2. Niche Development in Nursing Homes United Methodist Homes of New Jersey Larry Carlson, President & CEO Carol McKinley, Vice President of Operations Sara Ur, Executive Director - Bristol Glen CCRC

3. UMH Geography Bristol Glen Collingswood Manor Pitman Manor Francis Asbury Manor The Shores PineRidge of Montclair Bishop Taylor Manor Covenant Manor Wesleyan Arms Wesley by the Bay

4. Mission & Values Compassionately serving in community so that all are free to chose abundant life Compassion – demonstrating love in our daily interactions Respect – seeing and valuing sacred worth Stewardship – faithfully managing the resources entrusted to us Service – finding joy in caring

5. UMH Service Product Lines Affordable Housing Independent Living Assisted Living Assisted Living + Assisted Living Hospice Memory Support Residence Skilled Nursing including short-term stay Community Resource Hub

7. Hospital Partnership Strategy Develop a value-based relationship using data and metrics – Clinical Quality & Integration – Resident Satisfaction – DRG Gap Analysis – Care Transitions

8. DATA is KING Hospital Discharges Readmission Penalties Measuring clinical and financial results

9. Data Driven Partnerships The most important relationship is CEO to CEO, physician to physician Understanding and analyzing hospital discharge data – MEDPAR Understanding the differences among hospitals is the springboard for developing specific value-based relationships with each organization.

10. Opportunities Recognize high variance Understand admission rate Understand the implied revenue loss based upon length of stay Reduce and control hospital readmissions

11. Measure and Report Outcomes 30-day hospital readmission by diagnosis Rate of discharge to the community How each utilizes post-acute care: SNF, Home Health Clinical Outcomes

12. Hospital Profile Discharge Disposition CategoryHospital PercentNational Average Heart Attack21.3%19.9% Heart Failure27.7%24.7% Pneumonia19.7%18.3% Discharge DispositionTotal DischargesTotal Patient Days Average Length of Stay Skilled Nursing Facility1,37610,4577.60 Home Health Agency1,2909,1837.12 Inpatient Rehabilitation Facility5973,2505.44 Long Term Acute Care Hospital1221,62212.30 Other4,07316,6874.10 Total7,45841,1995.52

13. Hospital Med-Par Data MS-DRG Version 26 MS-DRG Name SNF Medicare Part A Discharges Acute Hospital Days CMS GMLOS Days ALOS at Hospital CMS GMLOS LOS Over (Under) GMLOS 191Chronic obstructive pulmonary disease w CC17116706.824.102.72 377G.I. hemorrhage w MCC17130837.654.902.75 690Kidney & urinary tract infection w/o MCC1783604.883.501.38 194Simple pneumonia & pleurisy w CC1572664.804.400.40 481Hip & femur procedures except major joint w CC1587815.805.400.40 177Respiratory infections & inflammations w MCC141301019.297.202.09 280Acute myocardial infarction discharged alive w MCC14127819.075.803.27 392Esophagitis gastroent & misc digest disorders w/o MCC1367365.152.802.35 308Cardiac arrhythmia & conduction disorders w MCC1297498.084.103.98 378G.I. hemorrhage w CC12100448.333.704.63 603Cellulitis w/o MCC1260475.003.901.10 Total5414,3142,8237.975.222.76

14. Hospital Med-Par Data MS-DRG Version 26 MS-DRG Name SNF Medicare Part A Discharges Acute Hospital Days CMS GMLOS Days ALOS at Hospital CMS GMLOS LOS Over (Under) GMLOS 945Rehabilitation w CC/MCC991,48085114.958.606.35 470Major joint replacement or reattachment of lower extremity662642384.003.600.40 291Heart failure & shock w MCC332811658.525.003.52 871Septicemia w/o MV 96+ hours w MCC332881828.735.503.23 292Heart failure & shock w CC261321075.084.100.98 190Chronic obstructive pulmonary disease w MCC241871207.795.002.79 193Simple pneumonia & pleurisy w MCC221411196.415.401.01 057Degenerative nervous system disorders w/o MCC21101824.953.901.05 689Kidney & urinary tract infections w MCC211431036.814.901.91 641Nutritional & misc metabolic disorders w/o MCC2085624.253.101.15 065Intracranial hemorrhage or cerebral infarction w CC18140777.784.303.48

15. Partnership Pathway Joint Operating Committee Develop a specialty clinical niche to match the hospital’s need Extend the hospital clinical pathway into the SNF Manage Transitions Share medical records through cloud technology

