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Session 101:Future Directions: Evaluating d E i P lli i C
2013 NAHC Financial Management Conference
and Executing a Palliative Care Strategy
Diana Franchitto, Home Care & Hospice of New England
Bill Musick The Corridor GroupBill Musick, The Corridor Group
Robert Parker, PRIME by AseraCare
Overview
INTRODUCTION
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What is Palliative Care?Center to Advance Palliative Care (CAPC)
Specializedmedical care for people with serious illnesses
d li f f h i d f• Focused on relief from the symptoms, pain, and stress of a serious illness
• goal is to improve quality of life for both the patient and the family
• provided by a team of doctors, nurses and other specialists who provide an extra layer of support at any age and at any stage in a serious illness and can be provided along with curativea serious illness and can be provided along with curative treatment
• support patient and family, not only by controlling symptoms, but also by helping to understand treatment options and goals
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What is Palliative Care?Center to Advance Palliative Care (CAPC)
• The palliative care team provides:• Expert management of pain and other symptoms• Expert management of pain and other symptoms
• Emotional and spiritual support
• Close communication
• Help navigating the healthcare system
• Guidance with difficult and complex treatment choices
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It’s Place in the Continuum of CareDeath
Serious, progressive conditions that limit d il ti iti
Advanced Illness Management
Hospice Care
Palliative C
Bereavement Support
Manageable, early, stable conditions
daily activities
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Disease Progression
CareCareTerminal Phase of Illness
Support
Diagnosis of Life-threatening or Debilitating
Illness or Injury
Objectives
• Determine what types of palliative care programsDetermine what types of palliative care programs operate today
• Identify the services that are provided in a Palliative Care Program and how palliative care is reimbursed
• Recognize the issues involved in integrating palliative care with Home Health Agency and Hospice programs
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Flow1. Survey of Models/Issues
2. Specific Case Studies• Home Care & Hospice of New England
• PRIME (Progressive Illness Management Expertise) by AseraCare
3. General Comments/Tips
4. Q&A
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Caveats• “If you’ve seen one palliative care program, you’ve seen one palliative care program.”one palliative care program.
• Beware of relying too much upon someone else’s experience
• Regulations vary by state and by payer and are continually evolving – please don’t take our comments as legal advice
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Who’s in the room…
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Palliative Care Models
CONTEXT
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What we know dimly…• Not a standardized benefit
• No common tracking/data base• No common tracking/data base
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Variations
• Setting
Acute
Skilled Nursing
Primary
Specialty Clinic
• Task‐specific (Advanced Directives vs P&SM)
• Disease‐specific (Cancer vs CHF)
Hospice
Home Health
Primary Care
• Symptom‐specific (Pain)
• Delivery method (Face to face, telephonic, video)12
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Continuum• Insert slideCommon Options for Palliative Care Delivery
Consultative IntegrativeConsultative Integrative
SettingConsult Service
Comprehensive Service *
Dedicated UnitCase‐Managed
Team
Acute
SNF/ALF
Clinic
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Home
Typical Focus
Pain & Symptom Management
(PSM)
PSM + Decision Support +
Emotional/Spiritual Support
PSM + Decision Support +
Emotional/Spiritual Support
PSM and/or Decision Support and/or
Emotional/Spiritual Support
* internal or outsourced; includes QA/PI of palliative services, staff in-service education, compliance with accreditation, development of policies and procedures, serving on Committees, input to strategic planning related to palliative care
Palliative Care Models
PAYMENT VARIATIONS
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Payment Billable Entitlement Programs • Medicare Part B
• Physician/NP
• LSCW (using mental billing codes only)
• Home Health
• Concurrent Hospice Care• Medicaid Pediatric Concurrent Care
