strategic options for hospice & palliative care in the era of acos



Strategic Options for Hospice and Palliative Care in the Era of Accountable Care Organizations

NHPCO 26th Annual Management &

Leadership Conference

April 2011

1


Presenters

Kyle R. Allen, DO, AGSF

Chief, Division of Geriatric Medicine

Medical Director Post Acute & Senior Services

Summa Health System

75 Arch Street, Ste G1, Akron, OH 44303330-375-3747; [email protected]

Jane Gorwin, RN, BSN, LNC, MA

Senior Home Health and Hospice Consultant

Health Dimensions Group

4400 Baker Rd, Ste 100, Minneapolis, MN 55343

760-250-4558; [email protected]

Jade Gong, MBA, RN

Vice President, Strategic Initiatives


4012 Nelly Custis Drive, Arlington, VA 22207

703-243-7391; [email protected]

2

mailto:[email protected]




Topics

• Health care reform and its impact on post-acute

and aging services providers

• Strategies for hospice and palliative care

providers

• PEACE model of care

• PACE as an accountable care organization (ACO)

model

3


Drivers of Partnerships for Future Success for Post-Acute Providers

4

• Accountable Care

Organizations

• Bundled Payment

• Hospital Readmission

Penalties


Home Health 30-Day Hospital Readmissions by State

5


Why Post-Acute Is Key to Managing Health Care Costs

6


Post-Acute Payments by Venue and Condition

7

In ACO-land, expect greater use of subacute skilled nursing and home health

Hospital

Condition

PAC

Average

OP

Rehab

Home

HealthSNF IRF LTCH

Stroke $10,680 $569 $2,478 $8,527 $18,923 $22,070

Hip & Femur

Procedures for

Trauma$10,392 $1,217 $2,595 $8,761 $16,018 $22,738

Cardiac Bypass

with

Catheterization$5,230 $837 $1,778 $5,737 $14,631 $24,526

Heart Failure $4,144 $612 $1,611 $6,462 $14,698 $20,236

Note: Data are preliminary and subject to change. Numbers reflect standardized payment rates and

therefore do not reflect provider-specific adjustments such as the area wage index or DSH payment

adjustments. Spending captures payments for all PAC services that occur within 30 days of discharge from

the hospital.

Source: MedPAC analysis of 5% Medicare claims files 2004 to 2006.


ACOs – One of the Ways Health Care Reform will Bend the Cost Curve

• Payment Changes

– Reimbursement cuts

– Value-based reimbursement

– Bundled payments

• Care Delivery System

Changes

– Accountable care

organizations

– Medical homes

– Health information exchange

8


How ACOs Provide Accountable Care in a New Delivery System

• Capacity to deliver continuum of care, grounded

in strong primary care and minimal use of high-

cost institutional settings

•Payment rewards slower cost growth so long as

combined with improvements in quality

• Reliable measures of a person’s health assure

that savings are achieved

through improvements in care

9


Accountable Care Organizations

Medical Group(s)

Community MDs

Medical Home

Accountable Care

Organization

Physician

NetworkAncillaries

Medicare/Other Payers 5,000+ Medicare

fee-for-service

beneficiaries

Accountable for all

Medicare Part A

and Part B service

Requires

integrated provider

network;

successful chronic

care management;

comprehensive

home-based

services

EHR across

settings

Continuum

of Care

Outpatient services

Skilled nursing

Home health

Hospice

Geriatric care management

Non-institutional home-based services

Prevention and wellness programs10


Medicare ACOs in 2012, But Many ACO Demonstrations Now

11

Tucson, AZ

Louisville, KY

Roanoke, VA

3 Medicare Pilot Sites Many Private Payer Pilots

Medica and Insurers

Torrance, CA

https://www.tmcaz.com/

http://www.nortonhealthcare.com/default.cfm

http://www.carilionclinic.org/Carilion/Home+Page

http://www.advocatehealth.com/default.cfm

http://www.bcbsil.com/index.html


Medicare ACO Eligibility

Who Can Be An ACO?