16. Bristol Glen CCRC Located in Newton, Sussex County NJ We offer Independent Living, Assisted Living, Memory Support, Rehabilitation, Long Term Care

17. Our Healthcare Neighborhood – 60 bed community – Average Medicare Number: 19 – Average Healthcare Census: 59

18. Hospital Med-Par Data MS-DRG Version 26 MS-DRG Name SNF Medicare Part A Discharges Acute Hospital Days CMS GMLOS Days ALOS at Hospital CMS GMLOS LOS Over (Under) GMLOS 871 Septicemia w/o MV 96+ hours w MCC 1199526378.005.352.65 470Major joint replacement or reattachment of lower extremity532512163.983.420.56 291Heart failure & shock w MCC412261545.513.991.52 194 Simple pneumonia & pleurisy w MCC 352341466.694.162.53 291Heart failure & shock w CC322441537.634.772.85 190Chronic obstructive pulmonary disease w MCC16120727.504.522.98 481Hip &Femur Procedures Except Major Joint w CC271501375.565.070.48 552Medical Back Problems with W/O MCC24125795.213.281.93 683Renal Failure W CC23131925.703.991.70 641Nutritional & misc metabolic disorders w/o MCC22114645.182.892.29 872Septicemia or Severe Sepsis W/O MV 96+hours W/O MCC22147966.684.462.22

19. Hospital Med-Par Data MS-DRG Version 26 MS-DRG Name SNF Medicare Part A Discharges Acute Hospital Days CMS GMLOS Days ALOS at Hospital CMS GMLOS LOS Over (Under) GMLOS 689Kidney & Urinary Tract Infections W MCC21125985.954.641.31 177Respiratory Infections and Inflammation W MCC191801299.476.812.67 392Esophagitis,Gastroent, &Misc Digest Disorders W/O MCC18112506.222.773.45 563 Fx. SPRN,STRN,&DISL, Except Femur,Hip,Pelvis,and Thigh W/O MCC 1657483.563.020.54 189Pulmonary Edema & Respiratory Failure15125658.334.334.00 378G.I Hemorrhage w CC1587535.803.522.28 280Acute Myocardial Infarction, Discharged Alive W MCC14115738.215.223.00 TOTAL5933,8142,5876.434.362.07

20. Hospital Med-Par Analysis Review of the Hospital Med-Par Analysis to indict where to focus – Top MS-DRGs – SNF Medicare Part A Discharges – Review of Hospital LOS versus CMS LOS – LOS Over/Under GMLOS Discussions with discharge planners regarding difficult discharges Readmissions Rates

21. Our Partners Active Members of the community that we brought together to review the results of the Med-Par Analysis to develop solutions Newton Medical Center Alliance Rehabilitation At Home Medical Ocean Medical Skyland's Medical Group Pulmonologist and APN attached to the hospital and Bristol Glen

22. Clinical Niche---- COPD Disease Management Program Who is a good candidate for the COPD management program? – A patient with a primary or secondary diagnosis of COPD – A patient that requires durable medical equipment Bipap,Cpap, Continous oxygen

23. Objective of the COPD Management Program Educate recently diagnosed COPD residents/ families assuring a better quality of life Reduce readmission rates. Provide proper medical equipment upon discharge.

24. Assessment and Planning Comprehensive assessment of respiratory status to determine baseline and criteria for COPD program. Complete medication reconciliation Consistently monitoring for cyanosis especially in therapy

25. Referral Received ↓ Respiratory Diagnosis __ COPD __ Other Respiratory Diagnosis ↙ ↘ __ Acute __ Chronic __ Stop __ Multiple Hospitalizations __ 0² Dependent __ New to 0² __ Nebulizer Treatments __ CPAPP/BIPAPP Treatments __ Percussion Vest ↓ Refer to Bristol Glen in House COPD Program

26. Equipment Company → No Equipment Company → Refer to At Home Medical COPD Program ↙ ↘ __ At Home Medical __ Other Medical Co.↓ Refer to At Home Medical Refer to VNA COPD Program COPD Program

27. Assessment Day 14-28 Interventions to Occur during care period: Assess and reconcile all medications. Instruct in purpose, route, frequency, side effects. Instruct on use of bronchodilator, mucolytics, expectorants, and nebulizers as ordered. Assess respiratory status – lung sounds, respiration rate, depth, rhythm, use of accessory muscles, etc. Assess level of dyspnea with activity and at rest, note change in status or assessment goal. Instruct: to avoid stressors precipitate disease exacerbation of (including temperature extremes & infection). Instruct: S/S infection including temp evaluation, change in sputum to yellow/green, and increased viscosity.

