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ACOs: Where Are We At?

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Overview of ACO climate. Kris Mastrangelo presented at Florida Health Care Association (FHCA) 2013.

Overview of ACO climate. Kris Mastrangelo presented at Florida Health Care Association (FHCA) 2013.

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  • 1. ACOs: Where are We At? Presented by: Kris Mastrangelo, OTR/L, MBA, NHA President & CEO Harmony Healthcare International (HHI)
  • 2. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 2 ‚Widen Your Gaze‛ ~Sherlock Holmes Welcome & Thank You
  • 3. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 3 The learner will be able to summarize goals of ACOs The learner will be able to identify and articulate examples of the ACO process The learner will be able to identify strategies for interdisciplinary management of ACOs Objectives
  • 4. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 4Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 4 Accountable Care Organizations ‚It is not the strongest of the species that survive, nor the most intelligent that survive. It is the one that is the most adaptable to change.‛ ~Charles Darwin
  • 5. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 5Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 5 Accountable Care Organizations ‚Voluntary groups of physicians, hospitals, and other health care providers that are willing to assume responsibility for the care of a clearly defined population of Medicare beneficiaries attributed to them on the basis of patients’ use of primary care services. If an ACO succeeds in both delivering high-quality care or improving care and reducing the cost of that care below what would otherwise have been expected, it will share in the savings it achieves for Medicare.‛ The New England Journal of Medicine (NEJM), October 20, 2011 Making Good on ACOs’ Promise – The Final Rule for the Medicare Shared Savings Program Donald M. Berwick MD, Administrator, CMS
  • 6. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 6 Team Medicine First building blocks of integrated team medicine: Model, data and leadership Create a care team that maximizes impact for patients Build a physician culture of multidisciplinary practice
  • 7. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 7 Team Medicine 1. An integrated, flexible physician model ‚Multispecialty group medical practice maximized physicians’ abilities to care for patients through doctor-to-doctor consultation, through the training and mentoring of young physicians, and through the inherent quality controls built into the group‛
  • 8. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 8 Team Medicine 2. Physician-Friendly Data Yields evidence-based medicine
  • 9. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 9 Team Medicine 3. Rethink physician leadership ‚We recruit physicians with a sense that we’re a group practice. We stand for quality. We measure quality and results. We think it’s important that we tell patients we’re going to give them the kind of quality they deserve. You then orient, evaluate, and promote people based on the same set of values and expectations. Eventually you end up with a culture that is very comfortable with a focus on quality, measurement, comparison, and improvement.‛ Jack Cochran, MD
  • 10. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 10 Healthy Bones: Tests and Prescriptions to Prevent Problem: In 2010, osteoporosis was the ninth most costly major illness among the top 5% highest cost Medicare beneficiaries In 2005, 2 million fractures cost the United States $17 billion for both acute and long-term care. By 2025, the annual fracture rate is expected to increase by 50% to about 3 million at a cost of $25 billion per year. On average, 24% of patients presenting with a osteoperosis- related fracture die within one year, and the mortality rate of men exceeds women Only 21% of women age 67 or older who have had an osteoporosis-related fracture had a bone mineral density test or a drug prescription to treat or prevent osteoporosis in the six months after the fracture * Information provided by Kaiser Permanente
  • 11. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 11 Healthy Bones Solution: Care managers, primary care physicians, and surgeons use daily reports generated from the electronic health record to identify members at risk for osteoporosis and fractures Care managers coordinate care for these patients to close care gaps Working together, the team provides patients with education, screening, treatments, and monitoring as needed. The multidisciplinary team includes: Orthopedic surgeons, endocrinologists, gerontologists, family practitioners, internists, rheumatologists, gynecologists, physical therapists, disease/care managers, radiologists and member education
  • 12. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 12 Healthy Bones Impact: Annual bone density screening rates increased by 474% from 2002 to 2009 People on anti-osteoporosis medications increased by 214% from 2002 to 2009 Over 45% reduction in rate of hip fractures (preventing >1400 hip fractures) by 2010 If the Healthy Bones approach were adopted in the United States, the country could achieve a 25% reduction in the rate of hip fractures, preventing 75,000 hip fractures per year
  • 13. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 13 Improvement Standard As the New York Times reported on its front page Tuesday, Reuters (10/24, Morgan) reports that the Obama Administration has proposed a settlement to a class-action lawsuit, promising to broaden current Medicare regulations to allow coverage to "maintain the patient's current condition or ... prevent or slow further deterioration." Previously, beneficiaries had to demonstrate improvement to continue to receive coverage, the change will likely benefit thousands of Americans with degenerative conditions like multiple sclerosis, Parkinson's, and cerebral palsy. An HHS spokeswoman said the settlement merely "clarifies" current policy, and continued, "We expect no changes in access to services or costs."
