hospital niche leadingage 2015 final

Niche Development in Nursing Homes

United Methodist Homes of New JerseyLarry Carlson, President & CEO

Carol McKinley, Vice President of OperationsSara Ur, Executive Director - Bristol Glen CCRC

UMH Geography

Bristol Glen

Collingswood Manor

Pitman Manor

Francis Asbury Manor

The Shores

PineRidge of MontclairBishop Taylor Manor

Covenant Manor

Wesleyan Arms

Wesley by the Bay

Mission & ValuesCompassionately serving in community so that all are free to chose abundant life

Compassion – demonstrating love in our daily interactionsRespect – seeing and valuing sacred worthStewardship – faithfully managing the resources entrusted to usService – finding joy in caring

UMH Service Product Lines• Affordable Housing• Independent Living• Assisted Living• Assisted Living +• Assisted Living Hospice• Memory Support Residence• Skilled Nursing including short-term stay• Community Resource Hub

Hospital Partnership Strategy

Develop a value-based relationship using data and metrics– Clinical Quality & Integration– Resident Satisfaction– DRG Gap Analysis– Care Transitions

DATA is KING• Hospital Discharges• Readmission Penalties• Measuring clinical and financial results

Data Driven PartnershipsThe most important relationship is CEO to CEO, physician to physician

Understanding and analyzing hospital discharge data – MEDPAR

Understanding the differences among hospitals is the springboard for developing specific value-based relationships with each organization.

Opportunities• Recognize high variance• Understand admission rate• Understand the implied revenue loss based upon

length of stay• Reduce and control hospital readmissions

Measure and Report Outcomes• 30-day hospital readmission by diagnosis• Rate of discharge to the community• How each utilizes post-acute care: SNF, Home Health• Clinical Outcomes

Hospital ProfileDischarge Disposition

Category Hospital Percent National Average

Heart Attack 21.3% 19.9%

Heart Failure 27.7% 24.7%

Pneumonia 19.7% 18.3%

Discharge Disposition Total Discharges Total Patient Days Average Length of Stay

Skilled Nursing Facility 1,376 10,457 7.60

Home Health Agency 1,290 9,183 7.12

Inpatient Rehabilitation Facility 597 3,250 5.44

Long Term Acute Care Hospital 122 1,622 12.30

Other 4,073 16,687 4.10

Total 7,458 41,199 5.52

Hospital Med-Par DataMS-DRG

Version 26 MS-DRG NameSNF

Medicare Part A

Discharges

AcuteHospital

Days

CMSGMLOS

DaysALOS atHospital

CMSGMLOS

LOS Over(Under)GMLOS

191 Chronic obstructive pulmonary disease w CC 17 116 70 6.82 4.10 2.72

377 G.I. hemorrhage w MCC 17 130 83 7.65 4.90 2.75

690 Kidney & urinary tract infection w/o MCC 17 83 60 4.88 3.50 1.38

194 Simple pneumonia & pleurisy w CC 15 72 66 4.80 4.40 0.40

481 Hip & femur procedures except major joint w CC 15 87 81 5.80 5.40 0.40

177 Respiratory infections & inflammations w MCC 14 130 101 9.29 7.20 2.09

280 Acute myocardial infarction discharged alive w MCC 14 127 81 9.07 5.80 3.27

392 Esophagitis gastroent & misc digest disorders w/o MCC 13 67 36 5.15 2.80 2.35

308 Cardiac arrhythmia & conduction disorders w MCC 12 97 49 8.08 4.10 3.98

378 G.I. hemorrhage w CC 12 100 44 8.33 3.70 4.63

603 Cellulitis w/o MCC 12 60 47 5.00 3.90 1.10

Total 541 4,314 2,823 7.97 5.22 2.76



Medicare Part A

Discharges

AcuteHospital

Days

CMSGMLOS

DaysALOS atHospital

CMSGMLOS


945 Rehabilitation w CC/MCC 99 1,480 851 14.95 8.60 6.35

470 Major joint replacement or reattachment of lower extremity 66 264 238 4.00 3.60 0.40

291 Heart failure & shock w MCC 33 281 165 8.52 5.00 3.52

871 Septicemia w/o MV 96+ hours w MCC 33 288 182 8.73 5.50 3.23

292 Heart failure & shock w CC 26 132 107 5.08 4.10 0.98

190 Chronic obstructive pulmonary disease w MCC 24 187 120 7.79 5.00 2.79

193 Simple pneumonia & pleurisy w MCC 22 141 119 6.41 5.40 1.01

057 Degenerative nervous system disorders w/o MCC 21 101 82 4.95 3.90 1.05

689 Kidney & urinary tract infections w MCC 21 143 103 6.81 4.90 1.91

641 Nutritional & misc metabolic disorders w/o MCC 20 85 62 4.25 3.10 1.15

065 Intracranial hemorrhage or cerebral infarction w CC 18 140 77 7.78 4.30 3.48

Partnership Pathway• Joint Operating Committee• Develop a specialty clinical niche to match the

hospital’s need• Extend the hospital clinical pathway into the SNF• Manage Transitions• Share medical records through cloud technology

