Managing Cost and Outcome of Managing Cost and Outcome of Post Hospital CarePost Hospital Care
Reg Warren, PhDReg Warren, PhD
The National Predictive Modeling SummitThe National Predictive Modeling SummitSeptember 22-23, 2008September 22-23, 2008
The dilemma for post hospital care?The dilemma for post hospital care?
2008 Medicare Advantage enrollment: 8.5 million* 2.2 million hospital admissions in 2008 (260 admits/k) 750,000 of hospitalized seniors will receive post acute care 250,000 of those will not go to the most appropriate setting MCO’s will spend $12.4B on SNF and Home Health in 2008* Challenges
Misalignment of incentives: per diem High degree of practice variation Lack of common measurement across care settings Over-utilization unnecessarily exposes members to
institutional risks and over-burdens taxpayers
*Kaiser Foundation 2008
2
Managing Cost and Outcome of Managing Cost and Outcome of Post Hospital CarePost Hospital Care
Diagnosis vs. Function A Predictive Model
Regression Severity adjustment
Application Real-time decision support Retrospective comparison
Influence on cost and outcome
3
People get postacute care because they are frail and Care Dependent:
Function Driven
People get postacute care because they are frail and Care Dependent:
Function Driven
People go to the Hospital because they are Sick:
Disease Driven
People go to the Hospital because they are Sick:
Disease DrivenTreat the
Illness
Treat the Illness
Restore the Ability
Restore the Ability
Acu
teA
cute
Pos
tacu
teP
osta
cute
Model ConstructsModel Constructs
4
Functional MeasurementFunctional Measurement
Functional Independence Measure (FIM)(18 – 126)
Expression Comprehension Social Interaction Problem Solving Memory
Eating Grooming Bathing Dressing Upper Body Dressing Lower Body Toileting Bladder Management Bowel Management Bed, Chair, WC Transfer Toilet Transfer Tub/Shower Transfer Walk/WC Stairs
5
Function Burden of Care Function Burden of Care
Functional needs
Drives >90% of skilled utilization Admit function- predict outcome 5 points FIM equate to one hour
caregiver burden/day SNF admission: FIM 65 (6 hrs care/day) HH admission: FIM 85 (2 hrs care /day)
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Calibrate the ContinuumCalibrate the Continuum
Home
Post-acute
Other
HH
SNF
20% of SNF patients would get the same result at home
20% of SNF patients would get the same result at home
SNF LOS can be reduced by 30% without impacting functional result
SNF LOS can be reduced by 30% without impacting functional result
HH Cost can remain stable even with increased referrals
HH Cost can remain stable even with increased referrals
Many Acute Rehab cases would get the same result in SNF
Many Acute Rehab cases would get the same result in SNF
Acute Discharges
Sr. Population
Acute Discharges
Sr. Population
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Discharge Site and Functional LevelDischarge Site and Functional Level(FIM 18-126)(FIM 18-126)
Discharge Site Considerations FIM Score
Home Alone
OP Therapy/Home Safety >108
Home with Assist
OP (Outpatient) Therapy >90
Home w/Assist or ALF
Home Health Services >80
Home, SNF, Custodial, B&C w/
24-hour Assistance <79
Diagnosis, medical complexity or other social, caregiver or medical issues may influence the functional level at which the patient is discharged.
8
Managing Cost and Outcome of Managing Cost and Outcome of Post Hospital CarePost Hospital Care
Diagnosis vs. Function The Predictive Model
Regression Severity adjustment
Application Real-time decision support Retrospective comparison
Influence on cost and outcome
9
Leader in post-acute outcome measurement since 1995
Manage over 900,000 Senior lives in SNF, Acute Discharge, Acute Rehab, Home Health
Database of 250,000+ post-acute cases Over 50,000 new records added each year
California, Colorado, Washington, Maryland, District of Columbia, Virginia and Tennessee
Kaiser Permanente, PacifiCare, Health Net, Group Health Coop, and AmeriGroup
MHS Participant
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““Not everything that counts can Not everything that counts can be counted, and not everything be counted, and not everything that can be counted counts”that can be counted counts”
Albert Einstein
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Improvement in Function in SNF: Improvement in Function in SNF: PredictablePredictable
ADMFIM
120100806040200
DIS
FIM
140
120
100
80
60
40
20
0
Correlations
1.000 .818**
. .000
500 500
.818** 1.000
.000 .