• Commercial Insurers
• CMS Demonstration Project?? 15
Payment (continued)Entrepreneurial
• Contracts• Commercial Insurer
• Hospital/Health System
• Innovation Award/ACO/Bundled Payment
• Philanthropic• Research
• Foundations
• Private Pay Fee for Service (Concierge) 16
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Cost Avoidance in Lieu of Payment
System-wide Cost
Net Investment in Palliative Care
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Cost Savings/Outcomes
Palliative Care Models
Examples of Variation in Delivery Models
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Examples: Advance Care PlanningGundersen Health System’s Respecting Choices Program• First Steps® ACP
T t di 55 ld• Target audience: 55 or older
• Focus: importance of ACP; select a healthcare
decision maker
• Outcome: a basic written advance directive for life‐sustaining treatment
• Next Steps® ACP• Target audience: patients with chronic, progressive illness + decline in functional status + risk for complications leaving them unable to make own healthcare decisionsown healthcare decisions
• Focus: assist patients in understanding…the progression of their illness
potential complications
specific treatments that may be considerations if their illness progresses
• Outcome: informed decisions19
Examples: Advance Care PlanningGHS Respecting Choices Program ‐ continued• Last Steps® ACPLast Steps ACP
• Target audience: Frail elders/others whose death with next 12 months would not be surprising
• Outcome: Physician Orders for Life‐sustaining Treatment (POLST) CPR
artificial nutrition and hydration
comfort care options
ACP b i ti idACP subscription videos • Designed to educate and empower patients about advance care planning and their informed/realistic choices for medical care
• http://www.acpdecisions.org/#sthash.9DNIU9rU.dpuf 20
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Example: UPHS CLAIM ProjectUniversity of Pennsylvania Health System CLAIM Project (Comprehensive Longitudinal Advanced Illness(Comprehensive Longitudinal Advanced Illness Management)
• Home Health‐based program with supplemental disciplines
• Cancer• Goal: reduce unnecessary end of life care costs and decreased quality of lifedecreased quality of life
• Seed funding: Health Care Innovation Awards • Long‐term: Cost avoidance, outcome improvements
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Examples: Entrepreneurial Services• Contractual arrangements by hospices/home health agencies to provide a combination of:agencies to provide a combination of: • billable physician/NP services with
• hospital payment for social work/chaplain and/or physician/NP administrative time
• Palliative care providers at risk for achieving savings through identification and care of high‐cost chronic care patients (insurer or health system ACO)patients (insurer or health system, ACO)
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Example: Lehigh Valley Health Network
• Optimizing Advanced Complex Illness Support (OACIS)
• Three‐pronged service• OACIS Home‐Based Consult Service
• OACIS/Palliative Medicine Inpatient Consult Service
• Palliative Care Outpatient Clinic (PCOC) – Cancer Center
• Medical Director, APNs, RN Case Manager
• Cost avoidance/improved outcomes• Cost avoidance/improved outcomes
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Comments/questions…
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Case Study
HOME CARE & HOSPICE OF NEW ENGLAND
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History/Rationale• Home & Hospice Care of Rhode Island (HHCRI)
Stats• Stats:
• Hospice ADC: 440’s
• Palliative ADC: 150
• Core competencies:
• Hospice
• Palliative since 2001Palliative, since 2001
• Home care, 2005‐2009
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History/Rationale• Visiting Nurse Home Care (VNHC)
Stats• Stats:
• Home Care: 500’s
• Hospice ADC, through 2012: 20’s
• Core competencies:
• Home Care (Rhode Island & Massachusetts)
• Public Health ServicesPublic Health Services
• Innovative Programming
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Affiliation Rationale• Financial Strength, position for future HH/H affiliations
• Care Transitions• Care Transitions
• Strong Home Care; Strong Hospice
• Partnership opportunities
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Affiliation Structure• Formation of parent: Home Care & Hospice of New EnglandEngland
• VNHC transition of hospice to HHCRI
• HHCRI to drive Palliative Care strategy
• How to create a strong Palliative Care program for Visiting Nurse Home Care?