• Group practices

• Networks of individual practices

• Partnerships or JV

arrangements between

hospitals and ACO

professionals

• Hospitals employing ACO

professionals

• Such other groups of providers

of services and suppliers as the

Secretary determines

appropriate

12

ACO Professionals

• Doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State

• Physician assistant, nurse practitioner, or clinical nurse specialist

• Certified registered nurse anesthetist

• Certified nurse-midwife

• Clinical social worker

• Clinical psychologist

• Registered dietitian or nutrition professional


How Do You Qualify as a Medicare ACO?

• Become accountable for quality, cost, and overall care

• Formal legal structure to receive and distribute payments for shared

savings

• Have enough primary care physicians

• Have a minimum of 5,000 beneficiaries

• Leadership and management structure that includes clinical and

administrative systems

• Processes to promote evidence-based medicine and patient

engagement, report on quality/cost measures, and coordinate care

• Meet patient-centeredness criteria

• Minimum three-year contract with Medicare

13


New Payment Model for Medicare ACOs: Shared Savings

• Current per-capita spending for assigned patients determined from

claims for past three years

• Spending target is determined (Medicare)

• If actual spending lower than target, savings are shared

• IF quality targets are also achieved

14

14

ActualShared Savings

ACO Launched

Target

Projected

Adapted from Brookings Institute


Sample ACO Calculation

15

* Actual costs for ―assigned‖ population are less than pre-set expected costs based on risk-

adjusted trends

** PGP demonstration gave groups 80% of savings; actual split for ACOs to be determined

Year 1 Year 2 Year 3

Quality Standards

Met?Yes No Yes

Cost Savings

Achieved?No Yes* Yes*

Medicare FFS

Payment

Medicare

Fee

Schedule

Medicare

Fee

Schedule

Medicare

Fee

Schedule

ACO bonus

payment that

year?

No No

Yes

X% of

Savings**

An

organization

must meet

quality

standards

AND

achieve cost

savings

to earn

bonus

payments


Three Strategic Partnership Imperatives for Post-Acute and Aging Services Providers

16

Partner with hospitals

and ACOs to address

biggest concerns:

• Length of stay

• Pending

re-admission

penalties

Partner with other

providers to enhance

your

post-acute and

home care continuum

Partner with like

providers to create

one-stop chronic

care management

Strategy includes care transitions management

and electronic health record


The New Reality for Aging Service Providers: Partnerships with Other Providers

17

• Provide an array of aging services, not just skilled nursing and

long-term care; be the navigator or partner for services or

venues you do not offer = care management

• Become preferred partner for integrated health systems or

ACOs from whence Medicare dollars will flow



Strategies for ACO and Hospice-Palliative Care Relationships

Jane Gorwin, RN, BS, MA


18


How Do Palliative and Hospice CareFit into an ACO Model?

•Laying the foundation for a palliative care

framework first

19


How Do Palliative and Hospice CareFit into an ACO Model? (continued)

Wellness

Specific Disease Intervention

Chronic Disease Management

• Focus still on interventions only

Interventional Palliation

• Combination medical treatment, comfort care

Hospice

• Focus on comfort, quality of life, symptom control

20


What Needs to Change?

• The basic way we work with patients, especially in

one of these three categories:

– Chronic Disease Management

• Need to better identify where a patient is within this trajectory

• Enhance acute to community-based transitional care coordination

– Interventional Palliation

• Educate/enlighten patient and family earlier

• Provide options for patient/family choice

– Hospice Care

• Marketing strategy and partnerships with hospitals and PCP

21


What Do ACOs Want from Post-Acute and Aging Services Providers?