500 500
Pearson Correlation
Sig. (2-tailed)
N
Pearson Correlation
Sig. (2-tailed)
N
ADMFIM
DISFIM
ADMFIM DISFIM
Correlation is significant at the 0.01 level(2-tailed).
**.
80 yr old female with CHF, cellulitis, UTI
and prior stroke
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ADMFIM
120100806040200
EP
ISO
DE
120
100
80
60
40
20
0
Length of SNF Stay: Length of SNF Stay: Less Predictable Less Predictable
Correlations
1.000 -.265**
. .000
500 500
-.265** 1.000
.000 .
500 500
Pearson Correlation
Sig. (2-tailed)
N
Pearson Correlation
Sig. (2-tailed)
N
ADMFIM
EPISODE
ADMFIM EPISODE
Correlation is significant at the 0.01 level (2-tailed).**.
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Specific Relevant ConditionsSpecific Relevant Conditions(Groupers)(Groupers)
Feeding tube (Peg/J vs. NG) Restricted Weight Bearing Pressure Wound: II, III or IV Vascular/ surgical wound IV Vent Severe Obesity (BMI>50) Hemodialysis
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Regression: Length of Skilled StayRegression: Length of Skilled StayIndependent
Variable*Coefficient Patient’s
Actual Value
Result
Random Error
(constant)
24.08
Admission FIM -.196 65 -12.74
Age .034 82 2.78
Days Post Onset
.074 6 .444
Condition(IV/Stage II)
10.87 1 10.87
Predicted Episode LOS =
25.43
X
X
=
=
=
+
+
+
X =
=
+
82 y/o femaleHip fractureAcute: 6 days
11.34
14.12
14.56
X
*sig p<.05
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How powerful is the model?How powerful is the model?
60%
38%
2%
SMTX Model Treatment Unknown
TherapyIntensity
DisabilityDPOAgeCondition Grouper
16
EACH patient is case adjusted:
Impairment Group
Age
DPO
Adm FIM
Grouper Condition
Pt. #30: CVA ,75 yrs, DPO 12, Adm FIM 30, and Med Complex 4
Pt. # 1: UTI, 82 yrs, DPO 31, Adm FIM 57, and Med Complex 3
Query
LOS: 15 days DC FIM: 50
LOS: 11 days DC FIM: 81
Best Practice Calculation
LOS: 13 days DC FIM: 62.5
Best Practice Calculation
LOS: 13 days DC FIM: 62.5
LOS: 21 days DC FIM: 50
LOS: 14 days DC FIM: 81
Actual Calculation
LOS: 18 days DC FIM: 62
Actual Calculation
LOS: 18 days DC FIM: 62
SMTX Best Practice
(25% most efficient facilities) Actual Practice
Pts #2-30
VARIANCELOS: 28%DC FIM: 1%
REGRESSION
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Managing Cost and Outcome of Managing Cost and Outcome of Post Hospital CarePost Hospital Care
Diagnosis vs. Function The Predictive Model
Regression Severity adjustment
Application Real-time decision support Retrospective comparison
Influence on cost and outcome
18
Ex
pe
cta
tio
ns
High Practice VariationHigh Practice Variation
Actual Result
As
se
ss
me
nt
Treatment
Dis
ch
arg
e
Pla
nn
ing
Admission Discharge
Postacute EpisodePostacute Episode
Ful
l R
ecov
ery
No
Rec
over
y
19
Real-Time Decision Support
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Reduced Practice VariationReduced Practice VariationA
sses
smen
t
Mo
st
Lik
ely
R
es
ult
Treatment
Exp
ecta
tio
ns
Dis
ch
arg
e
Pla
nn
ing
Actual Result
Admission Discharge
Traditional Timeframe
Value Added
Postacute EpisodePostacute Episode
21