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Current Palliative Care ModelLocation of Care Staffing Model Availability
Inpatient Hospital PC Consultation (contractual)
MD / NP Daily, 7‐day week coverageConsultation (contractual) coverage
Inpatient Hospital PC Consultation (non‐contractual)
NP M‐F, as available
Outpatient Hospital‐Based Cancer Centers (contractual)
MD Weekly
LTC Facilities NP Daily/Weekly rela‐
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tionship w/Hospice
Outpatient Practice MD Weekly
Brown PC Fellowship MD One slot
BCBSRI PC Initiative MD / NP With contracted hospitals
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Palliative Care in the HomeThe “Why”• Partner with Visiting Nurse Home Care
• “True” PC capability• True PC capability
• Service differentiator
• Patient transitions to hospice; potential to impact hospice LOS
• Meet the needs of health care partners to reduce re‐hospitalizations
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Palliative Care in the HomeThe “How”• Utilization of predictive modeling data through SHP, as a startstart
• Establishment of PC business unit within home care
• Weekly case conference review, utilizing PC tool
• Education for Home Care RN Case Managers
• Hospice/PC Physician Leadership/Liaison with Home Care
• House Calls by MD
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Statistics
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Statistics
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PC Patients in Home Care
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Future Plans/Considerations• Regularly assess model and adjust as necessary
• Patient enrollment in HCPatient enrollment in HC
• Case conference
• Palliative Care education
• Building the relationship
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Comments/questions…
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Case Study
PRIME by ASERACARE
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History/Rationale• Program Development
• 18 months (2010‐2011)18 months (2010 2011)
• Consultative Medical Model
• Inception November 2011• Piloted for 6 months in Omaha, NE
• Rapid expansion during 2012• 8 agencies
• Additional growth during 2013• 3 agencies
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Current Model• Target Population
• Chronically ill patientsChronically ill patients
• End‐stage disease trajectory
• Top Diagnoses• Chronic Obstructive Pulmonary Disorder (COPD)
• Cancer (cancer related symptoms)
• Alzheimer’s
• Cardiac (CHF, CVD, cardiac related symptoms)
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Current Model• Setting(s)
• Community based careCommunity based care
• Home, Skilled Nursing Facilities, Long‐term Care Facilities, Assisted Living Facilities, Personal Care Homes.
• Acute/Long‐term Acute Care (LTAC)• Selected agencies with specific relationships
• Practice:• Unduplicated census 789 (2013 1st half)• Unduplicated census 789 (2013 ‐ 1st half)
• Current active census 413 (June 30th)
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Current Model• Core Staff
• Board Certified MDBoard Certified MD• Collaborative Agreement
• Advanced Practice Registered Nurse (APRN)• Provider
• Licensed Clinical Social Worker (LCSW)• DSM‐IV diagnoses
• Supportive Care Staff• Supportive Care Staff• Social Worker
• Spiritual Care Coordinator
• Volunteer 42
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Statistics• Quality
• Pain – 91% on a goal of 80%Pain 91% on a goal of 80%
• Dyspnea – 92% on a goal of 70%
• Anxiety – 94% on a goal of 70%
• Goals of Care – 95% on a goal of 98%
• Re‐hospitalization – 0.4% on a goal of less than 5%
• Initial Consults• 486 (2012)
• 336 (2013 – 1st half)
• Subsequent Consults• 952 (2012)
• 1091 (2013 – 1st half)
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Financials• Evaluation & Management CPT Coding
• Break‐even model• Break‐even model• Proforma builds month‐over‐month
• Break‐even within 12 months
• Consults• 18‐22 Initial Consults per month
• 80‐90 Subsequent Consults per month
• Revenue• Start‐up mode
• 40% of expense44
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Integration with HH/Hospice• AseraCare Hospice
• Core businessCore business
• Setting Management
• 30% conversion rate• 103 (2012)
• 154 (2013 – 1st half)
• Care ContinuumA tti ti• Across settings over time
• Home Health Agencies are an integral component
• Acute Care
• Specific partnerships 45
Future Plans/Considerations• Ongoing expansion
• Complement Hospice AgenciesComplement Hospice Agencies
• Urban and Rural