  • 14. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 14 Improvement Standard The case, Jimmo v. Sebelius, resulted in a focus on skilled service delivery in the context of maintenance programs Historically, patients with chronic conditions and anticipated functional deterioration were considered skilled for the establishment of a maintenance program This settlement now allows for coverage of the actual delivery of maintenance therapy by licensed nurses and therapy professionals
  • 15. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 15 Improvement Standard Current Medicare skilled guidelines state: The services must be provided with the expectation, based on the assessment made by the physician of the patient’s restoration potential, that the condition of the patient will improve materially in a reasonable and generally predictable period of time, Or the services must be necessary for the establishment of a safe and effective maintenance program
  • 16. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 16 Improvement Standard The Proposed Settlement: ‚Instead, providers, contactors, and adjudicators must recognize ‚maintenance‛ coverage and a beneficiary’s need for skilled care that is performed or supervised by professional nurses and therapists.‛ The manual revisions will clarify that, under the Skilled Nursing Facility, Home Health, and Outpatient Therapy maintenance coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (‚skilled care‛) are necessary for the performance of a safe and effective maintenance program Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program
  • 17. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 17 Improvement Standard Quality Care is our number one objective Harmony embraces the OBRA 87 regulations which require facilities to provide services to meet “the highest practicable physical, medical and psychological well-being” of every resident This practice has been our standard since its inception. This new Improvement Standard, further supports our core values as providers of specialized services to the post acute care population.
  • 18. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 18 Continuum of Care Post Discharge ‚When the asthma attack is done, the patient goes home, and the game’s over. No one is accountable for any of the follow-up care.‛ George Halvorson , Chairman & CEO Kaiser Permanente
  • 19. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 19 Integrated Follow-up Call patient to make sure they are accurately taking their medications Call patient to make sure they are avoiding any allergic trigger
  • 20. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 20 Prevention Problem: One in eight women develops breast cancer, and nearly 40,000 die from it every year Regular mammograms – which can identify breast cancer early, when it is most treatable – can reduce breast cancer deaths by more than 30 percent The United States Preventive Services Task Force recommends screenings every one to two years for women aged 50-74 years. However, current screening rates fall short of these guidelines, and they have been steadily declining
  • 21. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 21 Prevention Through the Proactive Office Encounter program, the health care team identifies and targets patients with care gaps (including whether a patient is due for a mammography) or chronic medical conditions and encourages them to actively participate in own care
  • 22. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 22 Proactive Office Encounter and Mammography The program engages all members of the clinical care team in a coordinated and collaborative effort to encourage and support patient health Automated creation of care checklists for all patients whose records indicate gaps in care At every point of contact with patients, clinical care teams review checklists and help patients get the care they need Based on identified gaps in care, medical assistants during office visits discuss with patients the need for preventive screenings and routine care, such as cancer screenings and tests for abnormal blood sugar or cholesterol levels, and schedule appointments on the spot
  • 23. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 23 Proactive Office Encounter Also Helps Along with other concurrent improvement initiatives, the Proactive Office Encounter has contributed to: 30% increase in colon cancer screening 11% increase in breast cancer screening 5% increase in cervical cancer screening 13% improvement in cholesterol control
  • 24. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 24 Data, Data, Data ‚You cannot make bricks without clay.‛ ~Sherlock Holmes
  • 25. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 25 Better Patient Management Using Evidence-Based Medicine Patient Registry and Concurrent Tracking System Identifies all members in the population Risk stratifies population for targeting interventions and resources Tracks and monitors each patient for key indicators (lab, pharmacy, encounters, clinical indicators) Easy access (web-based)
  • 26. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 26 Better Patient Management Using Evidence-Based Medicine Care Management Systems Flags/alerts Supports telephone management and documentation Identifies all members in the population Supports Automated Clinical Decision Support and Practice Tools In-reach/outreach Health Education and Self-Care Support
  • 27. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 27 Evidence-based Medicine/Prevention Proactive care instead of reactive care Patients who have the largest ‚gaps‛ in recommended care do not routinely visit their primary care physicians Specialty clinics must play a role to achieve optimal results. Fewer than 40% of patients needing a mammogram or testing for diabetes visited their primary care physician. Appointments can be made on the spot or referrals generated so gaps can be readily addressed
  • 28. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 28 Beyond the Patient: Widen Your Gaze Focus on primary care and prevention, and addressing chronic disease requires looking at larger communitywide issues Behavioral factors are as important as specific treatments: better diet, promoting physical activity, and reducing smoking Community education for adults and children in recognizing bad health habits and taking action to create a better health outlook
  • 29. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 29Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 29 What is an Accountable Care Organization Healthcare organization with a coordinated set of providers< Provider mix dependent on whether federal or commercial ACO structure Who share responsibility for the continuum of care< Clinical accountability – Quality of care Financial responsibility – Cost of care By providing the highest possible value of care< Increase quality Decrease costs
  • 30. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 30Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 30 What is an Accountable Care Organization For financial incentives or ‚shared savings‛ Value-based payments Reimbursement for achieving cost and quality goals From participating payors Public payors (e.g., Medicare, Medicaid) Commercial payors (e.g., BCBS of MA)
  • 31. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 31Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 31 Key Principles and Elements of ACOs Local accountability Ability to provide and manage continuum of care Responsible and accountable for quality and cost of care Incentivize providers for quality – not quantity Shared Savings Legal entity and governance structure that allows receiving/distributing shared savings payments Invest shared savings in delivery system improvements Capable of financial and resource planning ‚AC0 Model Principles,‛ The Accountable Care Organization Learning Network, http://www.acolearningnetwork.org/why-we-exist/aco-model-principles (Accessed 09/16/2011)
  • 32. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 32Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 32 Key Principles and Elements of ACOs Performance Measurement Ongoing metrics to obtain evidence of meaningful outcome improvements and cost impacts Measurements must be transparent and accessible Essential cost savings are result of meaningful improvements ‚AC0 Model Principles,‛ The Accountable Care Organization Learning Network, http://www.acolearningnetwork.org/why-we-exist/aco-model-principles (Accessed 09/16/2011)
  • 33. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 33Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 33 Why Accountable Care? NationalHealth Expendituresper Capita, 1960-2009 Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file nhegdp09.zip).
