What do ACO s and Hospitals want from SNF s and CCRC s

Full text

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What do ACO’s and Hospitals want from

SNF’s and CCRC’s

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Assessing the match: What hospitals and ACO’s currently want from post–acute care providers and CCRC’s

• What do ACOs & Hospitals want from SNFs and Communities?

• What do SNFs want from ACOs?

• Marketing Analysis- an in depth look and plan

• Continuum Development – what is your offering? •

• Steps to get a seat at the table

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Accountable Care Organizations

What do ACOs & Hospitals want from SNFs?

• Nursing/Rehab clinical excellence • Documentation of quality outcomes

– All collecting, defining, and reporting identically

• System to track readmissions

– Process for continuous improvement

• Quality physical plant

• Medical Director leadership

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What do ACOs & Hospitals want

from SNFs and Communities

• Nursing/Rehab clinical excellence • Defined as Full time PT OT ST;

• Access to clinical outcome information for Rehab Patients by diagnosis and discipline • Managed Care proficient i.e.- efficiencies in

the delivery of care

• Outpatient rehab onsite

• Wellness programs and education to residents • Short term stay experience and bed

availability

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What do ACOs & Hospitals want

from SNFs and Communities

• Documentation of quality outcomes

• All collecting, defining, and reporting identically

• Facilities may want to determine which ACO they wish to join before adopting an EMR on their own

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What do ACOs & Hospitals want

from SNFs and Communities

• System to track readmissions

• Process for continuous improvement

• Hard statistics and solid data, preferably

provided by the medical director, to show the care at the facility and to demonstrate to

ACOs that the likelihood of hospital

readmission from that SNF would be less than

at other facilities.

• What partnerships are in place to support re-admissions if need be? Do you have direct admit arrangements with other Hospitals i.e. LTACH’s

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What do ACOs & Hospitals want

from SNFs and Communities

• Quality physical plant

– SNF’s will need to look attractive to hospitals and ACOs with whom they are looking to partner.

• Tour ready facilities

• Tour ready Rehab Departments • Customer service friendly staff

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What do ACOs & Hospitals want

from SNFs and Communities

• Medical Directors leadership and role in the care for residents in the facility:

• Medical Directors have to be actively communicating with ACOs and hospitals about the quality of care the facility provides.

• Medical Directors cannot be relied upon to simply be the physician of record for the patients.

• Lead Medical Directors need to be actively engaged in clinical education and pathway development in alignment with local ACO/Continuum models

• Other roles for the Medical Director – active liaison to other physicians,

– active participant in the evolution of medical care at the post-acute care setting.

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Accountable Care Organizations

What do SNFs want from ACOs?

• Complete patient record (meds, labs, tests, final DRG)

– If not complete at time of transfer, then as soon as available

• System to track patient health changes

– Communication established for 24/7 access MD, PA, or NP – Established process for continuous improvement

• Participation in care path planning & implementation • Transparency in tracking quality outcomes

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Marketing Analysis- in-depth look

• Do your research; internal and external

• Gather re-admission rates by hospital

• Outline current specialty care and or clinical programs that the nursing and rehab team are successful at providing care for- What are you known for?

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Medicare Tables – Sample Market Analysis

Glossary

-ALOS = average length of stay (days)

-GMLOS = geometric mean length of stay (DRG payment days)

-Avoidable days = number of days stayed after DRG payment days

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Boone Hospital - Service Line by D’C Disposition

Source: CMS, MedPAR 2011; Truven Health

MCR Cases Home SNF HHS Died IRF Hospice LTACH Acute Other Total SNF

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Boone - >5 ALOS – Avoidable Day Estimate

Cases > 5 LOS # Pts. ALOS GMLOS Pt. Days GM Days Avd Days Pot. Avd$ @ $800/d

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Care Continuum- what can your

community offer?

SHORT-TERM ACUTE CARE HOSPITALS LONG-TERM ACUTE CARE HOSPITALS INPATIENT REHAB SKILLED NURSING FACILITIES ASSISTED LIVING OUTPATIENT REHAB HOME HEALTH CARE HOSPICE

Intensity of Service Lower

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Potential partners to develop the

continuum offering

• Medical Home Model

• Care Management Resources

• Transition Coaches (liaisons)

• Physician Home Practitioner

• Clinical care paths extended to SNF/AL

 Physician Assistant (specialist or generalist)

• Radiology

• Therapy

• Geriatrician – On-site

• Pharmacist

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Steps to get a seat at the table

• -IT preparedness for data collection, reporting, and adaptability to change- identify what is needed • Quantify own:

o clinical strengths- including the Medical Director leadership

o operational performance,

o patient outcomes,

o quality metrics

• Outline relationship with similar post acute providers; LTACH’s, Home Healthcare, Outpatient Rehab Services

• Present a persuasive offering to partner with the referral

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Thank you

http://www.rehabcare.com Contact: Paula Avriett

West Region -Director of Business

925-200-8970

Paula.Avriett@rehabcare.com

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