NAHC 2014 Annual Meeting & Exposition October 2014 Session 613 Thinking Outside the Box of Medicare Hospice/Home Health: Palliative Care and Advanced Illness Management Sharyl Kooyer, Sutter Care at Home Bill Musick, The Corridor Group Robert Parker, PRIME by AseraCare Palliative Care Who-What-When- Where-How-Why Why Made Easy Overview INTRODUCTION 2 1
Objectives 3 Flow 1. Context: Models and Issues 2. Specific Case Studies PRIME (Progressive Illness Management Expertise) by AseraCare Advanced Illness Management Program Sutter Care at Home 3. Q&A 4 2
Caveats If you ve seen one palliative care program, you ve seen one palliative care program. one palliative care program. Regulations vary by state and by payer and are continually evolving please don t take our comments as legal advice Beware of relying too much upon someone else s experience 5 Questions in the room 6 3
Palliative Care Models CONTEXT 7 What? Advanced Illness Management Death Manageable, early, stable conditions Serious, progressive conditions that limit daily activities Palliative Care Hospice Care Bereavement Support Diagnosis of Life-threatening or Debilitating Illness or Injury Disease Progression Terminal Phase of Illness 8 4
What is Palliative Care? Center to Advance Palliative Care (CAPC) Specializedcare care for peoplewith seriousillnessesillnesses 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 layerofsupportat at any age andatat anystagein a 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 9 What is Palliative Care? Center to Advance Palliative Care (CAPC) The palliative care team provides: 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 10 5
Variations Setting Acute Specialty/ General Clinics Skilled Nursing Primary Care Hospice Home Health Task specific (Advanced Directives vs P&SM) Disease specific (Cancer vs CHF) Symptom specific (Pain) Delivery method (Face to face, telephonic, video) 11 Palliative Care HOW TO MAKE MONEY BREAK EVEN GET PAID 12 6
Payment Billable Entitlement Programs Medicare Part B Physician/NP LCSW (using mental billing codes only) Home Health Concurrent Hospice Care Revenue Cost Medicaid Pediatric Concurrent Care Commercial Insurers CMS Demonstration Project?? 13 Payment (continued) Entrepreneurial Contracts Commercial Insurer Hospital/Health System Innovation Award/ACO/Bundled Payment Philanthropic Research Foundations Private Pay Fee for Service (Concierge) 14 7
Cost Avoidance in Lieu of Payment System-wide Cost Savings/ Outcomes Net Investment in Palliative Care 15 * * Palliative Care WHO and WHY 16 8
Why? Service Goals Unmet need Move upstream Discharge option Financial Goals Loss is OK (at least to start) Break even Financial contribution 17 Who? All with need Top potential for savings Segmented population Highest Cost Disease Management Pre/Post Hospice 18 9
Palliative Care Examples of Delivery Models 19 Examples: Advance Care Planning Gundersen Health System s Respecting Choices Program 20 10
Example: UPHS CLAIM Project University of Pennsylvania Health System CLAIM Project (ComprehensiveLongitudinal AdvancedIllness Management) Home Health based program with supplemental disciplines Cancer Goal: reduce unnecessary end of life care costs and decreased quality of life Seed funding: Health Care Innovation Awards Long term: Cost avoidance, outcome improvements 21 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 22 11
Examples: Entrepreneurial Services Contractual arrangements by hospices/home health agenciesto 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) 23 Comments/questions 24 12
Case Study PRIME by ASERACARE 25 History Program Development: Due diligence 18 months (2010 2011) Identity PRIME by AseraCare What Services NP Consultative Medical Model NP Skilled Nurse Facility Primary Care Service Model NP Payer Medical Case Management Model 26 13
History Program Expansion: Community based NP 16 programs in 9 states Skilled Nursing Facility 5 programs in 3 states 10 programs in development Payer Medical Case Management 1 Managed Medicaid payer ACO, palliative outpatient clinics, hospital system partnership opportunities 27 Why Poor Transitional Care Care Silos Acute Skilled Nursing Facility Commercial/Managed Care Payers Physician/Physician Groups Community at Large 28 14