• Managed Care/Commercial Payors• Contracts
• Member benefits
• Healthcare Systems• LTAC
• Acute
• Build community care continuum46
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Comments/questions…
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Palliative Care
PLANNING AND DEVELOPMENT CONSIDERATIONS
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Issues in Financial Viability• Incomplete payment mechanisms
• Optimal utilization of high‐cost providers• Optimal utilization of high‐cost providers
• Over‐extending services• Services provided
• Patients served
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Tips• Focus on local needs
• Assess local resources• Assess local resources
• Look for creative leveraging of community resources
• When possible, shoot bullets first, then cannon balls
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Tips (continued)• Think outside of legacy models
• Trust and compatible culture of partners ranked• Trust and compatible culture of partners ranked higher than logistics/systems by hospital executives
• Value of practice management
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Palliative Care Models
Tips and Considerations from the Field
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Resources &Acknowledgements• Center to Advance Palliative Care ‐www capc orgwww.capc.org
• Amber Jones, CAPC Consultant/Advisor
• Palliative Care Center of the Bluegrass (Hospice of the Bluegrass) – Gretchen Brown, CEO• 1 of 8 CAPC Palliative Care Leadership1 of 8 CAPC Palliative Care Leadership Centers (PCLCs)
• Physician practice model providing services in academic and community hospitals, NFs and outpatient clinic
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Tips from the fieldCourtesy of Amber Jones, CAPC consultant
On Start‐up and Partnering• Pay attention to resistance ‐ it may be well‐founded and deserve further analysis
• No one knows what you will and will not do as a palliative care provider – tell them
• Don’t claim outcomes (cost avoidance, readmission rates, patient/family satisfaction) without having documentation to prove itprove it
• Your partner does not care/believe in cost avoidance findings from other providers – saying it louder won’t help
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Tips from the fieldCourtesy of Amber Jones, CAPC consultant
Especially for hospice providers…• Avoid palliative care as ‘hospice light’ – it is exactly as it sounds – less ‐ and not as good as should be expected
• Having the same provider offer both hospice and palliative care services contributes to the confusion
• Providers and consumers do not understand palliative care or hospice – saying one is not the other is not a clarification
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Tips from the fieldCourtesy of Amber Jones, CAPC consultantDiversify funding resources: • Learn or buy Part B billing expertise; obtain the necessary provider numbers; be sure to have all your ducks in a row
• Train clinicians to bill effectively and collect early and often –they will hate the first part and like the second
• Fund‐raise shamelessly – it’s a skill set we already own
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Tips from the fieldCourtesy of Palliative Care Center of the Bluegrass
Physicians• Remember that MDs are your most expensive staff, followed closely by NPs
• Set high expectations for productivity (8‐10+ visits/day)• MDs are your best marketers for PC• Use NPs in NFs to extend MDs
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Tips from the fieldCourtesy of Palliative Care Center of the Bluegrass
Payment• Do not expect PC to generate a profit• Do bill Part B and do it well (attention to accuracy and coding)• Don’t give away PC ‐ get a fair payment from hospitals• Require hospital partners to measure the impact of PC
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Tips from the fieldCourtesy of Palliative Care Center of the Bluegrass
Other• Think twice about offering palliative home care• Don’t provide PC to hospice patients or most of your discharged hospice patients
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Contact InformationDiana Franchitto – President & CEO, Home Care & Hospice of New England
[email protected](401) 415‐4201
Bill Musick ‐ Senior Associate, The Corridor [email protected]
(888) 942‐0405 (toll‐free)
Robert Parker – Program Manager, PRIME by [email protected]
(512) 422‐2911 60
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Comments/questions…
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