  • 34. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 34Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 34 Why Accountable Care? Hospital Care 31 % Physicians & Clinics 20% 1. Includes Research (2%) and Structures and Equipment (4%) 2. Includes expenditures for residential care facilities, ambulance providers, medical care delivered in non-traditional settings (such as community centers, senior citizens centers, schools, and military field stations, and expenditures for Home and Community programs under Medicaid 3. Includes Durable (1%) and Non-durable (2%) goods Dental Services and Other Professionals 7% Government Administration & Net Cost of Health Insurance 7% Nursing Care Facilities & Continuing Care Retirement Communities 6% Rx Drugs 10% Other – 14% Other Health, Residential, and Personal Care2 5% Home Health Care 3% Government Public Health Activities 3% Other Medical Products3 3% Investment1 6% Note: Sum of pieces may not equal 100% due to rounding. Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group.
  • 35. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 35 ACOs by Sponsoring Entity 60% 16% 23% 99 Hospital Systems 27 Health Plans 38 Physicians Groups Note: Percentages don’t total 100% due to rounding. Source: Leavitt Partners
  • 36. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 36Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 36 Perspective: Final Rule for Medicare Shared Savings Program ‚We believe that today’s ACO rule is the next step in our shared commitment to a better, more lasting health care system. We look forward to being a trusted partner in our nation’s journey toward patient-centered, coordinated care.” Donald M. Berwick MD, Administrator, CMS The New England Journal of Medicine (NEJM) October 20, 2011 Making Good on ACOs’ Promise The Final Rule for the Medicare Shared Savings Program
  • 37. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 37Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 37 Medicare Shared Savings Program ACO Requirements Legal Entity Formal legal structure established To receive and distribute any shared savings Proposed rule modified to allow participation of entities organized under Federal or tribal law Sufficient Size Sufficient number of primary care physicians To provide care for at least 5,000 beneficiaries ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.
  • 38. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 38Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 38 Medicare Shared Savings Program ACO Requirements 3-Year Commitment Must commit to participate in the program for at least three years Must provide CMS with 60 days advance notice if terminating agreement Participating ACO will not share in any savings in the performance year for which it notifies CMS of termination ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.
  • 39. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 39Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 39 Medicare Shared Savings Program ACO Requirements Leadership & Governance Must have a mechanism for shared governance and responsibility Management structure must include both clinical and administrative systems ACO participants must hold at least 75% control of the ACO’s governing body Where ACO comprises multiple, otherwise independent entities not under common control, governing body must be separate and unique to the ACO Must provide for beneficiary representation on governing body ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.
  • 40. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 40Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 40 Medicare Shared Savings Program ACO Requirements Leadership & Governance (Cont.) If governing body does not meet requirements, ACO must describe why it seeks to differ from requirements and how it will involve ACO participants in governance in innovative ways and/or provide for meaningful governance participation by Medicare beneficiaries ACO’s operations must be managed by an executive, officer, manager, or general partner, whose appointment and removal are under the control of the governing body Clinical management and oversight must be managed by a senior- level medical director who is one of the ACO’s physicians, is physically present in an established ACO location on a regular basis, and is board-certified and licensed in one of the states in which the ACO operates ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.
  • 41. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 41Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 41 Medicare Shared Savings Program ACO Requirements Performance Measurement Must define, establish, implement, and periodically update processes to promote evidence-based medicine Guidelines must cover those diagnoses with significant potential for achieving quality improvements, while taking into account individual beneficiaries’ circumstances Must define, establish, implement, and periodically update processes and infrastructure for ACO participants and providers/suppliers to internally report on quality and cost measures Must report data on 33 quality measures for each year of performance agreement ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.
  • 42. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 42Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 42 Medicare Shared Savings Program ACO Requirements Patient-Centered Must adopt a focus on patient-centered care that is promoted by the governing body and integrated into practice by leadership and management ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67807-08, 67814-16, 67821-22, 67825, 67827, 67829, 67891, 67980.