PRIME by AseraCare Four Pillars: Pain and Symptom Management Medication Management Setting Management Advance Care Planning 29 PRIME by AseraCare Core Staff: Advanced Practice Registered Nurse (APRN) Provider H&P Board Certified MD Collaborative Physician i Licensed Clinical Social Worker (LCSW) DSM diagnoses 30 15
PRIME by AseraCare Framework: Pti Patient caregiver t i Care Continuum Communication and Collaboration Healthcare Systems PCPs SNFs and SNF Attending Home Health lthagencies Other care settings NP as Community Case Manager 31 PRIME by AseraCare NP Community Model: Across all settings Seriously ill patients with progressive illness High risk for futile care End stage disease trajectory 1+ years out from being clinically eligible for Hospice 32 16
NP Community Model 33 PRIME by AseraCare NP SNF Model: Dedicated to individual SNF Chronically/Seriously ill patients Rehab to Home 2+ years out from being clinically eligible for Hospice Periods of decline and stabilization Potential for high risk of futile care Plus end stage disease trajectory 34 17
NP SNF Model 35 PRIME by AseraCare NP Payer Model: NP Medical Case Management Life altering, life limiting care needs 4+ years up stream from being clinically eligible for Hospice Focus on high utilization of resources Patient self management focus Risk stratified cost avoidance 36 18
NP Payer Model 37 Statistics Practice: Initial/New Consults 2664 (program to date July 31) Total Consults 10,128 (program to date July 31) Hospice Conversions 666 patients (program to date July 31) 25% conversion rate (program to date) 30% conversion rate (YTD 2014) 38 19
Statistics Quality: Pain 94% on a goal of 80% Dyspnea 99% on a goal of 70% Anxiety 98% on a goal of 70% Goals of Care 98% on a goal of 100% Re hospitalization 1.3% on a goal of <5% 39 Financial Reimbursement constraints: Fee for service Payer Gaps in knowledge: Consumer confusion Industry confusion 40 20
Financial Revenue: Break even model Proforma builds month over month Break even within 12 months SNF model Easier model to break even Consolidated patient set 41 Financial Revenue: Community consults per month 18 22 Initial/New 80 90 Subsequent/Established SNF consults per month 60 Initial 240 Subsequent 42 21
Financial Revenue: Evaluation & Management CPT Coding All three services lines Payer model additional revenue through gain sharing Negative margin before hospice conversion Other risk share, PMPM 43 Comments/questions 44 22
Sutter Health / Sutter Care at Home Advanced Illness Management (AIM ) A Model for Palliative Care and Complex Care Management 45 Health Care Innovations Awards Sutter Care at Home Advanced d Illness Management The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies." 46 23
THE AIM JOURNEY: 2008 PRESENT Imperative for AIM Model Design Characteristics Person Centered Care Identified the gap/burden in care Secure funding Research and design Evaluated pilot; decided on system wide implementation Implementation planning Conduct pilot System Integration ti Launch readiness planning Site implementation Infrastructure development Impact on Care Outcomes AIM Program Model : Better Health Better Care Lower Cost Program evaluationsystem & payer Continuous program development, improvement, maturing 47 "The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies." The AIM Patient Experience Additional Statistics Medicare will spend 28% of all their payments on a patient in the last year of life Medicare will spend ~$214M per year for 5,000 patients in the last year of life Patients have a 25% chance of receiving hospice care where they will spend 8 days on service before dying Patients in the last year of their lives represent 5% of the population that spends the highest amount of Medicare dollars and take the most time and resources from providers Source: Data of Sutter Experience The Care of Patients with Severe Chronic Illness. Dartmouth Atlas, 2006 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 48 24
