Transitional Care CEU

1. Transitional Care
CONTINUING EDUCATION COURSE
NATIONAL READMISSION PREVENTION COLLABORATIVE
FOR MORE INFORMATION & FURTHER RESOURCES VISIT WWW.NATIONALREADM ISSIONPREVENTION.COM

2. Why Transitional Care Matters
In 2010, President Obama passed the Patient Protection and Affordable Care Act of 2010
(PPACA). This act was in part passed to end the fee for service model of reimbursing healthcare
providers, to move to a value based care model that encouraged enhanced communication
between caregivers, reduced costs and improved quality.
PPACA mandated the creation of The Center for Medicare and Medicaid Innovation (The
Innovation Center), implemented a Hospital Readmission Penalty Program and led to the
establishment of Bundled Payments for Care Improvement (BPCI) initiatives as well.
Each of these factors increased the importance of improved transitional care for patients
frequenting acute hospitals and other inpatient and outpatient facilities.

3. A Brief History of the Hospital Readmission Penalty Program
In 2010, President Obama introduced the Patient Protection and Affordable Care Act of 2010 (PPACA).
PPACA is often referred to ‘ObamaCare.’ Included in the landmark legislation was a new program
titled “The Hospital Readmission Penalty Program”.
The program was designed to address several factors, including:
- Reducing the amount of Medicare dollars spent on avoidable re-hospitalizations
- To give acute hospitals a financial incentive to ensure proper care is delivered during hospitalization,
as well as to ensure the hospital provides and communicates to the patient and family a post acute
care plan
- To encourage communication between acute and post acute providers

4. - The Center for Medicare and Medicaid Services (CMS) defines readmissions eligible for
consideration in the penalty program as follows:
“A Medicare beneficiary who is readmitted as an inpatient to a short stay acute hospital within 30
days of discharge from any acute hospital.”
- Although the “all cause” readmission rate is considered in issuing penalties, the penalties are
assessed based on readmission rates in specific disease/condition categories.
How the Hospital Readmission Penalty Program Works

5. Causes of Avoidable Readmissions
There are many causes:
- Poor hydration and nutrition
- Mismanagement of medication
- Patient anxiety and fear
- Unclear discharges orders from the hospital
- Social determinants including lack of transportation
- Patient literacy (understanding of directions)
- Lack of understanding of alternatives to the hospital such as clinics, urgent care, telemedicine
or other patient resources

6. Other Readmission Facts
- CMS estimates that up to 75% of all readmissions are avoidable.
- The average all-cause readmission rate for Medicare patients is between 10-20%.
- CMS identified common causes of avoidable readmissions as:
◦ Not sharing all relevant clinical information with patient, family and caregiver
◦ Patients and family calling 911 prematurely, unnecessarily and for non-emergent situations
◦ Medication mismanagement and adherence
Enhanced transitional care management can improve this process.

7. Readmission Risk Factors
- CMS has identified several readmission risk factors, including:
- Age
- Race
- Health literacy
- Weight loss

8. Nursing Homes and Readmissions
- Approximately 20% of all hospital readmissions from skilled nursing facilities (SNF) occur in the
initial seven days after admission to the SNF
- CMS has identified main causes of SNF patients readmitting to the hospital include:
◦ Patient, family and caregiver expectations
◦ Increasing medical and psychological complexity
◦ Pressure on nursing home from payers and hospital to shorten the SNF length of stay
- As of 2018, skilled nursing facilities are also subject to penalties for excessive readmissions to
hospitals

9. Simplifying the Readmission Penalty
Point of Clarity: Hospitals do get reimbursed by CMS for readmissions. However, each fiscal year
their actual readmission rate is measured against its weighted, risk adjusted projected rate and if
it exceeds the projection, CMS withholds up to 3% of the hospitals overall Medicare spend.

10. Tactics to Reduce Avoidable Readmissions
Popular tactics hospitals and physicians implement to reduce avoidable readmissions include:
◦ Patient, family and care giver education
◦ Risk assessing each patient
◦ Communicating between providers
◦ Medication management and planning
◦ Medication reconciliation after hospitalization
◦ Implementing formal Care Coordination Programs
◦ Follow up phone calls
◦ Nurses and doctors requiring teach-back from the patients and caregivers to confirm care plan
comprehension
◦ Clear discharge instructions and guidelines
◦ Utilize home based care givers when dependents are not available

11. Bundled Payments for Care Improvement
A bundled payment methodology involves combining the payments for physician, hospital, and
other health care provider services into a single bundled payment amount. This amount is
calculated based on the expected costs of all items and services furnished to a beneficiary
during an episode of care. Payment models that provide a single bundled payment to health
care providers can motivate health care providers to furnish services efficiently, to better
coordinate care, and to improve the quality of care.
Health care providers receiving a bundled payment may either realize a gain or loss, based on
how successfully they manage resources and total costs throughout each episode of care.

