reading rehabilitation 11-13-08
TRANSCRIPT
Reading Rehabilitation
Implementing Patient-Focused Care
Reading Rehab Hospital Roots HealthSouth’s RRH Facility Built in 1925 the historic
Stone Manor on a 30-acre campus.
“The million dollar home”. Was originally the home
of Isaac Eberly, a prominent businessman and hosiery mogul.
Leading Change
Clint Kreitner: CEO of RRH from 1989-2000 History:
Early career as a Naval officerRespected entrepreneur with 4 successful
companiesOn board of RRH for 3 years
Kreitner’s Forecast
Kreitner: “The hospital had an awesome reputation, a dedicated staff, and no debt.”
Instincts: his insight of business told him that RRH was headed for difficult times
Reasons: Over 50% of RRH referels came from one large hospital Industry was inflicting double digit annual increases on the U.S.
economy Action:
He began forums with the staff to communicate need for change Opened the financial books to the staff to show them what he saw
Staff Reaction
This type of communication was a first for RRH and not typical for that industry.
It made many of the staff feel uncomfortable because they had been in a thriving industry for 15-20 years and did not want to believe they were in trouble.
Needless to say, his opinion was not universally shared due to his lack of healthcare industry experience.
Rehabilitation Services
Brief History of RRH from 1958 to present In 1998 RRH had 76 beds, 116 therapists and 25 million in
revenue Most patients came to RRH after treatment of an illness or injury
at an acute care hospital Rehab hospitals restore basic functioning, such as walking,
climbing stairs, getting dressed, and feeding oneself Used Functional Independence Measures (FIM's) Goal was to help patients leave functioning as independentely as
possible
Rehabilitation Services RRH, like other rehab hospitals, also differed from acute care hospitals in being smaller than
most of them. RRH's annual revenues of $25 million compared to more than $200 million for the largest and
$45 million for the smallest acute care hospital in its region RRH admitted patients with a wide range of diagnoses
Head injury Stroke Spinal cord injuries Orthopedic problems
Received care from 5 disciplines Physiatrists (rehab dr.) Nurses Social workers Physical therapists Occupational therapists
If patient had head injury or stroke: Psychologists Cognitive therapists Speech therapists
Effectiveness
Measured effectiveness by using three dimensions: Average length of stay Increase of functional outcomes Patient satisfaction
Average length of stay compared favorably to the national average which was 21 days Achieved nearly the same increase in the level of functional
independence Patients were more satisfied with quality of care at RRH compared to
national benchmark) Patient care declined over the next 8 years
This was due to shorter lengths of stay rather than due to fewer patients Fewer patient days = Less revenue
Mission
Mission of Reading Rehabilitation As a subsidiary of Adventist Health Ministries, Inc, Reading
Rehabilitation Hospital was a non profit organization in Pennsylvania.
The well being of the patient is the number one priority of the RRH, together with its sister companies.
Because of the center’s affiliation with the Adventist church, commitment to the patient’s well being became stronger.
The mission of the Reading Rehabilitation center did not limit itself to the physical healing, but spiritual healing as well.
Purpose
The organization’s values, as well as strategic and operational decisions were also base on this vision.
The mission and vision of Reading Rehabilitation Hospital was put at a test due to the competitive world of health care.
As mentioned by Kreitner, the CEO brought in since 1989, finding balance between mission and real world business practice was one of the greatest challenges faced by Reading Rehab.
Pressures from Managed Care 1980’s and 1990’s healthcare costs were escalating out of control
with adverse consequences for both the federal budget and U.S. corporations.
The government responded with changes to Medicare and Medicaid.
In 1983, Medicare introduced a Prospective Payment System (PPS) under which standard payments were made based on a patient’s diagnosis, regardless of the institution’s actual cost.
Medicaid, funded through state budgets, declined in funding over the 1980’s and 1990’s, reducing the level of reimbursements.
One of the most significant innovations affecting the U.S. healthcare industry was the rapid emergence of “managed care.”
What is “Managed Care”?
The term “managed care” is used to describe a variety of techniques intended to reduce the cost of providing health benefits and improve the quality of care.
According to the National Library of Medicine, “managed care” encompasses programs.
Main Purpose: To reduce unnecessary health care costs through a variety
of mechanisms such as:
Programs for reviewing the medical necessity of specific services
Increased beneficiary cost sharing
Economic incentives for physicians and patients to select less costly forms of care
Controls on inpatient admissions and lengths of stay
Selective contracting with health care providers
Intensive management of high-cost health care cases
Fee-for-Service (FFS)
Until 1980s private health insurance plans allowed patients to choose their own doctors.
Under this fee-for-service (FFS) model, the role of the insurance company was simply to “pay the bills.”
Doctors were free to prescribe any treatment consistent with accepted medical practice and to determine fees for such treatment.
Change… This all changed in 1980s with new state laws that allowed
insurance companies to negotiate prices directly with health care providers.
In attempt to reduce costs…
Managed care organizations (MCO) adopted a more business-like approach for delivering care.
The idea was to get doctors and hospitals under contract at discounted prices and then control the use of services by managed care health plan members.
What would happen …
Patients would choose from a predetermined list of participating doctors, a primary care physician (PCP) who served as the “gatekeeper” for the patient.
These changes meant that hospitals had to perform tasks more efficiently so costs did not exceed payments received from MCOs.
Reading Rehabilitation Hospital Acute Rehabilitation hospitals like RRH were cushioned
from some of these changes in the healthcare system…at least for the time being!