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Retrospective ComparisonRetrospective ComparisonSeverity-Adjusted ComparisonSeverity-Adjusted Comparison
Cas
es i
n S
MT
X
Reh
ab S
tart
Lag
Op
tim
al R
ehab
Cyc
le
Acu
tal
Reh
ab C
ycle
Reh
ab C
ycle
Var
ian
ce
Dis
char
ge
Lag
Reh
ab A
LO
S
Exp
ecte
d D
isch
arg
e F
IM
Act
ual
Dis
char
ge
FIM
FIM
Dis
char
ge
Var
ian
ce
% D
isch
arg
ed t
o C
om
mu
nit
y
Th
erap
y H
rs p
er D
ay
Jefferson Ave 45 1.4 7.9 10.2 28% 1.1 12.7 101.2 96.0 -5% 0.83 0.97
Mercy Court 67 1.3 11.7 12.1 3% 0.8 14.2 77.0 76.1 -1% 0.83 1.43St AllensGarden RidgeSan AngeloPacific CrestCareBrook
Total/Average
Efficiency Quality
Managing Cost and Outcome of Managing Cost and Outcome of Post Hospital CarePost Hospital Care
Diagnosis vs. Function The Predictive Model
Regression Severity adjustment
Application Real-time decision support Retrospective comparison
Influence on cost and outcome
23
SNF LOS Variance TrendSNF LOS Variance Trend
-10
0
10
20
30
40
50
July
Aug
Sep Oct
Nov
Dec Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
t
Month
Per
cen
t V
aria
nce
/Qu
ery
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Th
erap
y H
ou
rs/D
ay
cycle dcFIM Hours/Day
Client Q3, 2006 Source: SMTX
25% reduction in skilled days
24
73
96.793.2
105.8
115.5
50
60
70
80
90
100
110
120
130
140
SNF Admit SNF DC HH Admit HH DC Follow-up
Assessment
To
tal F
IM S
co
reFunctional recovery Across Settings:Functional recovery Across Settings:
SNF thru HH to Follow-up*SNF thru HH to Follow-up*11-01 to 9-0711-01 to 9-07
Source: SMTX
SNF: all dc homeHH: all admitted from SNFFollow –up: all records (N=1967)
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Improving Acute DC PlacementImproving Acute DC Placement
49%
58% 58%61% 63%
60%
67%64%
57%
40%
34%37%
32%28% 30% 28% 30% 31%
11%8%
5% 7% 9% 10%5% 6%
12%
0%
10%
20%
30%
40%
50%
60%
70%
80%
J an(N=291)
Feb(N=264)
Mar(N=260)
April(N=247)
May(N=284)
Jun(N=321)
July(N=334)
Aug(N=317)
Sep(N=195)
Home Skilled Other
No difference in HH and SNF outcome or acute readmit
26
Influence on UtilizationInfluence on Utilization
Average Medicare PlanLOS: 22 daysSNF Admits/k: 50-65SNF Days/k: 900-1100PMPM: $33
Predictive Model ResultsLOS: 16 daysSNF admits/k: 40-50SNF days/k: 600- 800PMPM: $22.50
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Reducing Practice Variation Using Reducing Practice Variation Using Predictive ModelsPredictive Models
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SNF Days of Treatment SNF Days of Treatment
Pat
ient H
ealth Im
pro
vem
ent
(Funct
ional
Im
pro
vem
ent M
easu
rem
ent)
Pre-Implementation Post-Implementation
SNF Days of Treatment SNF Days of Treatment
Pat
ient H
ealth Im
pro
vem
ent
(Funct
ional
Im
pro
vem
ent M
easu
rem
ent)
Pre-Implementation Post-Implementation
$5,655 average cost per case
23 point average gain in Functional Improvement Measurement (“FIM”), an internationally recognized scale of disability
$4,485 average cost per case (20.7% decrease)
23 point average gain in FIM (unchanged)
One Year
Cost efficiency …….Cost efficiency…….Cost efficiency