12. More on BPCI
A bundled payment also creates an incentive for providers and suppliers to coordinate and
deliver care more efficiently because a single bundled payment will often cover services
furnished by various health care providers in multiple care delivery settings.

13. Incentives for Creating Bundled Payment Programs?
- Lower healthcare spending
- Improved patient care
- Improved overall health
- Reduced avoidable admissions
- Improved coordination between doctors, hospitals, post acute providers and caregivers

14. More on BPCI
A bundled payment also creates an incentive for providers and suppliers to coordinate and deliver care more efficiently
because a single bundled payment will often cover services furnished by various health care providers in multiple care
delivery settings.
The original BPCI Initiative introduced four separate Bundled Payment models.
The first mandatory BPCI program launched April 1, 2016 focusing on total knee and hip replacements and was
introduced in 67 markets to 465 hospitals and is known as Comprehensive Care for Joint Replacement (CJR).
Why CJR as the first mandatory program?
- Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require long
recoveries making patients vulnerable to readmission unless care is coordinated.
- The variance in cost and quality between providers on hip and knee replacements was significant in fee for service

15. Retrospective Models
Models 1, Models 2 and Model 3 involve a retrospective bundled payment arrangement where
actual expenditures are reconciled against a target price for an episode of care. In Model 2, the
episode includes the inpatient stay in an acute care hospital plus the post-acute care and all
related services up to 90 days after hospital discharge. In Model 3, the episode of care is
triggered by an acute care hospital stay but begins at initiation of post-acute care services with a
skilled nursing facility, inpatient rehabilitation facility, long-term care hospital or home health
agency. Under these retrospective payment models, Medicare continues to make fee-for-service
(FFS) payments; the total expenditures for the episode is later reconciled against a bundled
payment amount (the target price) determined by CMS. A payment or recoupment amount is
then made by Medicare reflecting the aggregate expenditures compared to the target price.

16. BPCI Advanced
Launching October 1, 2018, the first BPCI Advanced cohort included 32 clinical episodes and will
end December 31, 2023.
The second cohort will accept applications in the Spring of 2019 and begin January 21, 2020.

17. Conveners
Conveners are private, third party entities that partner with hospitals and physician groups in bundled
payment initiatives to help manage the patient episode.
Conveners are contracted to reduce the cost of the patient episode and in turn are reimbursed
through risk-sharing models, most commonly known as gain-sharing.
LUPA: The Low Utilization Payment Adjustment transitions a per visit payment for the first four visits of
home health, to a bulk payment in excess of $2,300 for the 6-8 week episode after the fifth home visit.
For example, if the reimbursement for a knee replacement was $25k for the episode and the complete
episode costs $23k after all claims were paid, if the convener and the hospital had a 50/50 split then
the convener and hospital would each get $1,000 in gainsharing.

18. Who can manage a bundle?
BPCI Episode Initiators include acute care hospitals,
skilled nursing facilities, physician group practices,
home health agencies, inpatient rehabilitation
facilities, and long-term care hospitals that trigger an
episode of care.

19. What About Accountable Care Organizations?
ACO’s are coordinated care models in which the provider receives a flat sum per patient each
month to cover all of the patients care needs.
Much like Medicare Advantage, the payer aggressively manages the patients care plan to ensure
only necessary services are provided to ensure that over-spending on necessary care and tests is
avoided.
Most ACO’s utilize a team of a Medical Director(s) and Utilization Review nurses, Case Managers,
Care Managers, or Navigators to manage high risk patients after hospitalization. Much of this is
done electronically or on the phone, but often times they visit the patient in person as well.

20. Patient Safety Organizations
A PSO is a group, institution or association that improves medical care by reducing medical
errors.
Hospitals, for profit, not for profit and private entities are all eligible to become PSO’s.
PSO’s strive to create a secure environment where healthcare organizations can identify risks
and improve quality.

21. Quality Improvement Organization/Network
QIO is a Federally mandated organization contracted with each state or region, that provides
resources to providers, specifically hospitals and nursing homes, to improves care by reducing
readmissions, medical errors.
QIO/QIN’s are give specific initiatives to work on including readmissions, quality and other
identified care issues.