SYSTEM FRAGMENTATION SYSTEM INTEGRATION HOSPITALS Emergency Dept. Hospitalists Inpatient palliative care Case managers Discharge planners AIM Care Liaisons MEDICAL OFFICES Physicians Office staff Care managers Telesupport 911 HOME-BASED SERVICES Home health h Hospice Transitions Team Telesupport CRITICAL EVENTS Acute exacerbation Pain crisis Family anxiety New AIM staff & services 49 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. AIM MODEL DESIGN CHARACTERISTICS Target Population > 2 Chronic Illnesses; >1 Illness Advancing Poly pharmacy Clinical, Functional, and/or Nutritional Decline High Symptom Burden leading to repeat utilization MD Surprise Question 12 Months Model Principles Personal Goals Person &Physician Relationship Central Dual Therapeutic Approach Curative + Palliative Evidenced Based Clinical Care and Care Management Simplify and Drive Communication Pillars of Care Advanced Care Plans Self Management Plan of Red Flag Symptoms Medication Management Ongoing Follow Up Visits Engagement & Self Management Support Resting on Curative + Palliative Care Foundation Drivers of Outcome Aware and Skilled in Health Literacy & Patient Engagement Continue During Periods of Illness and Wellness, across all settings Frequent & Predictable MD Communication Teams Without Borders 50 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 25
PERSON CENTERED CARE Clinician Patient/ Family Teach Back Bubble Diagrams Chunk and Check Motivational Interviewing Stop Light Forms SMART Goals Evidence-based Care Medication Management Management POLST Evidence-based Palliative Care Mock Runs Personal Health Record 51 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. CLOSER LOOK AT INTEGRATION 52 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 26
STAFFING MODEL AIM Team Members AIM Home Health (HH RNs, MSWs, plus other disciplines) AIM Hospital Based (AIM Care Liaison, RN, former Hospice) AIM Team AIM Transitions (former Hospice RNS and MSWs) AIM Telesupport/ Office Based Case Management (RN mixed experience) Case Loads AIM Home Health:13 17 pts AIM Transitions: 15 20pts AIM Telesupport: 60 80pts Medical Director:.2.3 FTE AIM Administrator (also Hospice Administrator) Leadership Team=HH, Hospice, AIM 53 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. AIM: TOTAL COST OF CARE Hospital Home Health (AIM) Total Cost of Care Physician AIM Telesupport/ Office Based Case Management AIM Transitions 54 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 27
Examples of AIM Measures Care at the End of Life Outcomes, Resources and Costs % Transferred to Hospice Inpatient and ED visit Rates per 100 patients % Died in Hospital 30, 90 and 180 Day Pre/Post Hospital Days in Last 6 months Enrollment Utilization of life Hospital ED Ed Use in Last 30 Days of Life ICU ALOS in Hospice ICU Use in Last 30 Days of Life 90 Day Payer Impact, Hospital LOS of Hospice Stay Cost Impact, Total Cost of Care Independent Research and Evaluation 55 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Closer Look at Care Integration 56 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 28
Improving Health IMPACT ON CARE Improving Care Lowering Cost Change in Utilization 90 Days Post AIM Enrollment 9 of 10 sites reporting; Q2 2013 Q1 2014); n 1544 (Results not yet confirmed independently by CMS Evaluators) Now serving 15 counties; enrolled more than 6,500 persons with advanced illness; 335 staff members trained 1800 1600 1400 Current census is 2100+; 85,000 patient contacts last 12 months CMS awarded Sutter with a $13 million Innovation Challenge grant to fund the ongoing implementation and evaluation of the AIM program; Sutter provided $21.4 M Cha ange in Utilization 1200 1000 800 600 400 200 59% Reduction 19% Reduction 67% Reduction Pre Post Ongoing high patient and provider satisfaction. 0 Hospitalizations ED Visit ICU Days Service Utilization 57 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Interim Results: 90 Day Pre/Post Cost Analysis 12 Months Rolling Q2 2013 Q1 2014 9 Out of 10 Sites Reporting (Results not yet confirmed independently by CMS Evaluators) Cost of Care Impact (N=1,544) $15,417,246 $16,400,188 188 $12,799,460 $0 $2,000,000 $0 Cost of Care Impact Per Enrollee (N=1,544) $9,985 $10,622 $8,290 $4,000,000 $6,000,000 $8,000,000 $10,000,000 $2,000 $4,000 $6,000 $12,000,000 $14,000,000 $16,000,000 Change in Total Sutter Costs $8,000 $10,000 Change in Total Sutter Costs $18,000,000 Change in Net Charges Billed to Payers Change in Hospital Costs $12,000 Change in Net Charges Billed to Payers Change in Hospital Costs 58 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 29
