New pay mod­els mean hos­pi­tals need stel­lar post-acute net­works to thrive

Modern Healthcare - - BEST PRACTICES - By Shelby Liv­ingston

When St. Luke’s Univer­sity Health Net­work as­sumed a new level of fi­nan­cial risk for 84 ser­vices un­der Medi­care’s vol­un­tary bun­dled-pay­ment pro­gram, the sys­tem’s lead­ers knew they needed to whittle down the list of pre­ferred post-acute providers to im­prove out­comes and re­duce costs.

By an­a­lyz­ing data and work­ing with skilled-nurs­ing fa­cil­i­ties to im­prove their pro­cesses, the seven-hospi­tal sys­tem based in Beth­le­hem, Pa., dras­ti­cally cut the num­ber of days its pa­tients spent in the fa­cil­i­ties, as well as how fre­quently they needed to be hos­pi­tal­ized again when they left.

“Data anal­y­sis was re­ally key to our suc­cess, and hav­ing data on the per­for­mance of post-acute providers was ex­tremely eye-open­ing,” said Donna Sabol, St. Luke’s chief qual­ity of­fi­cer. “It was very ev­i­dent that pa­tients who were in man­aged-care prod­ucts had half the length of stay in (skilled-nurs­ing fa­cil­i­ties) com­pared to those that were Medi­care fee-for-ser­vice,” she said. Medi­care fee-for-ser­vice plans have broad net­works, while man­aged­care plans typ­i­cally di­rect pa­tients to spe­cific providers.

To cre­ate a high-per­form­ing posta­cute care net­work, St. Luke’s turned to the providers with whom it al­ready had a strong re­la­tion­ship. It then col­lected per­for­mance data from nurs­ing fa­cil­i­ties to pro­mote com­pe­ti­tion, in­form­ing them that they could be re­moved from the pre­ferred list if they don’t per­form well enough. The sys­tem also went a few steps fur­ther to train, ed­u­cate and build care pro­to­cols and tran­si­tion-of-care pro­cesses for those providers. It even em­bed­ded its own physi­cians in the nurs­ing fa­cil­i­ties to bet­ter teach them pro­to­cols and held quar­terly meet­ings with their ad­min­is­tra­tive teams to talk progress.

Charlotte, N.C.-based Premier, a group pur­chas­ing and health­care per­for­mance im­prove­ment com­pany, high­lighted St. Luke’s strate­gies and re­sults in a guide in­tended to help other hos­pi­tals get a han­dle on the wide vari­a­tion in cost and qual­ity of care across post-acute providers. Hav­ing a strong post-acute net­work can help hos­pi­tals earn bonuses and avoid penal­ties un­der bun­dles and other emerg­ing pay­ment mod­els.

For high-risk pa­tients, St. Luke’s physi­cians phoned skilled-nurs­ing fa­cil­i­ties to touch base once a pa­tient was dis­charged. Skilled-nurs­ing fa­cil­i­ties then did the same with pri­mary- care physi­cians after pa­tients left their care.

By the sec­ond quar­ter of 2016, St. Luke’s had nar­rowed its pre­ferred post-acute care net­work to nine providers from 16 in 2014. The re­sults have been dra­matic, Sabol said.

In 2014, the av­er­age length of stay for Medi­care fee-for-ser­vice pa­tients in the bun­dles was about 36 to 40 days. As of the sec­ond quar­ter of 2016, stays av­er­aged 14 to 19 days at the nine pre­ferred skilled-nurs­ing fa­cil­i­ties. More­over, St. Luke’s sig­nif­i­cantly re­duced the num­ber of skilled-nurs­ing pa­tients read­mit­ted to the hospi­tal within 90 days of dis­charge. It was any­where from 34% to 45% in 2014 and had de­clined to 21% in the sec­ond quar­ter of 2016, Sabol said.

Hos­pi­tals his­tor­i­cally have had lit­tle to do with the post-acute care that fol­lows a pa­tient’s hospi­tal stay, leav­ing phys­i­cal ther­apy and di­etary coun­sel­ing up to the skilled-nurs­ing fa­cil­i­ties and home health or­ga­ni­za­tions that take over once a pa­tient is dis­charged.

But Medi­care’s new value-based pay­ment ini­tia­tives—such as the read­mis­sions re­duc­tion pro­gram and bun­dled pay­ments—re­quire hos­pi­tals to man­age care for months after dis­charge.

“It’s a very, very di­verse ar­ray of providers that en­com­pass the posta­cute space,” said Andy Ede­burn, prin­ci­pal with Premier’s pop­u­la­tion health ad­vi­sory ser­vices. “Be­cause these sites man­age such dif­fer­ent pa­tient types, it’s a chal­lenge for hos­pi­tals or health sys­tem lead­ers to re­ally know which of these are ap­pro­pri­ate” to en­gage and how to start.

It may take some heavy lift­ing. St. Luke’s, for ex­am­ple, hired a pro­gram man­ager for bun­dled-pay­ment pro­grams along with tran­si­tion-of-care spe­cial­ists and other clin­i­cians to help train post-acute care providers. It also opened up the elec­tronic health records to the skilled-nurs­ing fa­cil­i­ties so they could eas­ily ac­cess pa­tient records. These mea­sures can be costly, but they’re also in­creas­ingly nec­es­sary.

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