  • 43. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 43Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 43 Medicare Shared Savings Program Eligible Entities Final Rule Designation Potential Provider Organizations ACO professionals in group practices • Primary Care Physician Practices Networks of individual practices of ACO professionals • Independent Practice Associations (IPA) • Multispecialty Physician Groups (MSPG) Partnerships or joint venture arrangements between hospitals and ACO professionals • Integrated Delivery Networks (IDN) • Clinical Integrated Networks (CIN) Hospitals employing ACO professionals • Hospital Medical Staff Organizations (MSO) • Physician Hospital Organizations (PHO) • Extended Hospital Medical Staff • Critical Access Hospitals Such other groups of providers of services and suppliers as the Secretary determines ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67812; ‚Accountable Care Organizations: A Roadmap for Success: Guidance on First Steps‛ By Bruce Flareau and Joe Bohn, 1st ed., Virginia Beach, VA: Convergent Publishing, LLC, 2911, pg. 45.
  • 44. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 44Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 44 Medicare Shared Savings Program Quality Reporting Requirements 33 quality reporting criteria across 4 domains include: Domain CMS Criteria 1. Patient/Caregiver Experience Measures 1-7 2. Care coordination/Patient Safety Measures 8-13 3. Preventive Health Measures 14-21 4. At-Risk Population Measures 22-33 ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67889-67890, 67897.
  • 45. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 45 Medicare Shared Savings Program Quality Reporting Requirements Patient/Caregiver Experience (1-7): Getting Timely Care, Appointments, and Information How Well Your Doctors Communicate Patients’ Rating of Doctor Access to Specialists Health Promotion and Education Shared Decision Making Health Status/Functional Status
  • 46. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 46 Medicare Shared Savings Program Quality Reporting Requirements Care coordination/Patient Safety (8-13): Risk-Standardized, All Condition Readmission: The rate of readmissions within 30 days of discharge from an acute care hospital for assigned ACO beneficiary population. Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease [AHRQ Prevention Quality Indicator (PQI) #5] Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure [AHRQ Prevention Quality Indicator (PQI) #8] Percent of PCPs who successfully qualify for an EHR incentive program payment Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility Falls: Screening for Fall Risk
  • 47. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 47 Preventive Health (14-21): Influenza Immunization Pneumococcal Vaccination Adult Weight Screening and Follow-up Tobacco Use Assessment and Tobacco Cessation Intervention Depression Screening Colorectal Cancer Screening Mammography Screening Portion of Adults 18+ who have had their Blood Pressure measured within the preceding two years Medicare Shared Savings Program Quality Reporting Requirements
  • 48. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 48 At-Risk Population (22-33): Diabetes Composite (All or Nothing Scoring): Hemoglobin A1c Control (<8%) Diabetes Composite (All or Nothing Scoring): Low Density Lipoprotein (LDL) (<100) Diabetes Composite (All or Nothing Scoring): Blood Pressure > 140/90 mmHg Diabetes Composite (All or Nothing Scoring): Tobacco Non Use Diabetes Composite (All or Nothing Scoring): Aspirin Use: Daily Aspirin use for patients with Diabetes and Cardiovascular Disease Diabetes Mellitus: Hemoglobin A1c Poor Control (>9%) Medicare Shared Savings Program Quality Reporting Requirements
  • 49. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 49 At-Risk Population (Cont.) Hypertension (HTN): Blood Pressure Control: Percentage of patient visits for patients aged 18 years and older with a diagnosis of HTN with either systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥ 90 mmHg with documented plan of care for hypertension Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL Control <100mg/dl Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Medicare Shared Savings Program Quality Reporting Requirements
  • 50. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 50 At-Risk Population (Cont.) Coronary Artery Disease (CAD) Composite (All or Nothing Scoring): Drug Therapy for Lowering LDL-Cholesterol Coronary Artery Disease (CAD) Composite (All or Nothing Scoring): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular stolic Dysfunction (LVSD). Percentage of patients aged 18 years and older with a diagnosis of CAD who also have Diabetes Mellitus and/or LVSD (LVEF <40%) who were prescribed ACE inhibitor or ARB Medicare Shared Savings Program Quality Reporting Requirements
  • 51. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 51Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 51 Medicare Shared Savings Program Payment Mechanism – Shared Savings ACOs to receive payment for shared Medicare savings provided it Meets the quality performance requirements Demonstrates that it has achieved savings against benchmark of expected average per capita Medicare FFS expenditures An ACO shall be eligible for payment of shared savings ‚*O+nly if the estimated average per capita Medicare expenditures under the ACO for Medicare FFS beneficiaries for Parts A and B services< is at least the percent specified by the Secretary below the applicable benchmark.‛ ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67910, 67927-67930.
  • 52. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 52Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 52 Medicare Shared Savings Program Payment Mechanism – Shared Savings ACOs receive bonuses for achieving resource use and quality targets over the course of a year ACOs face penalties for failing to meet these requirements The final rule sets out two risk models with various incentives for ACOs to receive shared savings payments ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule‛ Federal Register, Vol. 76, No. 212 (November 2, 2011), p. 67910, 67927-67930.
  • 53. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 53Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 53 Federal Anti-Kickback Statute (AKS) Federal Physician Self-Referral Law (Stark Law) Federal Civil Monetary Penalty (CMP) Federal Antitrust Law Federal Tax Law State Regulations Antitrust Fraud and Abuse False Claims Corporate Practice of Medicine Insurance Law Regulatory Considerations
  • 54. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 54Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 54 Regulatory Considerations Federal Anti-Kickback Statute Definition Prohibition against soliciting, receiving, or paying remuneration in exchange for the referral healthcare service billed to Medicare, Medicaid, or any other federal healthcare program. ACO Implication Current safe harbors to potentially shield ACOs from possible violations Direct employment Co-management arrangements Gainsharing ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations and Medicare Program: Waiver Designs in Connection With the Medicare Shared Savings Program and the Innovation Center; Proposed Rule and Notice‛ Federal Register, Vol. 76, No. 67 (April 7, 2011).