28. Therapy Best Practices Initial Assessment/Evaluations – Record Vitals/Monitor BORG and RPE – Assess ROM of all 4 extremities – Assess strength of all major muscle groups through manual muscle testing – Assess Gait Pattern with or without a device – Perform the Six Minute Walk Test – Perform Dynamic Gait Index on patients with suspected balance dysfunction

29. Stage/MET LevelADL and MobilityExercise CapacityRecreation Stage 1 1.0 to 1.4 MET(s) Bed Mobility Hands & face washing Self-Feeding Transfers required 10 to 15 min/extremity and deep breathing Increase sitting tolerance progressively Light handwork and table games Stage II 1.4 to 2.0 MET(s) Unlimited sitting Bathing, shaving, Grooming and dressing Room ambulation only Increase extremity # of Repetitions No Isometrics Sitting activities i.e. Crafts, sewing, knitting Stage III 2.0 to 3.0 MET(s) Brief standing for Hygiene and grooming Short outside room Ambulation Balance and light mat Activities Paced ambulation at comfortable pace Any form of tolerable Sitting activities Stage IV 3.0 to 3.5 MET(s) Standing : total Washing and dressing Light advanced ADL(s) i.e. cooking, cleaning Unlimited ambulation Increase # and speed of repetitions Stair climbing, cycling to 5mph and treadmill at 1mph to 1.5 @ 2% Driving Light gardening, ability to weed and plant Stage V 3.6 to 4.0 MET(s) Washing dishes, making beds, ironing, & hanging clothes Increasing the speed and repetitions of Stage IV. Cycling to 8mph (no resistance) +sitting exercises Swimming, golfing with cart and light home repairs Stage VI 4.1 to 5 MET(s) Standing showering in hot water, raking and mopping Walking up 4-6% grade hills and cycling up to 10mph. Also, 10-17 #’s of resistance for limbs Slow dancing and light calisthenics to tolerable range of motion Suggested Interdisciplinary Stages for Patients with Cardiopulmonary History/Precautions (METs and ADL Category)

30. Durable Medical Equipment to Home Oxygen Testing: Documentation of Qualifying ABG (P02 of < 55) or pulse oximetry (<88%) results obtained under the following conditions in the patient’s medical record (must document testing condition): ABG or pulse oximetry results within 48 hours of Hospital discharge ABG or pulse oximetry results within the last 30 days Office/Facility Resting on room air (if at 88% or below, only this condition needs to be documented) Ambulating on room air Ambulating with oxygen applied Nocturnal Nocturnal oximetry must be for a minimum of 2 hours and include 5 cumulative minutes of qualifying saturations – PO2 of 88% or less will qualify a resident for DME at Home under Medicare

31. The Home Visit Providing clinical follow-up and re-education on DME if ordered. Evaluating patient for an oxygen conserving device PRN. Instructing on proper breathing exercises and technique. Educating on proper nutrition. Discussing shortness of breath scale. Reviewing medications and ensuring prescriptions have been filled. Reviewing/instructing on proper MDI and nebulizer usage, techniques and care.

32. Resident/Caregiver Outcomes (V) Verbalizes (D) Demonstrates Knowledge of reasons to take medications as ordered with understanding of route, frequency, purpose and side effects, as appropriate. (V) Correct use of 0², nebulizers, inhalers. (D) Effects of stressors on disease process, breathing and lifestyle. (V) Coughing and deep breathing exercises; energy conservation. (D) Correct use of bronchodilators, mucolytics, expectorants, nebulizers. (D) Adequate fluid intake to help liquefy secretion. (V) 3 safety issues regarding use of oxygen. (V) Importance: Consulting with physician before using OTC meds. (V)

33. The Outcomes The communication that was developed between the partnerships and discussions from the hospital provided: – Readmission Rate for the Healthcare Neighborhood for August and September: 0% Readmission Rate – Average Medicare COPD Admissions for the last 6 months: 40% admissions

34. Next Steps--- Where are we going Hiring of a Respiratory Therapist to the team to enhance the needs of our residents Continuing to strengthen the lines of communication with the hospital for Bundling Payments Outpatient Therapy to allow residents to continue achieving their goals and quality of life. Home and Community Based Services – reaching out to the community, providing services, answering their needs. Meeting the needs of the community outside our walls.

