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Post Acute Integration Strategies as we care for more individuals with higher acuity

Post Acute Integration Strategies as we care for more individuals with higher acuity

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  • What we want to talk about today: Update you on our continued progress as a company… Our progress on our quality, people and financial goals Progress on RehabCare merger and integration and Thank You ! (Vista, Dallas TCC’s, Growing Home Health and Hospice Services and Follow-up our Everybody’s Business communication on the difficult reimbursement environment and what it will and will not mean to us Talk about our exciting path forward together and opportunities to we have to continue to grow
  • What we want to talk about today: Update you on our continued progress as a company… Our progress on our quality, people and financial goals Progress on RehabCare merger and integration and Thank You ! (Vista, Dallas TCC’s, Growing Home Health and Hospice Services and Follow-up our Everybody’s Business communication on the difficult reimbursement environment and what it will and will not mean to us Talk about our exciting path forward together and opportunities to we have to continue to grow
  • ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________
  • Relationship spans almost 2 years. 955 patients cared for under this model through May 2011

Idea hour Kindred Healthcare Idea hour Kindred Healthcare Presentation Transcript

  • The Case for Post-Acute Partnerships Kindred Healthcare William M. Altman, Senior Vice President of Strategy & Public Policy
  • Discussion Agenda
    • Why Develop a Post-Acute Strategy?
    • Kindred’s Integrated Care Strategy
    • Partnership Examples of Acute and Post-Acute Collaboration
  • Why Develop a Post Acute Strategy? Demand for Post-Acute Services Aging Demographics Post-Acute Utilization Payment Reform Value Based Purchasing Readmission Penalties Episodic / Bundled Payment Increased Competition Customer Satisfaction Care Coordination Reducing Hospital Readmissions
  • Positioned to Take Advantage of a Changing Healthcare and Payment Environment “ Continue The Care ” Patient Service Intensity Patient Illness Severity HOME SKILLED NURSING FACILITIES HOSPICE HOME HEALTH CARE OUTPATIENT REHAB ASSISTED LIVING ACUTE CARE HOSPITALS TRANS CARE ICU IN-PATIENT REHAB LTACs FREESTANDING/ HIH SAU TCC & TCU ADULT DAY CARE
  • 35% of Medicare beneficiaries are discharged from acute hospitals to post-acute care (1) Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System Tremendous Opportunities Exist to Better Manage Patient Care for Patients Discharged to Post-Acute Medicare Patients’ Use of Post-Acute Services Throughout an “Episode of Care” (1) Patients’ first site of discharge after acute care hospital stay Patients’ use of site during a 90 day episode SHORT-TERM ACUTE CARE HOSPITALS Intensity of Service LONG-TERM ACUTE CARE HOSPITALS Lower Higher INPATIENT REHAB SKILLED NURSING FACILITIES OUTPATIENT REHAB HOME HEALTH CARE 37% 2% 10% 11% 41% 52% 9% 21% 2% 61%
  • Positioned to Help Determine the Most Appropriate Setting for Patients as they Continue Their Care Throughout a Patient Episode 35% 25% 5% Skilled Nursing and Rehab Centers (1) Source: Kindred Internal Data, 2010 data. Home * (16% with Home Health) Inpatient Rehab Facility Patients Discharged From Kindred Long Term Acute Care Hospitals 13% 77% Skilled Nursing and Rehab Centers Home * (45% with Home Health) Patients Discharged from Kindred Inpatient Rehabilitation Facilities 50% Home* (31% with Home Health) Patients Discharged Kindred Nursing and Rehabilitation Centers
  • Operational Imperatives with Payment Reform PREPARING FOR SHARED RISK Stakeholders Physicians Providers Patients Payors Clinicians Improve Patient Quality Reduce Hospital Readmissions Provide Greater Transparency Be More Efficient / Grow Volumes Aligned Incentives Information Sharing Care Management Models Physician Engagement Key Enablers Operational Imperatives
  • Hospital Readmissions Hospital Readmissions By the Numbers 1 20% of Medicare patients are readmitted within 30 days 34% of patients are readmitted within 90 days 56% of patients readmitted within one year 50% of patients readmitted within 30 days and had NOT visited a physician between discharge and readmission
    • Heart Failure
    • COPD
    • Pneumonia
    • AMI
    • CABG
    • PTCA
    • Other Vascular
    Top Readmission Diagnostic Categories 1 “Rehospitalizations Among Patients in the Medicare Fee-For Service Program”, Jencks, Williams, and Coleman, New England Journal of Medicine, April 2, 2009
  • Step-Wise Approach to Integrated Payment
    • Mechanisms to Track and Share Key Data
    • Baseline Performance Measures
    • Processes for Patient Placement
    • IT Linkages
    • Clinical Program Alignment
    • Coordinated Case Management
    • Physician Integration
    • Shared Quality Measures and Goals
    • Aligned Financial Incentives
    • Strategic Oversight
    • Strengthen referral relationships between current sites of care
    • Establish Joint Operating Committee
    • Initial Focus on High Impact Outcomes (e.g., rehospitalizations)
    Path to Integration
    • Collaborative Oversight
    • Information Sharing
    • Care Management Strategies
    • Care and Payment Integration
  • Options for Developing a Post-Acute Strategy Develop Internally Establish and develop internal post-acute care capacity – deploying limited capital and clinical resources Outsource Manage relationships with multiple providers for all levels of post-acute care Partner Partner with progressive post-acute providers to fulfill patient needs
  • Discussion Agenda
    • Why Develop a Post-Acute Strategy?