  • 55. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 55Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 55 Regulatory Considerations Federal Stark Law Definition Prohibition against physician referrals to providers of Designated Health Services with whom the referring physician has a financial relationship . ACO Implication Compliance with the AKS and Stark may be waived, ‚as may be necessary,‛ to conduct: Any payment model for ACOs that the Secretary determines will improve the quality and efficiency of items and services furnished under the Medicare program The bundled payment/episode of care pilot ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations and Medicare Program: Waiver Designs in Connection With the Medicare Shared Savings Program and the Innovation Center; Proposed Rule and Notice‛ Federal Register, Vol. 76, No. 67 (April 7, 2011).
  • 56. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 56Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 56 Regulatory Considerations Federal Civil Monetary Penalties Definition Civil penalties against hospital payments to physicians for Reducing length of stay Reducing readmission rates Other forms of fraud and abuse ACO Implication HHS has provided a waiver similar to those given for Stark Law and the AKS. ‚Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations and Medicare Program: Waiver Designs in Connection With the Medicare Shared Savings Program and the Innovation Center; Proposed Rule and Notice‛ Federal Register, Vol. 76, No. 67 (April 7, 2011).
  • 57. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 57Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 57 Regulatory Considerations Federal Tax Law Definition Integration between providers coordinating care may cause nonprofit, tax exempt providers and for profit, taxable entities, to merge. ACO Implication Tax-exempt participants in ACOs should be able to remain that way as long as ACO furthers charitable purposes. ‚Accountable Care Organizations: Promise of Better Outcomes at Restrained Costs; Can They Meet Their Challenges?‛ By C. Frederick Geilfuss and Renate M. Gray, BNA’s Health Law Reporter, Vol. 19, no. 956 (July 8, 2010). ‚Herding Cats? What Health Care Reform Means for Hospital-Physician Alignment and Clinical Integration,‛ By Daniel H. Melvin and Chris Jedrey, McDermott, Will & Emery (October 13, 2010), p.38.
  • 58. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 58Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 58 Regulatory Considerations Federal Antitrust Definition Sherman Act, Section 1 prohibits contracts, combinations and conspiracies that unreasonably restrain trade •Applies to independent, competing providers •Does not apply to: •Physicians all within the same group •A hospital and its full-time, employed physicians •A hospital and its controlled subsidiaries ACO Implication FTC and DOJ released proposed rules governing mandatory antitrust monitoring, based on the percentage of market share an ACO has for any specific service line. ‚Proposed Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Saving Program‛ 76 FR 75 (April 19, 2011), p. 21895.
  • 59. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 59Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 59 Large health systems may be in best position to form ACOs Attract more PCPs Vertical Integration will likely aid in transition to ACO May easily meet quality requirements Greater access to capital and IT requirements Potential Hurdles: May need to lower cost or increase private insurers’ cost to generate shared savings Reimbursement Considerations Hospitals ‚Investors Not Likely to Provide ACO Funding Under Proposed Rule, Venture Capitalist Says‛ By Sara Hansard, Bureau of National Affairs, Health Law Reporter, Vol. 20, No. 1026, 2011; ‚Quality over Quantity‛ By Bryn Nelson, The Hospitalist (December 2009), www.the-hospitalist.org/details/article/477391/quality_over_quantity.html, (Accessed 2/28/11).; ‚Will Mayo Clinic save money as an ACO?‛ By Christopher Snowbeck and Don McCanne, Physicians for a National Health Program (February 8, 2011), www.pnhp.org/print/news/2011/february/will-mayo-clinic-save-money-as-an-aco, (Accessed 2/28/11).
  • 60. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 60Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 60 Technology Considerations Electronic Medical Records Significant cost Help eliminate silos and increase continuity of care Meaningful use standards The technological impacts on providers choosing to participate in an ACO are rooted in the primary issue of purchasing or updating an EHR system Costly Must meet meaningful use standards to be eligible for savings EHR integration and alignment among ACO participants is critical to ensure benefits of HIT utilization are obtained ‚Technology Fundamentals for Realizing ACO Success‛, Medicity, September 2010, http://www.himss.org/content/files/Medicity_ACO_Whitepaper.pdf, (Accessed June 30, 2011).
  • 61. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 61Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 61 Key Principles of Accountable Care Underlying Causes of Poor Performance Principles of Accountable Care Lack of clarity about aims, and about whose perspectives are most relevant. Clear aims: better overall health through higher- quality care and lower costs with a focus on patients. Providers are fragmented and unable to coordinate care well; providers accept responsibility only for what they directly control. Establish provider organizations accountable for achieving better results for all of their patients at a lower cost. Payment system drives fragmentation, rewards unnecessary care, and penalizes care coordination and overall efficiency. Align financial, regulatory, and professional incentives with the aims of better health through higher-quality care, lower costs. Inadequate information to support provider and patient confidence about the value of reforms. Valid, meaningful performance measures that support provider accountability for aims and support informed and confident patient care choices.
