As Medicare’s Bundled Payments for Care Improvement Advanced (BPCI Advanced) model continues to incentivize the transition toward value-based care, hospitals are innovating with new services and capabilities to meet its goals.
CHA Hollywood Presbyterian Medical Center (CHA HPMC) in Los Angeles designed and implemented a post-acute care program that allows sepsis patients on Medicare to continue receiving high-quality care during a 90-day period after discharge.
Early results indicate that the program is successfully meeting its objectives with improved quality measures, reduced readmission rates, and enhanced patient and physician satisfaction while contributing to cost reductions, says Jamie Chang, MD, MBA, FACEP, chief clinical operations officer.
Chang notes that patients who are 65 and older are especially susceptible to sepsis. CHA HPMC’s Continuing Care Program is designed to encourage the patient’s recovery at home and help him or her stay healthy and avoid readmission, he says.
CHA HPMC relies on data to identify the priority areas for intervention during the post-acute period, providing patient navigators, case managers, a 24/7 nurse triage line and support services, and other assistance. The program also relies on a comprehensive data and performance management platform.
Outcomes measures from CHA HPMC’s Continuing Care Program have demonstrated its success with lower readmission rates and improved CMS quality measures.
Fourth-quarter 2018 data show that the sepsis population increased in overall case volume by 17%, but the 30-day readmission rate went down from 32% to 25%, Chang says.
The 90-day readmission rate was reduced from 40% to 34%, and the 90-day utilization rate for skilled nursing facilities and inpatient rehabilitation facilities decreased from 57% to 48%.
The program resulted in cost savings of 14% below the Medicare target price for sepsis episodes of care, he says.
Internal and External Specialists
CHA HPMC created the Continuing Care Program by assembling a multidisciplinary team of internal hospital resources and external specialists to collaborate on delivering effective post-acute care for sepsis patients, Chang explains. The team includes representatives from case management, social work, nursing, pharmacy, quality, and coding.
“Our vendor partners include technology companies to provide patient tracking and notification systems, a team of patient navigators who engage patients at bedside and also at home, an on-campus care transitions clinic, SNF [skilled nursing facility] specialists, and a comprehensive data and performance management platform,” Chang says.
“In addition, we contracted with multiple community physicians to support our efforts to reduce the cost of care, with gain-sharing agreements per CMS guidelines.”
This multidisciplinary team spent several weeks working together to design the detailed workflows, operations, and communication strategy for the program, Chang says. Then, they went live with executing the plans in October 2018, and continue to meet every week to refine operations in an effort to continuously improve.
CHA HPMC was accepted in the first cohort of hospitals to participate in BPCI Advanced, Chang notes. This bundled payment program created the incentives for the hospital to invest in the technology, services, and resources required to establish an effective post-acute care program to reduce the cost of care after discharge.
“More broadly, CHA HPMC recognizes that hospitals are operating during a period of transition from fee-for-service to value-based reimbursement. As more financial risk for the cost of care is transferred to hospital providers, we understand that there needs to be increasing attention to the costs that are incurred not just during the acute hospital encounter, but also the costs of care after discharge,” he says.
“Specifically, as traditional Medicare tests innovative payment models, we recognize that this change to value-based reimbursement is inevitable for this population. The only decision for hospitals is whether or not they will adapt and be ready for this change before it becomes mandatory.”
Cost of Care Difficult to Determine
The hospital’s initial challenge was having little to no visibility into the cost of care for patients after discharge from the hospital, Chang says. While they had a lot of data on the cost of care during the acute inpatient encounter, they did not know what costs were being incurred by Medicare after the patient left the hospital.
“Since we were now faced with financial liability for these costs after discharge, we needed to partner with a vendor to help us understand where these costs were being incurred so we could effectively manage them,” he says. “This intelligence about post-acute spending was critical to helping us identify which physicians and post-acute facilities to focus our attention and efforts to align incentives for success in the program.”
Another challenge has been physician adoption for the innovative program. Physicians were skeptical about why the hospital was investing in so many resources to proactively manage these patients after discharge.
“We overcame this obstacle by directly contracting with physicians to incentivize them to partner with us on reducing costs of care, and then providing regular performance updates so they could have more visibility into what healthcare expenditures were being incurred by their patients,” Chang says. “Just providing this data was very illuminating to physicians, who otherwise had very little insight into the cost of care being incurred by their patients.”
SNF Cooperation Lacking
The other major challenge has been cooperation with post-acute facilities such as SNFs because the objective has been to reduce spending in these sites of care.
“We have been able to overcome these obstacles by establishing a narrow network of post-acute facilities who understand that healthcare reimbursement is changing, and so are willing to collaborate with us on this effort,” Chang says.
“These early adopter post-acute facilities realize that aligning themselves with acute care hospitals and working together to coordinate transitions of care is good for patient care, and will ensure that these post-acute facilities are relevant in the market in the future.”
Readmissions Decreased, Savings Improved
Chang says the hospital has demonstrated through the Continuing Care Program that it is able to deliver higher-quality care to patients in terms of both patient satisfaction and improvements in outcome measures. Comparing 2017 with Q4 2018, Chang cites these results:
• 90-Day Readmission Rate: Across all patients included in seven selected bundles, CHA HPMC improved this metric from 40% to 31%.
• Cost Savings: For patients admitted with a diagnosis of sepsis, the hospital achieved cost reductions that are 14% below the target price that CMS has set for CHA HPMC for this population of patients. CHA HPMC projects that it will receive a $3 million reconciliation payment annually for this bundle alone, helping fund program expenses and also generate incremental net revenue for the hospital.
• Improvement in CMS Quality Star Rating Measures: By participating in the program, CHA HPMC has been able to use the anticipated reconciliation payments to fund the services, technology, and capabilities to improve overall hospital quality. Specifically, the reduction in the 30-day readmission rate for congestive heart failure (40% to 11%), pneumonia (12% to 9%), and acute myocardial infarction (28% to 18%) directly improves its CMS Star Rating and its performance in the CMS Hospital Readmissions Reduction Program.
“While delivering higher-quality care to our patients, we are able to achieve this at a lower overall cost to Medicare, indicating that this would be a sustainable model of care for the future,” Chang says.
“Implementing a post-acute program to provide care for patients after discharge requires additional resources, technology, and services that hospitals have not traditionally invested in. Innovative payment models, such as BPCI Advanced, can help to finance the change that is required for us to deliver higher-quality care.”
- Jamie Chang, MD, MBA, FACEP, Chief Clinical Operations Officer, CHA Hollywood Presbyterian Medical Center, Los Angeles. Phone: (213) 413-3000.