    • Kindred’s Integrated Care Strategy
    • Partnership Examples of Acute and Post-Acute Collaboration
  • $2.8 billion revenues (1) HOSPITALS Long-term Acute Care Hospitals Inpatient Rehabilitation Hospitals
    • Largest operator in U.S. (2)
    • 120 LTAC hospitals 8,609 licensed beds (3)
    • 5 IRFs
    • 183 licensed beds (3)
    $2.2 billion revenues (1)
    • Third largest nursing center operator in U.S. (2)
    • 224 nursing centers 27,252 licensed beds (3)
    • 6 assisted living facilities 413 licensed beds (3)
    NURSING CENTERS Nursing & Rehabilitation Centers $1.3 billion revenues (1)
    • Largest contract therapy company in U.S. (2)
    • 1,760 external locations served through 10,300 therapists (3)
    • 104 hospital-based acute rehabilitation units (3)
    REHABILITATION SERVICES RehabCare
    • (1) Proforma revenues for the twelve months ended June 30, 2011 (divisional revenues before intercompany eliminations).
    • Ranking based on revenues.
    • As of June 30, 2011.
    Diverse Post-Acute Service Lines
  • Positioned to Take Advantage of a Changing Healthcare and Payment Environment “ Continue The Care ” Patient Service Intensity Patient Illness Severity HOME SKILLED NURSING FACILITIES HOSPICE HOME HEALTH CARE OUTPATIENT REHAB ASSISTED LIVING ACUTE CARE HOSPITALS TRANS CARE ICU IN-PATIENT REHAB LTACs FREESTANDING/ HIH SAU TCC & TCU ADULT DAY CARE
  • Coordinating Clinical Services & Programs Across Service Lines to Improve Outcomes and Prevent Readmissions Long-Term Acute Care Hospitals Hospital Based Sub-Acute Units Inpatient Rehabilitation Facilities Skilled Nursing & Rehabilitation Centers Rehabilitative Therapy Kindred Long-Term Acute Care Hospitals: 28,766 (64%) patients went home or to a lower level of care in 2010 after an average length of stay of 30 days Kindred Inpatient Rehabilitation Facilities 34,960 (76%) patients returned home after an average length of stay of 12 days in 2010 Kindred Rehabilitative Therapy Patient functional improvement from evaluation to discharge was 76.4% in 2010 Kindred Nursing and Rehabilitation: 39,836 (50%) patients returned home after an average length of stay of 32 days in 2010. Home Health & Hospice Services Services Services Specialty Programs Therapies Respiratory & Pulmonary Care Cardiac Care Pulmonary Care Intensive Short-Term Complex Rehabilitation Cardiac Care Pulmonary Care Cardio-Pulmonary and Medically Complex Complex Wound Care IV antibiotic Therapy Clinically Complex Care Reconditioning Wound Care Severe Stroke, Brain, Spinal Cord, and Other Neurological Impairment Wound Care Wound Care Therapies for Complex Wounds Short-Term Rehabilitation Intensive Short –Term & Orthopedic Rehabilitation Complex Cognitive, Physical Rehabilitation Orthopedic and Neurological Rehabilitation Orthopedic Rehab Neurological / Stroke Rehabilitation Dialysis Pain Management IV Therapy Dialysis, Wound Care, Pulmonary Therapy Long-term Chronic Care Palliative & Hospice Care Palliative & Pain Programs Services Skilled Nursing Care w/ Specialty Programs Wound Care, CHF, Methadone Dosing, Med Management, Safety Assessments, IV Therapy Physical, Occupational & Speech Therapy Psychiatric Nursing
  • Increased Focus on Developing Market Specific Integrated and Coordinated Care Delivery Models With Focus On Developing Cluster Market Service Offerings LTACHs (121) Inpatient Rehab Hospitals (5) Nursing and Rehabilitation Centers (224) Acute Rehabilitation Units (113) RehabCare External Customers (1,563) Home Care and Hospice (19) Existing Cluster Market Potential New Cluster Market (as of June 1, 2011)
    • Provide superior clinical outcomes and quality care with an approach which is patient-centered, disciplined and transparent
    • Lower costs today by reducing lengths of stay in acute care hospitals and transition patients home sooner at the highest possible level of function
    • Reduce rehospitalization through our integrated and interdisciplinary care management teams and protocols