35. The Shores at Wesley Manor 190 Apartment Community – Memory Support – Hospice – Assisted Living – Assisted Living Plus 60 Unit Health Care – 22 Sub-Acute – 38 Long Term

36. Hospital Med-Par Analysis Community Hospital Major care provider in local area. Affiliations with Philadelphia Hospitals 296 Acute Beds 30% Skilled Nursing Discharge Dispositions

37. Hospital Med-Par Analysis

38. Hospital Med-Par Data MS-DRG Version 26 MS-DRG Name SNF Medicare Part A Discharges Acute Hospital Days CMS GMLOS Days ALOS at Hospital CMS GMLOS LOS Over (Under) GMLOS 945Rehabilitation w CC/MCC991,48085114.958.606.35 470Major joint replacement or reattachment of lower extremity662642384.003.600.40 291Heart failure & shock w MCC332811658.525.003.52 871Septicemia w/o MV 96+ hours w MCC332881828.735.503.23 292Heart failure & shock w CC261321075.084.100.98 190Chronic obstructive pulmonary disease w MCC241871207.795.002.79 193Simple pneumonia & pleurisy w MCC221411196.415.401.01 057Degenerative nervous system disorders w/o MCC21101824.953.901.05 689Kidney & urinary tract infections w MCC211431036.814.901.91 641Nutritional & misc metabolic disorders w/o MCC2085624.253.101.15 065Intracranial hemorrhage or cerebral infarction w CC18140777.784.303.48

39. Hospital Med-Par Data

40. Heart Failure LOS 4.57

41. Initial Discussions for Cardiac Niche CEO Selected Hospital Leaders (CMO; CNO) Cardiology Group

42. Partnerships Determined partnerships based on like philosophies and outcomes: – Non-profit backgrounds – High standards of care – Collaborative in nature – Person-centered in service – Invested in process

43. Original Partnerships Mainland Heart Consultants

44. Protocols Collaborative Effort Care Pathways Training Equipment Telehealth Staffing

45. Goal of Program Overall agreed goal of program: To provide the highest level of care to residents with the condition of CHF and to improve their quality of life, prevent exacerbations and re-hospitalizations

46. Care Pathways Examples Who should be in program: CHF; cardiomyopathy; Ejection fraction < 40%; Hx of significant valvular disease Established Care Guide Initiatives that include: Vital signs q shift/prn Orthostatic BP q week sitting/standing 1 minute Pulse Oximetry q shift Measure intake/output q 8 hrs Daily weight at same time q day; same type of clothing and on same scale. Follow set reporting parameters for weight gain

47. Care Pathway Examples Obtain baseline laboratory and diagnostics: CBC; complete Metabolic panel; Urinalysis; microalbuminuria, fasting lipid profile, albumin, TSH, chest x-ray, and EKG. Peripheral Edema Management Protocols/Parameters Observation for signs and symptoms of CHF: Unexplained weight gain > 3lbs in 24 hours, or 5 lbs in 3 days New edema New dyspnea New abdominal symptoms

48. Education Appropriate staff members received CHF training Telehealth training

49. Equipment Needs Telehealth – weigh scale – provided by home health agency Portable Cardiac Monitor EMR reflection of protocols/orders Disease Managed Assessment Software (COMS)

50. Staffing Registered Nurses Cardiac nurses Utilized NPs of Cardiology Group Therapists Adding RT Moving to 12 hour nursing shifts subacute

51. Physicians Utilized their requested standing orders for Heart Failure Adjusted as requested by MD

52. Outcomes In last six months – 37 admissions (50%) for CHF from the hospital 25 were discharged to home 6 discharged to assisted living 4 to long term care 2 readmissions for end stage failure due to lack of DNH/DNR Robust census 0% readmission in last quarter.

53. Issues Changing Environment – Change in hospital leadership – Mergers/affiliations of physicians and cardiac groups – Shortages of cardiac physicians – Changes of personnel in physician groups ie NP or PA

54. Potential Concerns Multiple hospitals serve you/selection Multiple DRG/LOS issues Speaking to the right person Competition (Super PACS; Developed Programs for sale)

55. Conclusion Health Care Environment Changing SNFs are at risk ACOs, Hospital Systems, Insurance Carriers are driving the conversation Being Creative and Assertive is Essential Determine the Value You Bring to the Relationship

56. “Our real problem, then, is not our strength today; it is rather the vital necessity of action today to ensure our strength tomorrow.” ~ Dwight D. Eisenhower -

58. Questions??????