  • 62. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 62 ACOs: The Numbers The first 32 Medicare ACOs, called ‚Pioneer ACOs‛ were announced in late 2011 In 2012, 27 shared savings ACOs were announced in April 89 more (later decreased to 87 due to attrition) joined in July In January 2013, CMS announced the addition of 106 ACOs
  • 63. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 63 106 Additional ACOs January 2013 On January 10, 2013 CMS announced that 106 ACOs will join the Medicare Shared Savings Program There are 428 ACOs existing in 49 states Physician groups have overtaken hospital systems and have now become the largest backer of ACOs
  • 64. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 64Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 64 ACOs by State
  • 65. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 65Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 65 ACOs by State The only state without an ACO is Delaware, though there have been discussions about forming an ACO in the state California, Florida and Texas lead the nation with 46, 42 and 33 ACOs respectively
  • 66. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 66Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 66 ACOs Growth Growth is focused around population centers, particularly along the West Coast and the Northeast In the past year ACO, growth has increased dramatically around Phoenix, Baltimore/Washington DC, Indianapolis, Omaha, and Portland Maine. Minneapolis, Central Ohio and the large Texas cities continue to have high numbers of ACOs Boston and Los Angeles have the highest concentration of ACOs with 19 each, followed by Orlando with 13
  • 67. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 67Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 67 ACOs Growth In 2012 and the beginning of 2013 ACOs have nearly tripled in number again, with growth coming among all types of sponsoring entities Of the 282 new ACOs in this period 158 (56%) are sponsored by physician groups, 103 (36.5%) by hospital systems, 17 by insurers (6%) and 4 by community-based organizations (1.5%) Research has found similar results among private sector ACOs, with hospital-led ACOs having, on average, considerably larger ACO populations than those led by physician groups
  • 68. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 68Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 68 Differences between ACOs There are significant differences across ACO models in how they try to achieve savings and manage their patient population, particularly between those sponsored by hospital systems and physician groups
  • 69. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 69Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 69 Physician Groups - ACOs Have a general approach that ACOs save money by keeping a patient out of the hospital They accomplish this by managing patient care in outpatient settings, such as by using patient-centered medical homes to coordinate care among specialists
  • 70. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 70Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 70 Hospital Systems - ACOs Focus on better managing patients once they have been admitted to a hospital by trying to coordinate care among departments and providers
  • 71. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 71Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 71 ACOs: Goal Both types of ACOs hope to break down artificial silos so that the appropriate providers will work together to treat the patient at the proper time, as well as follow best practices and more effectively monitor their patient population An ideal ACO will focus on keeping patients from entering a hospital and cost- effectively treating those that are admitted
  • 72. Harmony Healthcare International, Inc. 72 Stewart NF Requests Copyright © 2013 All Rights Reserved
  • 73. Harmony Healthcare International, Inc. 73 Stewart NF Requests ACO goal to use shared blueprint for long-standing quality improvement efforts between our ACOs and nursing facilities and their provider teams The ultimate goal is to help support the "Triple Aim" of improved patient health, improved experience of care, and lower cost of care for the patients we serve. Copyright © 2013 All Rights Reserved
  • 74. Harmony Healthcare International, Inc. 74 Stewart NF Requests The following provides a common starting point for discussion and collaboration Copyright © 2013 All Rights Reserved
  • 75. Harmony Healthcare International, Inc. 75 Stewart NF Requests Performance Expectation /Aspirations Copyright © 2013 All Rights Reserved
  • 76. Harmony Healthcare International, Inc. 76 GENERAL Staffing a. Low staff turnover b. Minimal use of agency nursing/nurse's aides c. A nursing supervisor on all shifts (far preferably on- site) d. A primary care RN/LPN on-site 24/7 for short-stay units e. Facility has a primary nursing (RN or LPN) model with consistent assignment for nurses and CNAs f. Facility has access to adequate interpreter services Copyright © 2013 All Rights Reserved
  • 77. Harmony Healthcare International, Inc. 77 GENERAL System Continuity a. Facility will offer the group‘s preferred providers to all of the group's patients at discharge b. e.g. DME, VNA specialists Copyright © 2013 All Rights Reserved
  • 78. Harmony Healthcare International, Inc. 78 GENERAL Quality Improvement Efforts a. Facility will participate in collaborative QI work with the group (e.g. STAAR Cross- Continuum meetings, monthly case reviews, receive warm hand-offs, etc.) b. Facility will participate in meetings with the group on an as needed basis to cover related topics (e.g. customer service, etc.) Copyright © 2013 All Rights Reserved
  • 79. Harmony Healthcare International, Inc. 79 Stewart NF Requests PRE-ADMISSION Copyright © 2013 All Rights Reserved
  • 80. Harmony Healthcare International, Inc. 80 Pre-Admission Screening /Admission a. Facility will provide patient screens and determination of bed offer within 2 hours of referral b. Facility is willing to collaborate with group on late evening admissions c. Facility will both screen and accept patients seven days per week Copyright © 2013 All Rights Reserved
  • 81. Harmony Healthcare International, Inc. 81 Pre-Admission Screening/ Admission (continued) d. Facility will accept direct admits for qualified patients from home/ER/clinician office e. Facility will identify the patient‘s as group patients when bed offer is made, as reported by the ACO to the facility Copyright © 2013 All Rights Reserved
  • 82. Harmony Healthcare International, Inc. 82 Pre-Admission Medical Coverage a. Facility will assign patients to the group's selected attending physician at time of bed offer (unless patient expresses alternative request) Copyright © 2013 All Rights Reserved