    • Support integrated care and payment models and better manage transitions in care because of the diversity of post-acute service lines and experience in managing a post-acute episode of care
    Kindred’s Post-Acute Value Proposition – Generating Savings Today and Tomorrow
  • Key Attributes for Successful Collaboration Information Sharing Communication mechanisms - Joint Operating Committees Information Technology Linkage Inclusion of stakeholders Care Transitions Post-acute clinical programs designed fit hospital need Coordinated staffing, training, and nurse competencies Shared clinical protocols; Care pathways Physician Engagement Physician leadership and buy-in Medical privileges across sites of care Awareness of practice patterns, confidence in partners Quality & Outcomes Shared quality and operating measures Established baseline performance and agreed targets Focus on high impact outcomes (e.g., re-hospitalizations)
  • Discussion Agenda
    • Why Develop a Post-Acute Strategy?
    • Kindred’s Integrated Care Strategy
    • Partnership Examples: Advancing Acute and Post-Acute Collaboration
  • Kindred is Actively Engaged with Hospitals, Health Systems, and Managed Care Organization in Piloting Integrated Care and Payment Models (ACOs, Bundling, Rehospitalization Pilots, Etc.)
  • Partner-Specific Collaborative Strategies The right starting point is the one that we can act on together, today Variety of ways advance coordinated care models Physician Integration CHF Care Pathway Shared PI Process & Nurse Training Cleveland Clinic Saint Francis Healthcare Though the initial focus of the partnerships are different, they key processes supporting their success are the same:
    • Joint Operating Committees with key clinical and administrative leadership
    • Specific operating goals and objectives
    • Performance dashboards, with a focus on high Impact outcomes for immediate results
    Levels of Care for Patient Placement Healthcare Partners Norton Healthcare
  • Physician Integration
    • Kindred Post-Acute Service Lines
    2 Long-Term Acute Care Hospitals 1 Hospital-based Sub-acute Facility 3 Area Skilled Nursing and Rehab Centers 1 Assisted Living Facility Continuity of Rehabilitation Services across Sites of Care
    • Partnered with the Cleveland Clinic for post-acute services to better manage care transitions outside of the Short Term Acute Care delivery system
    • Cleveland Clinic physicians follow patients to Kindred’s post-acute operations, including Medical Leadership at the sub-acute skilled nursing center.
    • Established linkages between the Clinic’s EHR and Kindred post-acute site of services.
    • Formal joint operating committee with Cleveland Clinic leadership with a collaborative focus on continuity of care, re-hospitalizations, and quality.
    • Clinical Programs include Wound Care, Ventilator Care, Infection Management, and short–term Orthopedic and Neurological Rehabilitation.
    Operate 50% of acute care beds Care model includes employed Physicians Health System has Electronic Health Record (EHR) Cleveland Clinic Re-hospitalization rates from SNF have been substantially reduced Kindred Healthcare and the Cleveland Clinic
  • Kindred - Cleveland Clinic Relationship
    • Cleveland Clinic physician coverage for both LTAC & SubAcute level of care
    • Cleveland Clinic physician offices at Kindred Fairhill LTAC
    • Kindred begins as an academic site for Cleveland Clinic residents & medical students
    2009 2010 2011
    • Initiation of the Cleveland Clinic – Kindred “Futures” Committee
    Kindred and the Cleveland Clinic established a post-acute collaborative in 2009 through a Cleveland Clinic RFP with an initial focus on Kindred’s hospital based sub-acute facility and long-term acute care hospitals.
    • Monthly Joint Quality Committee
    • Full-time Dedicated project management
    • Information technology infrastructure in place
    • 675 patients cared for under this model of care.