• Not likely to be a partner, with ―skin in the game‖, but

rather a contractor

• ACOs will want few PAC provider-contractors who:

√ Can demonstrate value (quality and cost reductions) with credible data

Few 30-day hospital readmissions

High volume of discharges to home

√ Have evidence-based clinical programs for most common SNF-HHA

discharges and a care transitions program between venues

√Have facilities/services that are geographically convenient to primary care

physicians and hospitals

√ Already have positive relationship with hospitals and PCPs

√ Willing and able to be part of health information exchange

22


Hospice: Well Positioned for the Future

•Aging demographics – baby boomers

• Chronic disease ―explosion‖

• Key offenders:

– Congestive Heart Failure

– Diabetes

– Chronic Obstructive Pulmonary Disorder

– Pneumonia

– Parkinson’s – ALS – Dementias

– Depression

23


Not-for-Profit Accountable Care Readiness Strategy: Aging Services Provider Partnerships

24

• Create a not-for-profit consortium within a market that has

more value than any organization individually

• Benefits:

– One-stop shopping for hospitals and ACOs

– Benchmarks for hospital readmissions

and ongoing comparison

– Post-acute provider partnerships in

geographic areas creating care

continuum with standardized protocols

– Care management projects

– Bundling experiments with Medicare Advantage Plans as we learn

to take risks

– Apply for grants for demonstration projects


To Be a “Player” in the ACO Arena

• You have to be ahead of the curve in developing

relationships with hospitals, primary care physician

groups, and even insurers/managed care

• Partnerships must be value-based:

what do you bring?

– Hospital readmission reduction

– Cost reductions for post-acute episode of care

– Care coordination across the continuum

– Chronic care management to reduce ED visits and hospitalizations

– Electronic information exchange

– Ability to share payment risk based on outcomes

25


Define Your Services: What are You Providing Within the Continuum?

• Palliative Care: interventional and comfort care

focus

– Palliative care in–patient hospital versus home health

• Hospice Care: comfort care and quality of life

focus

– Routine hospice care

– Respite

– Continuous care

– General in patient

26


Overarching Strategy of Why You Will Benefit an ACO

• Ability to reduce 30-day (+) hospital readmissions

• Ability to reduce emergency/urgent care visits

•Reduce hospital length of stay

• Potentially decrease in-patient hospital mortality

rates

27

KNOW YOUR

DATA AND

SHARE IT!


Critical Elements for a Successful Strategy Implementation

• Evidence-based practice (interventional PC and

hospice)

– Use of aligned, care protocols

• Patient/family centered—self-care management

driven

– Coaching: motivational interviewing skills

– Patient/Family self goal-setting

– Medication awareness (PHR)

– Self symptom management and interventions

28


Critical Elements for Successful Strategy

• An integrated care management and health

system navigator approach

• Effective electronic information exchange

– From provider to provider

– Patient/family to provider (tele-health, bio-sensory

technology, video-audio interface)

•Real-time data management decision-making

29


What are Some of the Current Challenges?

• Current fiscal realities (shrinking margins)

– Hospitals

– Home Health

– Hospice

• Regulations and future Medicare payment models

are always ―behind‖

– Hospice: limited to 6-month end-of-life prognosis

– Palliative care: not officially recognized

– No specific reimbursement for care management

models…..yet

30


More Challenges

• Need for highly sophisticated data management

information systems that will:

– Enhance traditional quality care indicators (pain

management, satisfaction surveys post-death)

– Provide predictive statistical modeling as relates to

primary diagnoses and co-morbid conditions

– Help to identify patients’ clinical and social needs within

their trajectory (chronic disease management,

interventional palliation, hospice)

31


Next Steps to Move Your Strategy Forward

• Evaluate your current services

– Do you provide what your hospital(s) and PCP(s) need?

– Do you collect the right data?

• Research your most likely ACO partners

– What are their specific needs?

– Get their data: mortality rates, lengths of stay, top

chronic diseases causing the readmissions

32


Moving Your Strategy Forward

• Develop your presentation to meet with potential

ACO partners: hospitals and PCPs

– Be specific with your data to show how YOU will be

essential to their accountable care organization

• Explore current funding opportunities:

– Shared risk ventures with Medicare Advantage plans

– Grants

– Demonstration projects

•Be proactive to get a ―seat at the

table‖ and start now!

33


If everything seems under control, you're just not going fast enough

34

Mario Andretti.

