
PCP offices
©2014 The Advisory Board Company • advisory.com
Revenue from
PCP services at
non-Agapé ALFs
Source: Agapé Senior; Post-Acute Care Collaborative interviews and analysis