  • 83. Harmony Healthcare International, Inc. 83 Pre-Admission Care Transition a. Facility will develop and maintain a process for the nursing staff to receive a "warm hand-off“ from any referral site Copyright © 2013 All Rights Reserved
  • 84. Harmony Healthcare International, Inc. 84 Stewart NF Requests DURING STAY Copyright © 2013 All Rights Reserved
  • 85. During Stay Facility Environment a. The Facility will provide: An environment (e.g. food, cleanliness, noise, comfort, etc.) that meets patient expectations Critical medications (e.g. pain, antibiotics, anticoagulation, cardiac, etc.) are available at patient's arrival Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 85
  • 86. During Stay a. The Facility will provide (continued): DME that is in the patient's room prior to their arrival when appropriate Suitable work space available for MD and APCs as well as computer/printer access Wireless internet access made available to both patients and to MD/APCs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 86
  • 87. During Stay Care Systems a. Facility will train staff and implement the INTERACT program. If alternative protocols/tools are in place, facility to make available to group. b. Facility will provide high quality mental health coverage: At a minimum for emergent needs, continuous 24/7 telephonic coverage until resolution of emergency All other, telephonic coverage, as well as face-to-face consultation within 2 to 3 days Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 87
  • 88. During Stay Care Systems (continued) c. Facility will provide high quality palliative care consultations d. Facility will assure STAT Radiology, Laboratory obtained and resulted within 4 hours e. Facility will assure STAT prescriptions delivered within 6 hours Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88
  • 89. During Stay Care Systems (continued) f. Facility will assure PT /OT are provided as ordered at least six days per week; if patient arrives before 2 pm, assessment and initial evaluation will be completed and documented on the day of admission. If admitted after 2 pm, evaluation must be completed and documented by the end of the next day. Therapies are available seven days per week. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
  • 90. During Stay Care Planning/Coordination a. Facility will implement care planning meetings that occur within three days of admissions. Patients, families, legal representatives and PCP's care manager are to be notified at least 48 hours prior the family meeting and are encouraged to participate. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 90
  • 91. During Stay Care Planning/Coordination b. Outcomes of this first care planning meeting include: Establishing and documenting the functional goal required for patient to be transferred safely home. Establishing and communicating to patient, care team and group designee the estimated discharge date. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91
  • 92. During Stay Care Planning/Coordination c. Facility will establish a consistent day-of-week and time-of-day (e.g. every Tuesday at 9am) for the interdisciplinary team for the meetings for the group’s patients. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92
  • 93. During Stay Care Planning/Coordination d. Facility case managers are responsible for: Assessment, creation, implementation and documentation of a discharge plan that begins at admission. The discharge plan is revised as appropriate, documents functional status, delivers notification of discharge/termination of benefits letters, etc. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93
  • 94. During Stay Care Planning/Coordination d. Facility case managers are responsible for: Timely collaboration with the group's Case/Care Management staff (e.g. Care Coaches and Case Managers) or their designee with any significant change in status or plan, including, discharge date. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 94
  • 95. During Stay Care Planning/Coordination e. The facility will identify a "point person" who will be responsible for providing both rehabilitation and clinical updates [could be case manager or alternate with easy availability and access to coordinate with group's staff or SNF provider team), including tele-rounding with the group case manager Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95
  • 96. Harmony Healthcare International, Inc. 96 Stewart NF Requests AT DISCHARGE AND POST-DISCHARGE Copyright © 2013 All Rights Reserved
  • 97. At Discharge And Post Discharge Medication Reconciliation and Education a. The facility with assure that patients are given a typed list - in large font - of current medications upon discharge from SNF; medication changes are highlighted and explained; the list is fully reconciled with the home and hospital discharge summary medication lists Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97
  • 98. At Discharge And Post Discharge Advance Directive Documentation a. The facility will assure that: If patient does not arrive to facility with advance directives documented, these will be discussed and documented prior to discharge. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98
  • 99. At Discharge And Post Discharge Advance Directive Documentation a. The facility will assure that: Of note, if the patient is DNR or a completed MOLST form is available, the form will be sent with the patient upon any transfer and through every area of care (including outpatient appointments). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 99
  • 100. At Discharge And Post Discharge Communication of Discharge Paperwork to the Group a. The facility will comply with the standard for completion of page l, 2, 3 referrals and will include a typed discharge medication list to be faxed to the appropriate group and/or PCP fax number for scanning into electronic medical record. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 100
  • 101. At Discharge And Post Discharge Communication of Discharge Paperwork to the Group b. Will fax Falls Assessment to group's designee upon discharge. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 101
  • 102. At Discharge And Post Discharge Standard discharge planning checklist The facility will use a standard discharge planning checklist that includes at least the following: a. Identify family/caregiver availability b. Discharge medication list: Determine patient's ability to acquire needed medications including cost and transportation. Patient will receive appropriate education on medications. Prescriptions for medications. Technique review for example, for inhaler use. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 102