Kyle R. Allen, DO*Steven Radwany, MD*

Susan Hazelett, MS, RN*Denise Ertle, MSN, RN, CNS* *

Susan Fosnight, RPh, CGP, BCPS* Pamela Moore, PharmD, BCPS*

Patricia Purcell, MSN, RN, CNS* * *Barbara Palmisano, MA * * * *

Ruth Ludwick, PhD, RN.C, CNS* * * * *

* Summa Health System, Health Services Research and Education Institute

* * Area Agency on Aging 10B, Inc. * * * The University of Akron

* * * * Northeastern Ohio Universities Colleges of Medicine and Pharmacy

* * * * * Summa Affiliate, Robinson Memorial Hospital

The PEACE Trial is supported by The National Palliative Care Research Center

& the Summa Foundation

Area Agency on Aging, 10B, Inc. | Summa Health System | NEOUCOMKent State University | The University of Akron

PEACE TRIALPromoting Effective Advanced

Care for Elders

Key Points

A National Palliative Care Research Center-funded trial

($154,000 over 2 years)

Collaboration between The University of Akron, Kent

State University, Northeastern Ohio Universities

Colleges of Medicine and Pharmacy, the Area Agency

on Aging 10B Inc., and Summa Health System

A randomized controlled pilot study

A palliative care case management intervention for

PASSPORT consumers

Intervention involves collaborative care between a

hospital-based interdisciplinary team, the Area Agency

on Aging, and the consumer’s PCP36

The S.A.G.E. Project(Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project: A Successful Health Collaborative(Est. 1995)

Improving Care through Collaboration: Integration of the Aging Network and Acute and Post Acute Medical Care

Services37

SAGE Goal

S.A.G.E. Project is an example of how to partner with a community agency:

Acute hospital and medical care services; and,

A community-based Area Agency on Aging

Goal: To integrate a comprehensive geriatric hospital-based clinical program with the community aging network to improve the health, functional status, and prevent institutionalization of older adults at risk for nursing home placement.

38

The SAGE Project

A 15-year collaboration partnership

Multiple initiatives, a “cast of thousands”, well maybe 100s,

but you get the point

Common goal to improve the health, well being and

functional status of Akron region frail older adult population

Identified major gaps in the continuum and care processes

from each partner

Searched and defined mutual benefits

Shared mutual threats and concerns

Built trust

Grew and multiplied to other regional systems

Communication, communication, communication

Vision, Vision, Vision, Vision 39

Area Agency on Aging Programs

Mission: To provide older adults andtheir caregivers long-term care choices, consumer protection and education so they can achieve the highest possible quality of life.

Aging Resource Center

PASSPORT Home Care Medicaid Waiver

Assisted Living Medicaid Waiver

Community Services Division

Care Coordination

Alzheimer’s Respite Program

Family Caregiver Support

Elder Rights Division

40

Who were the partners?Summa Health System

Geriatric Medicine Department

6 Hospital System 2,027 licensed beds

61,800 admissions

Level 1 Trauma 113,059 ED visits

Community Locations 4 outpatient health centers

Wellness Institute –

• medically-based fitness

Health Plan 110,000 Covered Lives

16,000 Medicare Risk HMO

Major Teaching Residency and Fellowship Program

Post Acute/Senior Service Line 10 Certified Geriatricians

12 Geriatric Certified APNs

Continuum of Care Acute Care/Acute Rehab/ LTAC/ SNF

Beds

Home Care/ Hospice/ Home Infusion/ HME

SummaCare, Inc.

Summa Akron City Hospital Summa St. Thomas Hospital

Summa Western Reserve

Hospital

41

Summa’sInstitute for Seniors and Post-Acute Care

42

Transitions of Care:AD-LIFE, PEACE, and Bridge to Home

Post-discharge care

management of low income

frail elderly

Advance care planning and

palliative care/geriatric

syndrome management for

low income seniors

Nurse care manager

activation of client

Collaboration between a

hospital-based

interdisciplinary team, Area

Agency on Aging, and PCP

Integration of acute and long-

term care

Transitional care to reduce

readmissions

AD-LIFE trial is supported by the Agency for Healthcare

Research and Quality Grant # R01 HS014539. PEACE is

funded by the National Palliative Care Research Center.