Bristol Glen CCRC

• Located in Newton, Sussex County NJ• We offer Independent Living, Assisted Living,

Memory Support, Rehabilitation, Long Term Care

Our Healthcare Neighborhood– 60 bed community– Average Medicare Number: 19– Average Healthcare Census: 59



Medicare Part A

Discharges

AcuteHospital

Days

CMSGMLOS

DaysALOS atHospital

CMSGMLOS








481 Hip &Femur Procedures Except Major Joint w CC 27 150 137 5.56 5.07 0.48

552 Medical Back Problems with W/O MCC 24 125 79 5.21 3.28 1.93

683 Renal Failure W CC 23 131 92 5.70 3.99 1.70


872 Septicemia or Severe Sepsis W/O MV 96+hours W/O MCC 22 147 96 6.68 4.46 2.22



Medicare Part A

Discharges

AcuteHospital

Days

CMSGMLOS

DaysALOS atHospital

CMSGMLOS


689 Kidney & Urinary Tract Infections W MCC 21 125 98 5.95 4.64 1.31

177 Respiratory Infections and Inflammation W MCC 19 180 129 9.47 6.81 2.67

392 Esophagitis,Gastroent, &Misc Digest Disorders W/O MCC 18 112 50 6.22 2.77 3.45

563 Fx. SPRN,STRN,&DISL, Except Femur,Hip,Pelvis,and Thigh W/O MCC 16 57 48 3.56 3.02 0.54

189 Pulmonary Edema & Respiratory Failure 15 125 65 8.33 4.33 4.00

378 G.I Hemorrhage w CC 15 87 53 5.80 3.52 2.28

280 Acute Myocardial Infarction, Discharged Alive W MCC 14 115 73 8.21 5.22 3.00

TOTAL 593 3,814 2,587 6.43 4.36 2.07

Hospital Med-Par Analysis

• Review of the Hospital Med-Par Analysis to indict where to focus– Top MS-DRGs– SNF Medicare Part A Discharges– Review of Hospital LOS versus CMS LOS– LOS Over/Under GMLOS

• Discussions with discharge planners regarding difficult discharges

• Readmissions Rates

Our PartnersActive Members of the community that we brought together to review the results of the Med-Par Analysis to develop solutions• Newton Medical Center• Alliance Rehabilitation• At Home Medical • Ocean Medical• Skyland's Medical Group• Pulmonologist and APN attached to the hospital and

Bristol Glen

Clinical Niche---- COPD• Disease Management Program • Who is a good candidate for the COPD

management program? – A patient with a primary or secondary diagnosis of

COPD– A patient that requires durable medical equipment• Bipap,Cpap, Continous oxygen

Objective of the COPD Management Program

• Educate recently diagnosed COPD residents/ families assuring a better quality of life

• Reduce readmission rates.• Provide proper medical equipment upon

discharge.

Assessment and Planning • Comprehensive assessment of respiratory

status to determine baseline and criteria for COPD program.

• Complete medication reconciliation• Consistently monitoring for cyanosis especially

in therapy

Referral Received↓

Respiratory Diagnosis

__ COPD __ Other Respiratory Diagnosis ↙ ↘

__ Acute __ Chronic __ Stop

__ Multiple Hospitalizations __ 0² Dependent __ New to 0² __ Nebulizer Treatments __ CPAPP/BIPAPP Treatments __ Percussion Vest

↓

Refer to Bristol Glen in House COPD Program

Equipment Company → No Equipment Company → Refer to At Home Medical COPD Program

↙ ↘ __ At Home Medical __ Other Medical Co.

↓ ↓ Refer to At Home Medical Refer to VNA COPD Program COPD Program

Assessment Day 14-28• Interventions to Occur during care period: • Assess and reconcile all medications. Instruct in purpose, route,

frequency, side effects. Instruct on use of bronchodilator, mucolytics, expectorants, and nebulizers as ordered.