  • 103. At Discharge And Post Discharge Standard discharge planning checklist The facility will use a standard discharge planning checklist that includes at least the following (continued): c. Discharge instructions. d. Ensure patient can "teach back" using consistent teaching tools. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103
  • 104. At Discharge And Post Discharge Selection of Transfer Facility a. If patient requires transfer to acute care facility, patients are to be transferred to original referring acute care facility unless medically contraindicated or due to patient preference. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104
  • 105. Harmony Healthcare International, Inc. 105 Stewart NF Requests Reporting Expectations Copyright © 2013 All Rights Reserved
  • 106. Reporting Expectations During the Relationship with the Group, Facilities Are Expecting To Have The Following Data Updated On At Least A Month Basis (Or Quarterly If Specified Noted Below) To be Made Available In Regular Reports To The Group (Or On Request) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 106
  • 107. Reporting Expectations Bed screen outcomes: a. Bed offer made and bed accepted; b. Reason bed not offered. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 107
  • 108. Reporting Expectations INTERACT QI Review Summary Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 108
  • 109. Reporting Expectations Clinical Programs a. Provide list of specific clinical programs (e.g. cardiac, pulmonary, behavioral) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 109
  • 110. Reporting Expectations Patient satisfaction results a. The facility will survey patients regarding their satisfaction (at least two questions in the survey are from the CAHPS surveys and includes at least and "willingness to recommend") and share the results quarterly with the group. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 110
  • 111. INTERACT QI Review Summary STAFFING a. Staff turn-over rate by staff type (e.g. RN, LPN, CNA, etc.); b. Nurse staffing ratios by staff type (e.g. RN, LPN, CNA, etc.) for both short-stay and long-term patients; c. Flu vaccination rate Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 111
  • 112. Reporting Expectations DPH/Joint Commission Results a. Namely, details of any survey deficiencies. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 112
  • 113. Reporting Expectations QI process measures (as established w/ group) a. For example, number of admissions w/ completed warm hand-offs. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 113
  • 114. Reporting Expectations Functional Improvement Scores a. Use of MDS measures acceptable. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 114
  • 115. Reporting Expectations The following information is expected to be reported to the group in real-time without prompting: 1) Change in Director of Nursing, Administrator or other senior leadership. 2) Change in any "point person" per above, including admission director, case manager etc. 3) If not already employed by the group, any change in staffing of medical coverage or any concerns regarding the ability of the medical coverage provider team of meeting the nee ~s of existing or new patients. 4) If facility is closed for admission (e.g. flu outbreak or other unforeseen event). Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 115
  • 116. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 116 ACOs: Where Do We Go Next?
  • 117. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 117Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 117 ACOs: Next Steps Between care levels (such as between inpatient and outpatient), there is less progress being made The next step in the accountable care movement will require a recognition that levels and locations of care are artificial constructs Payer source should matter much less than focusing on connecting patients with the right provider in the right location for their illness acuity
  • 118. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 118Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 118 ACOs: Next Steps Large physician groups and hospital systems (and eventually post-acute and long term care providers) to work together and align their goals around patient care
  • 119. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 119Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 119 ACOs: Future While ACO growth will undoubtedly continue for at least the immediate future, it still represents a small minority of care delivered in the United States
  • 120. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 120Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 120 ACOs: Future In 2013, many ACOs will complete their first year under a risk-based ACO contract, and their early results will influence how payers, providers and policymakers experiment with future iterations of accountable care If the results are good, then the ACO model may become the dominant form of health care in the United States over the next decade If the results are negative, accountable care may never gain a permanent foothold in our delivery system
  • 121. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 121 Impact on the Skilled Nursing Facility
  • 122. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 122Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 122 Impact on SNF Transparency Might as well adjust to the fact that entities, other than surveyors, will be more interested in what SNFs are doing Outcomes Coordinated, efficient, error free ‚transitions of care‛ Length of Stay Functional rehabilitation progress: Service delivery Re-hospitalization rates Patient and Family Satisfaction
  • 123. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 123Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 123 Impact on SNF Regulatory Level Outcomes Clinical QMs (falls, pressure sores, infection, restraints, pain, psychotropic meds, etc) Pharmacy Error Rates and Safety Annual and Complaint Survey Compliance
  • 124. Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 124Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 124 Depression, PHQ-9 The monitoring and prevention in the geriatric population requires closer scrutiny
  • 125. Questions/Answers Harmony Healthcare International (978) 887 - 8919 www.Harmony-Healthcare.com Connect with Us! @KrisMastrangelo @Harmonyhlthcare facebook.com/HarmonyHealthcareInternational H linkedin.com/company/harmony-healthcare 125Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  • 126. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Harmony Healthcare International, Inc. 126Copyright © 2013 All Rights Reserved