CHALLENGES Time required to adopt and hardwire new clinical and care management skills Regulatory & legal environment not aligned with health care reform innovation Expanding Access to AIM Services and Evaluating the Model of Care Immediate demand for clinical, operation, and financial integration outpaced IS infrastructure Resources and skills to perform specialty analytics in timely, consistent and reliable manner 59 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. OPPORTUNITIES Investment in infrastructure for broader complex care management Participate in design or evaluation of model of care for persons with advanced illness Develop new payment model to serve this complex growing population of patients 60 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 30
living in two worlds at the same time is challenging Fee For Service Value Based Population Reimbursement 61 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 62 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 31
Health Care Innovations Awards The project described was supported by Grant Number 1C1CMS331005 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. 63 The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Resources What is Palliative Care?, Center to Advance Palliative Care, 2012 http://www.getpalliativecare.org/whatis/ Palliative Care Services: Solutions for Better Patient Care and Today s Health Care Delivery Challenges, American Hospital Association, November 2012, http://www.hpoe.org/reports HPOE/palliative_care_services_solutions_bet ter_patient_care.pdf Hospice and Palliative i Mdii Medicine: What Are the Next Steps for a Match (National Resident Matching Program) (2012) Signer http://apps.aahpm.org/default.aspx?tabid=251&productid=594 64 32
Resources University of Pennsylvania School of Medicine. "Care At The End Of Life: Room For Improvement, Ideas For Change." Medical News Today. MediLexicon, Intl., 23 May. 2013. Web. 12 Aug. 2013. http://www.medicalnewstoday.com/releases/260840.php Palliative Care and Hospice Care Across the Continuum, Center to Advance Palliative Care, http://www.capc.org/palliative care across the continuum/ Improving Care for People with Serious Illness through Innovative Payer Provider Partnerships, Center to Advance Palliative Care, http://www.capc.org/payertoolkit/ 65 Contact Information Sharyl Kooyer AIM Program Director, Sutter Care at Home KooyerS@sutterhealth.org (916) 797 7856 Bill Musick Senior Associate, The Corridor Group BMusick@corridorgroup.com (888) 942 0405 (toll free) Robert Parker Program Manager, PRIME by AseraCare Robert.Parker@aseracare.com (512) 422 2911 66 33
Comments/questions 67 Compare & Contrast Targeting and Triggers* Interdisciplinary Team Composition* 24/7 Clinical Response * Integrated Medical and Social Supports* Concurrent Care* Setting Specific or Agnostic? * CAPC Essential Structural Characteristics of High-Value Palliative Care 68 34
Palliative Care PLANNING AND DEVELOPMENT CONSIDERATIONS 69 Issues in Financial Viability Incomplete payment mechanisms Optimal utilization of high cost providers Over extending services Services provided d Patients served 70 35
Tips Focus on local needs Assess local resources Look for creative leveraging of community resources When possible, shoot bullets first, then cannon bll balls 71 Tips (continued) Think outside of legacy models Trust and compatible culture of partners ranked higher than logistics/systems by hospital executives Value of practice management 72 36
Palliative Care Models Tips and Considerations from the Field 73 Resources & Acknowledgements Center to Advance Palliative Care www.capc.org Palliative Care Center of the Bluegrass (Hospice of the Bluegrass) Gretchen Brown, CEO 1 of 8 CAPC Palliative Care Leadership Centers (PCLCs) Physician practice model providing services in academic and community hospitals, NFs and outpatient clinic 74 37
Tips from the field 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 it Your partner does not care/believe in cost avoidance findings from other providers saying it louder won t help 75 Tips from the field 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 76 38
Tips from the field Diversify 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 77 Tips from the field Courtesy 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 78 39
Tips from the field Courtesy 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 79 Tips from the field Courtesy 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 80 40