• Assess respiratory status – lung sounds, respiration rate, depth, rhythm, use of accessory muscles, etc.

• Assess level of dyspnea with activity and at rest, note change in status or assessment goal.

• Instruct: to avoid stressors precipitate disease exacerbation of (including temperature extremes & infection).

• Instruct: S/S infection including temp evaluation, change in sputum to yellow/green, and increased viscosity.

Therapy Best Practices• Initial Assessment/Evaluations– Record Vitals/Monitor BORG and RPE– Assess ROM of all 4 extremities– Assess strength of all major muscle groups through

manual muscle testing– Assess Gait Pattern with or without a device– Perform the Six Minute Walk Test– Perform Dynamic Gait Index on patients with

suspected balance dysfunction

Stage/MET Level ADL and Mobility Exercise Capacity RecreationStage 1

1.0 to 1.4 MET(s)Bed MobilityHands & face washingSelf-FeedingTransfers required

10 to 15 min/extremity and deep breathing Increase sitting tolerance progressively

Light handwork and table games

Stage II1.4 to 2.0 MET(s)

Unlimited sittingBathing, shaving, Grooming and dressingRoom ambulation only

Increase extremity # of RepetitionsNo Isometrics

Sitting activities i.e.Crafts, sewing, knitting

Stage III2.0 to 3.0 MET(s)

Brief standing for Hygiene and grooming Short outside room Ambulation

Balance and light matActivitiesPaced ambulation at comfortable pace

Any form of tolerableSitting activities

Stage IV3.0 to 3.5 MET(s)

Standing : totalWashing and dressing Light advanced ADL(s) i.e. cooking, cleaning Unlimited ambulation

Increase # and speed of repetitionsStair climbing, cycling to5mph and treadmill at 1mph to 1.5 @ 2%

Driving Light gardening, ability to weed and plant

Stage V3.6 to 4.0 MET(s)

Washing dishes, making beds, ironing, & hanging clothes

Increasing the speed and repetitions of Stage IV. Cycling to 8mph (no resistance) +sitting exercises

Swimming, golfing with cart and light home repairs

Stage VI4.1 to 5 MET(s)

Standing showering in hot water, raking and mopping

Walking up 4-6% grade hills and cycling up to 10mph. Also, 10-17 #’s of resistance for limbs

Slow dancing and light calisthenics to tolerable range of motion

Suggested Interdisciplinary Stages for Patients with Cardiopulmonary History/Precautions(METs and ADL Category)

Durable Medical Equipment to Home Oxygen Testing:

• Documentation of Qualifying ABG (P02 of < 55) or pulse oximetry (<88%) results obtained under the following conditions in the patient’s medical record (must document testing condition):

ABG or pulse oximetry results within 48 hours of Hospital dischargeABG or pulse oximetry results within the last 30 days Office/Facility

• Resting on room air (if at 88% or below, only this condition needs to be documented)• Ambulating on room air• Ambulating with oxygen applied• Nocturnal• Nocturnal oximetry must be for a minimum of 2 hours and include 5 cumulative

minutes of qualifying saturations– PO2 of 88% or less will qualify a resident for DME at Home under Medicare

The Home Visit

• Providing clinical follow-up and re-education on DME if ordered.• Evaluating patient for an oxygen conserving device PRN.• Instructing on proper breathing exercises and technique.• Educating on proper nutrition.• Discussing shortness of breath scale.• Reviewing medications and ensuring prescriptions have been

filled.• Reviewing/instructing on proper MDI and nebulizer usage,

techniques and care.

Resident/Caregiver Outcomes(V) Verbalizes (D) Demonstrates

• Knowledge of reasons to take medications as ordered with understanding of route, frequency, purpose and side effects, as appropriate. (V)

• Correct use of 0², nebulizers, inhalers. (D)• Effects of stressors on disease process, breathing and lifestyle. (V)• Coughing and deep breathing exercises; energy conservation. (D)• Correct use of bronchodilators, mucolytics, expectorants, nebulizers. (D)• Adequate fluid intake to help liquefy secretion. (V)• 3 safety issues regarding use of oxygen. (V)• Importance: Consulting with physician before using OTC meds. (V)

The Outcomes• The communication that was developed

between the partnerships and discussions from the hospital provided: – Readmission Rate for the Healthcare Neighborhood for August and

September:

0% Readmission Rate

– Average Medicare COPD Admissions for the last 6 months: 40% admissions

Next Steps--- Where are we going• Hiring of a Respiratory Therapist to the team to enhance

the needs of our residents• Continuing to strengthen the lines of communication with

the hospital for Bundling Payments • Outpatient Therapy to allow residents to continue

achieving their goals and quality of life.• Home and Community Based Services – reaching out to

the community, providing services, answering their needs. Meeting the needs of the community outside our walls.