22. Transitional Care Models
There are several formal transitional care programs. Two of the most popular are the four-pillar
Care Transitions Intervention (sometimes referred to as the Coleman Model as developed by Dr.
Eric Coleman) and Project RED (Re-Engineered Discharge).
These models enhance communication between caregivers, patients and families and provide a
formal structure to avoid readmissions and improve care.
Common components of transitional care models are risk assessment, identifying patient goals,
collaboration between care givers and follow-up support.

23. Discharge with Dignity™: The Discharge Planners NewRole - Adopt a “Home-first” Mentality
Startfromtheleftsideofguideandworkyourwaytotherightifa dischargehomeisnot anoption
TheFinancialImpactofPostAcuteReferralPatternsforhospitals,ACO’s& Bundles
Home Care /
Private Duty
Assisted
Living
Transitional
Care Visit
Chronic Care
Management
Home Health Hospice/
Palliative
SNF Acute
Rehab
LTACH
Degree of Financial
and Quality
Penalty to
Discharging
Hospital
Start Here
H
None None Negligible
(its less than 10%
of the cost of
home health –
and it covers 30
days as opposed
to 6-8 weeks for
HH)
Negligible Nominal
(should rarely be
ordered in acute OR
SNF setting; send
Dr./NP to the home
for Transitional Care
visit to assess need
for HH)
None
NA
Moderate Severe
(only for
specialized
needs that
can’t be met
at a SNF)
Severe
(LTACH is truly
specialized acute
care, not post
acute care)
Discharge Level
FO FOADH AHD ADWCD ASN LR A A
Patient Financial
Responsibility $ $$ Nominal Nominal Nominal NA 20% after 20
days
Varies Varies
A – Avoid unless specialized need; requires physician advisors approval LR – Last Resort if skilled need (if patient is unsafe to go home with resources) FO – First Option and consideration for all patients
ASN – Consider as alternative to SNF if skilled need & Home Care not an option ADWCD – (Order for) All Discharges with Chronic Diseases AHD – (Order for) All Home Discharges
FOAHD – First Option After Discharge Home; Assisted Living can cause delays in hospital discharge; engage AL before discharge
Step 1: Ask, “can we discharge this patient directly home safely?”
Step 2: What resources will the patient and family need? Step 3: What risks do we need to communicate to the family?

24. Alternative Level of Care
Pre-Authorization
Required?
Doctor’s Order
Required? Notes
Observation Floor No Yes High Cost to Hospital;
should be last resort
Physician Office/Urgent Care No No
Long Term Acute Care (Alt Acute) No Yes New admission criteria makes this process more challenging but
still an option if patient meets STACH criteria
Acute Rehab No Yes Easiest
Skilled Nursing/Sub-Acute No** Yes ** Patients discharged from a hospital or SNF within last 30
calendar days
Assisted Living/Board & Care No No Cash pay; not a covered benefit; discharge delay
Home Health No Yes
Home Care No No Patient pays; not a Medicare covered benefit but no caps or
limits on service
Hospice or Palliative No Yes
Acute Psychiatric Hospital Yes Yes Can vary based state to state
Options for Direct Transfer from Emergency Department
Patients with a Medicare benefit can be transferred directly from
the Emergency Department to the following levels of care

25. Transitional Care Management
Transitional Care Management
- As of 2013, Medicare reimburses physicians for Transitional Care Management (TCM).
Reimbursement in general ranges from approximately $172 (code 99495) to $243 (code 99496).
- Requires a face to face visit, monitoring and communication for thirty days.
Resource: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/MLN-Publications-Items/ICN908628.html

26. Chronic Care Management (CCM)
Chronic Care Management (CCM)
- As of 2015, Medicare reimburses physicians for Chronic Care Management (CCM).
Reimbursement in general ranges from approximately $30 (code 99490) to $45 per month.
- Requires multiple (two or more) chronic conditions, creation of a care plan, and ongoing
monitoring and communication.
Resource: https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-
initiatives/chronic-care-management.html

27. Transitional Care Resources
Key resources for learning about, staying current and developing effective plans for transitional
care include:
- www.CMS.gov (also known as Medicare Compare)
◦ Regulations & Patient Safety Organizations
◦ Readmission rates and penalty amounts by hospital
◦ BPCI, CJR and BPCI Advanced
◦ Quality Improvement Organizations
◦ Transitional Care Management & Chronic Care Management
- www.NationalReadmissionPrevention.com
◦ Non for profit entity with case studies and experts on preventing Readmissions
- www.NTOCC.org
◦ NTOCC is a leading organization for updates to the penalty