Both are supported by the Summa Foundation.

Bridge to Home is funded by SummaCare.

The Primary

Care

Physician• Medical model

• Limited time with

patient

The Center for Senior

Health and Senior

Services

• Consult and support across

the continuum including

outpatient, inpatient, house

calls and skilled/long- term

care

• Addresses medical and

psychosocial

The Area Agency on Aging

• Social service model but now

becoming more integrated

• Care management and services for

long-term care

• Limited interaction with PCP

• Addresses functional

abilities/geriatric syndromes but

challenged with high risk enrollees

with multiple chronic illnesses

AD-LIFE,

PEACE, &

SummaCare’s

Bridge to

Home

43

Purpose of the PEACE Pilot Study

This randomized pilot study will determine the

feasibility of a fully powered study to test the

effectiveness of an in-home interdisciplinary palliative

care management intervention to improve the quality of

palliative care for consumers of Ohio’s community-

based long-term care Medicaid waiver

program, PASSPORT

44

Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System

Hospitalization prompting

advance care decisions

(often by the family)

Community-dwelling chronically

ill patient with poor symptom

control and coordination of care

whose advance care wishes are

rarely documented

Exacerbation of chronic illness

45

Palliative Care and Advance Care Planning

Independent

Management HospiceAdvance Care Planning

Symptom Management

Disease Management

Diagnosis Death

46

Patient Centered Care

47

Frailty

Advanced Organ Failure

Dementia

Chronic Critical Illness

Cancer

Stroke

Well Older Adults

Osteoporosis

Geriatric syndromes

Peri-operative care

Stable chronic dx

Preventive care

Gait DisordersAIDS

Cancer (<65)

TBI

Cystic Fibrosis

Genetic/

Developmental

Disorders

Pediatric Oncology

Morrison, S . National Palliative Care Research Center

Target Population for the PEACE Pilot Study

New PASSPORT enrollees >60 years old with one of the

following diseases and the corresponding level of severity will

be eligible for inclusion:

CHF and being actively treated (AHA class C)

COPD and on home O2 or nebulizer treatments

Diabetes with renal disease, neuropathy, visual problems, or CAD

End-stage liver disease, cirrhosis

Cancer (active, not history of) except skin cancer

Renal disease on dialysis

ALS with history of aspiration

Pulmonary hypertension

Parkinson’s disease (stages 3 and 4)

48

Enrollment

RN assessors from the AAoA will screen consumers at the time of their initial PASSPORT assessment

RN assessor will obtain HIPAA release

Research nurse will obtain consent and obtain baseline measures

Consumers will be randomized to usual care or the intervention group

49

Intervention

Each Care Manager will have approximately 10 consumers

Care Manager will make 2 home visits centered on symptom

assessment & advance care planning

Care Manager will take her assessment findings to an

interdisciplinary team

Team produces recommendations for consumer & PCP

Care Manager accompanies consumer to 1 PCP visit to assist

consumer in discussing advance care goals with PCP

Care Manager & Palliative Care Nurse supervisor make another

home visit to begin implementation of plan of care

Care Manager follows-up with consumer monthly for 1 yr to

assure team recommendations are implemented

PEACE Intervention

50

OutcomesMeasured at 3, 6, 9 and 12 months

5 Domains Measurements made to determine

domain score

1) Symptom management Memorial Symptom Assessment Scale

2) Quality of life/death QUAL-E

3) Relationships Meaning in Life Scale

4) Decision making; care

planning; continuity;

communication; patient

activation

Palliative Outcome Scale, Patient

Activation Measure

5) Depression and anxiety Hospital Anxiety and Depression Scale

51

Challenges

Getting buy-in from case managers

Education and knowledge gaps

Changing culture of the AAA

Needing to get more top-down support for the

project so AAA CM supported for the project

Not over “medicalizing” the care plans

52

Successes

Strong working relationship and commitment

by the AAoA

A team that has gone from forming to storming,

not yet norming

Culture sensitivity and knowledge between

aging network and acute care sector—

“becoming bilingual”

Outgrowths of other educational projects,

additional funding for PC research, and

bridging the community network and acute

sector53

Additional PEACE Related Projects

A survey of knowledge and attitudes about ACP and

PC sent to all area PCPs. Funded by the Summa

Foundation.