The Shores at Wesley Manor• 190 Apartment Community– Memory Support– Hospice– Assisted Living– Assisted Living Plus

• 60 Unit Health Care– 22 Sub-Acute– 38 Long Term

Hospital Med-Par Analysis• Community Hospital• Major care provider

in local area.• Affiliations with

Philadelphia Hospitals• 296 Acute Beds• 30% Skilled Nursing

Discharge Dispositions

Hospital Med-Par Analysis



Medicare Part A

Discharges

AcuteHospital

Days

CMSGMLOS

DaysALOS atHospital

CMSGMLOS


945 Rehabilitation w CC/MCC 99 1,480 851 14.95 8.60 6.35







057 Degenerative nervous system disorders w/o MCC 21 101 82 4.95 3.90 1.05

689 Kidney & urinary tract infections w MCC 21 143 103 6.81 4.90 1.91


065 Intracranial hemorrhage or cerebral infarction w CC 18 140 77 7.78 4.30 3.48

Hospital Med-Par Data

Hospital Med-Par Data

Heart Failure

• LOS 4.57

Initial Discussions for Cardiac Niche• CEO

• Selected Hospital Leaders (CMO; CNO)

• Cardiology Group

Partnerships• Determined partnerships based on like

philosophies and outcomes:– Non-profit backgrounds– High standards of care– Collaborative in nature– Person-centered in service– Invested in process

Original Partnerships

Mainland Heart Consultants

Protocols• Collaborative Effort• Care Pathways• Training• Equipment• Telehealth• Staffing

Goal of Program• Overall agreed goal of program:

To provide the highest level of care to residents with the condition of CHF and to improve their quality of life, prevent exacerbations and re-hospitalizations

Care Pathways Examples• Who should be in program: CHF; cardiomyopathy; Ejection fraction < 40%; Hx of significant valvular disease• Established Care Guide Initiatives that include:

• Vital signs q shift/prn• Orthostatic BP q week sitting/standing 1 minute• Pulse Oximetry q shift• Measure intake/output q 8 hrs• Daily weight at same time q day; same type of clothing and on same scale. Follow set reporting parameters for weight gain

Care Pathway Examples• Obtain baseline laboratory and diagnostics: CBC; complete Metabolic panel; Urinalysis; microalbuminuria, fasting lipid profile, albumin, TSH, chest x-ray, and EKG.• Peripheral Edema Management Protocols/Parameters• Observation for signs and symptoms of CHF:

• Unexplained weight gain > 3lbs in 24 hours, or 5 lbs in 3 days• New edema• New dyspnea • New abdominal symptoms

Education• Appropriate staff members received CHF

training

• Telehealth training

Equipment Needs

• Telehealth – weigh scale – provided by home health agency

• Portable Cardiac Monitor• EMR reflection of protocols/orders• Disease Managed Assessment Software

(COMS)

Staffing

• Registered Nurses• Cardiac nurses• Utilized NPs of Cardiology Group• Therapists • Adding RT• Moving to 12 hour nursing shifts subacute

Physicians• Utilized their requested standing orders for

Heart Failure

• Adjusted as requested by MD

Outcomes• In last six months – 37 admissions (50%) for CHF from the

hospital• 25 were discharged to home• 6 discharged to assisted living • 4 to long term care• 2 readmissions for end stage failure due to lack of

DNH/DNR• Robust census • 0% readmission in last quarter.

Issues• Changing Environment– Change in hospital leadership– Mergers/affiliations of physicians and cardiac

groups– Shortages of cardiac physicians– Changes of personnel in physician groups ie NP or

PA

Potential Concerns• Multiple hospitals serve you/selection• Multiple DRG/LOS issues• Speaking to the right person• Competition (Super PACS; Developed

Programs for sale)

Conclusion

• Health Care Environment Changing• SNFs are at risk • ACOs, Hospital Systems, Insurance Carriers are

driving the conversation• Being Creative and Assertive is Essential• Determine the Value You Bring to the Relationship

“Our real problem, then, is not our strength today; it is rather the vital necessity of action today to ensure our strength tomorrow.”

~ Dwight D. Eisenhower -

Questions??????

hospital niche leadingage 2015 final

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