Most RRH patients were on Medicare, and the more generous the Medicare rate was, the more advantage it was for the Reading Rehabilitation Hospital.
Kreitner noted, “”At times, we would keep patients twice as long as we do, and get reimbursed for it.”
“But we can’t afford to get lazy. So we strive to keep costs down and maximize incentive pay, rather than maximizing the reimbursement.”
Main Goal…
RRH (Reading Rehabilitation Hospital) was at advantage because they would keep patients longer and they would get reimbursements
Prospective Payment System did not force them to lower their cost because Medicare would pay the difference between average cost and what their limit was
“TO MAXIMIZE INCENTIVE PAY”
Competition
Reading Rehabilitation Hospital Only acute rehab in Pennsylvania market Accounted for about 6% of market share Shared the market with 3 acute care hospitals
Reading Hospital & Medical Center (RHMC): 57% St. Joseph’s Medical Center: 24% Community General Hospital: 13%
Upstream acute care hospitals
Rehabilitation Hospitals
Downstream Organizations
Patient FlowLocal Acute Care Hospitals
Trauma Centers
Physicians (home/nursing homes)
Incoming Patients
Discharged Patients
Home
Nursing homes
Continuum of Care
Acute care hospitals kept patients longer Create new efficiencies and fill empty beds Traditional nursing homes began offering
many rehab services Rehab expansion of other industry
participation would have a negative effect on RRH
Market Conditions
RRH = only licensed provider of acute rehab services in Berks County
RHMC tried to buy RRH’s license Clint Kreitner valued it at $6-$8 Million Pennsylvania Regulations required Certification of
need (CON) before granting license for new acute rehab service
CON limited rehabs services others could provide
Market Conditions
Increasing competition in product market Highly competitive labor market
Occupational Therapists Physical Therapists
Unfavorable Supply/Demand Kreitner: “We constantly live in fear that our therapists
will bail out en masse and as a result, the organization will be brought to its knees.”
The Rehabilitation Process
Admission from upstream providers Care providers from multiple discipline
evaluate patients Weekly conference involving interaction
between the patient and care providers Integrated plan care Discharge
The Rehabilitation Process
Process Improvement
Kreitner assumed Leadership Patient care across disciplines ineffective Delay in treatment and inconsistency among
treatments Kreitner Implemented Continuous Improvement
Initiative Kaizen Effect Process
Process Improvement
Process Improvement (Barriers)
Issues impacting the process improvementStaff disciplines cannot cross trainStaff could not be in “ready” statusPatient severity was not known in advanceShorter length of stay, immediate need to the
discipline
Performance Improvement (Barriers) Variance in patient acuity leads to
scheduling problems Service lines are not flexible for the short
length of stay Medicare reimbursement is driven to the
therapy target – loss of revenue
Staffing Barrier Specifics
COP for CMS Requirements for IRFDaily access to Physician24 hour nursingMinimum 3 hours per day/5 daysTwo forms of therapy available
Reading Rehabilitation Hospital:Where are they now?
Acquired by HealthSouth Corp in 1998 One of multiple purchases in the 1990’s Others included NovaCare, Columbia/HCA Mix of facilities, including acute care rehab
Not unlike RRH, faced challenges due to changing reimbursement landscape Medicare Balance Budget Act Managed Care Organizations
Succeeded in maintaining, then increasing revenue projections Diversification Capturing market share (simultaneously solving RRH volume problem)
Changes in Organization Model
Prior to sale, RRH returned to the “departmental” structure Staffing efficiencies returned Issues relation to patient care addressed via better process coordination
As HealthSouth, RRH continues to use this model, now lead by a primary nurse
“24-hour team of registered nurses and personal care assistants assess and attend to each patient's needs. They work in partnership under the primary nurse-model, which assures continuity of care. “
Although “time-limited” twice weekly conferences were piloted, weekly interdisciplinary team meetings have been adopted under HealthSouth
“Each week your treatment team will meet to discuss your progress, goals and discharge plan.’
Continued Growth and Success
The HealthSouth Reading Rehabilitation Hospital has expanded to offer Inpatient Rehabilitation Outpatient Rehabilitation Home Heath Care Service
Continues to demonstrate high levels of patient satisfaction, as evidenced by higher than average ratings in two important measures: “Would You Recommend” “Overall Quality of Care.”
Utilizes an “Outcomes Measurement” tool to track each patient’s functioning both upon admission and after treatment
Uses such data to benchmark outcomes and ensure programs are meeting patient rehabilitation needs
Reading Rehab Group:
Jimmie Olazaba Stacey Benson Anemone Basabakwinshi Tahira Raza Ailiya Raza Quynh Smith Charles Workman Kenith Causey Grace Cruz
References
Commitment Quality. Retrieved November 7, 2008, from HeathSouth Reading Rehabilitation Web site:http://www.healthsouthreading.com/quality_commit.asp
Frequently Asked Questions. Retrieved November 7, 2008, from HeathSouth Reading Rehabilitation Web site:http://www.healthsouthreading.com/quality_commit.asp
Gittell, J.H (1999). Reading Rehabilitation Hospital: Implementation Patient-Focused Care, Teaching Note. Harvard Business Review, 5(899-139), 1-16.
Managed Care. Medline Plus. Retrieved November 4, 2008, from http://www.nlm.nih.gov/medlineplus/managedcare.html
Managed Care. Retrieved November 4, 2008, from http://en.wikipedia.org/wiki/Managed_care