    • Relationship expands to “The Greens” free-standing Transitional Care Center
    • Interface for physician notes from EPIC to ProTouch goes live
    • Collaborative process improvement initiatives resulting in better performance
    • Developed methodology to determine avoidable return to acute care
    • Identification and review of quality indicators, definitions and calculations to assure true performance comparisons
    • Kindred SAU & SNF admits first patients to the Heart 2 Home program
    • Dr. Michael Felver Medical Dir. of Transitional Care Unit
    • Patient outcomes managed by the Cleveland Clinic physician group reviewed separately
    • Quality indicators have improved since the beginning of the relationship
    Information Sharing Care Transitions Physician Engagement Quality & Outcomes
    • Physician Communication
    • EMR Linkage
    • Joint Operating Committee (JOC)
    • Performance Improvement
      • Employed physician model contributes to relationship continuity
      • Cleveland Clinic physicians provide coverage at Kindred Post-Acute Sites
      • Improved responsiveness to Clinic physicians
    • Developed an interface for the patient registration systems
    • Setup medical record access to the Cleveland Clinic’s HER
    • Automating movement of H&Ps, progress notes, and discharge summaries
      • Monthly meeting composed of administrators, physicians, quality and case management staff
      • Operates under charter defining the objectives of the committee, the parameters of the relationship, and the establishment of a mission
      • JOC uses performance dashboard including LOS, readmission rates, patient satisfaction, quality metrics (e.g., falls, wounds, infections, wean rates, mortality)
        • Cleveland Clinic patients are reviewed separately from the general population
    Key Elements of Kindred-Cleveland Clinic Relationship Multiple Communication Elements Drive Success
  • Clinical Integration
    • Norton is a Brookings – Dartmouth ACO demonstration site
    • Strong connection exists between Norton Hospitals and Kindred LTACs in terms of patient referrals and physicians practicing in both systems
      • Norton hospitals account for ~ 25% of the total admissions to the 2 Louisville Long-term care hospitals
      • Norton hospitals account for ~ 11%of the total admissions to the seven nursing and rehabilitation centers in the market area.
    Kindred Post-Acute Service Lines 2 Long-Term Acute Care Hospitals 1 co-located hospital based sub-acute unit 2 Louisville nursing and rehab centers with 1 transitional care unit 5 southern IN nursing and rehab centers with 2 transitional care units 4 not-for-profit hospitals 1.4 million yearly patient encounters 11,000 employees 2,000 physician medical staff 60,000 admissions per year Norton Healthcare Kindred and Norton Healthcare
  • Clinical Integration
    • Established a task force to evaluate Hospital readmissions and potential opportunities to improve performance
    • Analyzed post-acute utilization, physician practice patterns, and readmits with Kindred leadership
      • To address concerns – engaged the System director for Case Management and Clinical Effectiveness to evaluate:
        • Competencies
        • Performance Improvement
        • Quality
      • Strengthening care coordination, patient assignment, and coverage between Norton physicians and Kindred sites of service:
      • More physicians following patients
      • Improved communication
      • Utilize shared analytics with a focus on reducing Rehospitalization
      • Shared staff competencies, quality measurements
    Hospital Readmissions and Length of Stay
      • Physicians within the same physician group had different practice patterns for patients discharged to post-acute care settings:
        • STAC LOS
        • Readmit rate
      • Barriers needed to be addressed in order to improve utilization of post-acute, specifically, physician confidence in the quality of care and continuous performance improvement processes
    Kindred - Norton Collaborative Physician Alignment Established a “Joint Operating Committee” Kindred clinical liaisons screen patients on day 3 of hospital stay Implemented Norton critical care training for Kindred clinical staff Developed a shared quality dashboard & PI process Clinical Competencies & Nurse Training Expanding hospitalist coverage between acute and post-acute sites of care Kindred and Norton Healthcare
  • Care Pathways
    • Kindred has partnered with Saint Francis Health System, implementing a Joint Operating Committee that is supported by a formal charter and specific objectives
    • The focus is to better integrate our clinical teams and to develop diagnosis specific care pathways, with initial focus on CHF patients.
    • Approach is data driven, utilizing six-sigma trained members
    • Kindred has an Integrated approach to Medical Leadership across our post-acute sites of care, including:
      • Joint physician advisory board to promote care coordination between sites of care.