A statewide survey of all care managers at all AAoA

that will examine knowledge and attitudes regarding

ACP and PC. Funded by Northeastern Ohio

Universities Colleges of Medicine and Pharmacy.

An educational program to teach AAoA care managers

how to bring PC upstream in the disease process.

Funded by the First Merit Foundation.

54



PACE as an ACO Model of Care

Jade Gong, MBA, RN


55


Comprehensive Services

• Integrates preventive, acute, and long-term care

services

• All Medicare and Medicaid services, plus

community long-term care services

• No benefit limitations, co-payments,

or deductibles

• PACE is the only fully capitated and integrated

Medicare and Medicaid program to serve frail

nursing home eligibles

56


PACE Eligibility Criteria

• 55 years of age or older

• Live in a PACE service area

•Be certified as eligible to receive

a nursing home level of care

• Be able to live safely in the

community at point of enrollment

57


PACE Enrollees Snapshot

58

Mean Age 80

Gender75%

women

Average Number of Basic

ADL Deficits3.5

Cognitive Impairment 63%

Average Life Expectancy4.5

years


PACE Nationally

• 79 PACE organizations and growing

•31 states

• 20,000 PACE

participants

•100 to 2,000

participants

per program

59


Home

Care

Nutrition

Personal

Care

OT/PT Transportation

Primary

Care

Activities

Pharmacy

Social

Services

Well-functioning IDT Key to PACE Success

60


PACE Network

Specialty Care

Medication Supplies

DME

Transportation

Meals

Personal Care

Subacute Care

Hospital Care

61


PACE Payment Sources

• Payment features are unique

• Capitated payment system—per member per

month (PMPM)

• Combines funding from multiple payor sources to

meet all participant needs

62


Integrated Financing

63

Pooled Capitation

(PMPM)

Medicare Part D

Medicare Medicaid

Private Pay


21%

45%

34%

Hospital Home Nursing Home

Place of Death in PACE

53%

20%

Older Americans

64


Survival in PACE

0

1

2

3

4

5

Median Survival (years)

2.3

3.5

4.2

NH Waiver PACE

• South Carolina

• Two counties

• PACE group same

baseline risk as NH

group

• PACE group higher

baseline risk than

Waiver group

65


PACE Core Competencies

• Provider-based model

• Tightly controlled care management and utilization systems

• Serves a nursing home-eligible population in the community when enrolled

• Good health care outcomes, high enrollee satisfaction, and low disenrollment rates

• Established existing program with a proven track record

66



Opportunities for Hospice and PACE Collaboration in the Delivery of Person-Centered Care

67


Exploring Common Ground:PACE and Hospice

• Patient centered

• Holistic approach to care

•Utilizes interdisciplinary teams

• Supports caregivers

• Utilizes managed care efficiency

•Receives capitated payment (per diem or per

month)

68


Why Should Hospice Develop PACE Programs?

• Meet community needs with broader care options

for frail seniors at the end of life

• Build upon community awareness of hospice

• Draw upon greater stability of multiple revenue

streams

•Greater efficiency through shared allocation of

administrative expenses

69


PACE with Hospice Opportunities for Collaboration

• Each provider can focus on providing

patient-centered care

– Some hospice referrals may be more appropriate

for PACE

– Some PACE referrals may be more appropriate

for hospice

• PACE can utilize hospice expertise through contracting:

– Pain and symptom consultation/pain management

– Use of hospice interdisciplinary team (IDT)

– Training in end-of-life care

– Inpatient hospice facility if needed by participant

70

strategic options for hospice & palliative care in the era of acos

Health & Medicine