      • Market Medical Director for Wound Care
      • Physicians which attend in both acute & post-acute settings
    Kindred Post-Acute Service Lines 2 Long-Term Acute Care Hospitals 6 Skilled Nursing and Rehab Centers Hospice and HomeHealth Continuity of Rehabilitation Services across Sites of Care 4 major hospital systems provide short -term acute care services within the Indianapolis market These health systems utilize a broad range of physician affiliations Key Market Characteristics Kindred and the Saint Francis Healthcare System
  • Kindred-Saint Francis Joint Operating Committee
    • Integrate Kindred case management services with St Francis Hospitals, St Francis Health Network and ADVANTAGE Health Solutions case management processes, related to inpatient hospitalizations as well as emergency department admissions
    • Develop and implement processes, procedures, and workflow that contribute to high-quality, efficacious and cost-effective care in the post-acute settings
    • Jointly develop, deliver and analyze key metrics relating to care management across the acute-post acute continuum and within post acute venues
    • Develop key clinical focus areas for improvement (e.g., CHF care pathways) and develop processes, tools and systems to implement the programs
    • Develop a continuous quality improvement mechanism to assure early indicators of success or failure are recognized and incorporated
    • Develop a strategy to imbed SFHN physicians in Kindred post-acute sites of care to enhance clinical capabilities, communication and continuity
    • Share best practices as they evolve, including tools for predicting patients at high risk for readmissions and action steps to manage these patients
    Goals and Objectives for the Collaborative
  • Patient Placement Criteria for Post-Acute Levels of Care
    • Kindred Post-Acute Service Lines
    3 Long-Term Acute Care Hospitals 1 Hospital-based Sub-acute Facility 2 Area Skilled Nursing and Rehabilitation Centers Continuity of Rehabilitation Services
    • Kindred post-acute services agreement is with Healthcare Partners a physician group who contracts with Managed Care Payors to provide health care and case management services.
    • Eight distinct levels of care across three Kindred post-acute service lines, with corresponding rate and clinical criteria for each care level.
    • Centralized Kindred post-acute assessment and admissions function to place patients in the most clinically appropriate setting.
    • Formal joint operating committee with HCP, with a collaborative focus on continuity of care, re-hospitalizations, quality, and cost efficiency.
    • Benefits include cost optimization and improved care coordination.
    Higher than Average Managed Care Penetration Rate Several Managed Care Payors Retain Physician Case Management Group Key Market Characteristics Kindred and Healthcare Partners, Las Vegas - Physician Group
  • Healthcare Partners - Las Vegas, NV
    • HCP IPA at risk w capitation
    • Recognize value of post-acute care
    • Physician involvement in post acute settings is high
    • Patient type matched with post acute site capabilities
    • Priced by patient type as PPD
    Key Aspects of the Kindred and Healthcare Partners Relationship
    • 24 Hour Centralized Admissions
    • Direct Admissions from ER, Home and Physician Office
    • Manage patients down AND up the Continuum
    • Bi-Weekly Interdisciplinary Team Meetings
    • Systemic / Quality Responses
    • Joint Family Conferences
    Kindred’s Las Vegas Continuum of Care Coordination of Care
    • Patient Change in Status
      • Kindred staff performs assessment
      • HCP physician determines action
    • RTA Categorizations (for JOC discussion)
      • Scheduled: Planned service; Upgrade within Kindred
      • Preventable: Kindred responsibility contributed to the need for transfer
      • Non-preventable: Clinical need supported transfer
      • Avoidable: Non-Kindred responsibility contributed to the need for transfer
    Kindred’s Las Vegas Continuum of Care Process: Joy Cleveland 12 Readmission Process and Categorization
  • How is the Continuum Performing- Numbers at a Glance
    • 34.8% of all Hospital Division LTACH discharges went to a SNF
    • 27.2% of Las Vegas LTACH discharges went to a SNF
    • 61.6% of the Las Vegas LTACH discharges that went to a SNF went to a Kindred SNF/SAU
    • 16.8% of Las Vegas LTACH discharges went to a Kindred SNF/SAU
    • 32.5% of total Kindred Las Vegas market admissions were HCP specific
      • SNF/SAU HCP Admits: 49.2%
      • HD HCP Admits: 6.3%
    • 7.3% of total Kindred Las Vegas market admissions were cross-referral (came from another Kindred facility)
  • Important Considerations in Evaluating Kindred as a Post-Acute Partner
    • Culture of quality improvement, track record of producing quality outcomes, and a commitment to transparency
    • Expertise / commitment to enhance patient care episode management across the post-acute continuum
    • Willingness and ability to commit capital
    • Commitment to “evidence-based” operations and research to advance innovations and improvement
    • Willingness to work with Texas Health Resources as a partner
    Working more closely, we have significant opportunities to advance our clinical coordination and improve patient care and quality.