1. Post Acute Care
William Mills, M.D.
©AAHCM

2. Disclosures
Dr. Mills is an employee and shareholder of Kindred Healthcare and has equity interests in HopeBridge Hospice, LLC and
chroniccaremanagement.com, LLC.
©AAHCM

3. Agenda Post acute care today Care transitions Post acute care tomorrow
How HBPC can partner with post acute care
©AAHCM

4. Post Acute Care Today 37% 2% 10% 11% 41% 52% 9% 21% 61%
47.6 million Medicare beneficiaries with an estimated 9,100 individuals added to the program each day.(1)
35% of Medicare Beneficiaries Discharged from Acute Hospitals Need Post-Acute Care (2)
Medicare Patients’ Use of Post-Acute Services Throughout an “Episode of Care”
Higher
Intensity of Service
Lower
Patients’ first site of discharge after acute care hospital stay
Patients’ use of site during a 90 day episode
SHORT-TERM ACUTE CARE HOSPITALS
LONG-TERM ACUTE CARE HOSPITALS
INPATIENT REHAB
SKILLED NURSING FACILITIES
OUTPATIENT REHAB
HOME
HEALTH
CARE
37% 2%
10%
11%
41%
52% 9%
21%
61%
Tremendous Opportunities Exist to Better Manage Patient Care for Patients Discharged From Acute Care Hospitals
Currently there are 47.6 million Medicare beneficiaries with an estimated 9,100 individuals added to the program each day.
35% of Medicare Beneficiaries are Discharged from Acute Hospitals to Post-Acute Care
More importantly, as we study the core needs of our patients over a 90 day episode, more and more need continued care in multiple settings on their journey home.
(1) Kaiser Family Foundation, 2011 statehealthfacts.org and AARP 2011 projections
(2) Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System

5. Patient severity of illness varies by PAC setting
Short-term Acute-care Hospital (STACH) and PAC Severity of Illness (SOI), in Prior STACH Stay
Source: The Moran Company. Analysis of 2008 Medicare acute-care hospital data sorted by APR-DRG grouper.
Note: SOI is measured by the 3M APR-DRG Grouper.

6. Clinical and non-clinical factors help determine the best PAC setting for a given patient
Provider
Relationships with local PAC providers
Practice patterns
Clinical
Current health status
Comorbidities
Prognosis
Payer coverage rules
PAC Facility
Specialization
Proximity
Capacity
Relationship with acute sites
Referring Provider
Patient
Psychosocial support
Ability/willingness for self-care
Treatment preferences

7. IMPACT ACT 2014
Intent: To enable interoperability and access to longitudinal information in post acute care to facilitate coordinated care, improved outcomes, and overall quality comparisons.
Requirements:
LTACH, IRF, SNF, and HHA providers must submit to CMS specified quality and resource utilization assessments.
Measure Domains to be standardized:
Skin integrity and changes in skin integrity;
Functional status, cognitive function, and changes in function and cognitive function;
Medication reconciliation;
Incidence of major falls;
Transfer of health information and care preferences when an individual transitions;
Resource use measures, including total estimated Medicare spending per beneficiary;
Discharge to community; and
All-condition risk-adjusted potentially preventable hospital readmissions rates.

8. Emerging Tactics in Post Acute Care1
Physician Alignment and Access that assures immediate access to office-based primary care or house calls as well as primary care management in acute and post-acute venues 2
Robust IT Platform and Just-in-Time Business Intelligence that provides cross continuum information in real time for pre-acute, acute, post-acute, and home-based encounters 3
Risk-Adjusted Enterprise Care Management that includes stratifying population and tailoring care management as well as longitudinal management of beneficiaries 4
Developing Network of Post-Acute Providers for standardized, evidence-based care across the acute/post-acute continuum and seamless, optimal patient experience

9. Characteristics of Today’s Most Effective Post-Acute Care Partnerships
Physician integration – physician participation in care across settings
Agreed-upon clinical protocols
Clearly defined expectations
Clinical Collaboration
Regularly established forum for communication and performance improvement; for example, joint operating committee
Communication
Hospital volume is concentrated in a small number of post-acute providers to allow for increased clinical collaboration
Concentration
Partnership
True partnership around improving patient outcomes and reducing utilization
Process to review and improve care on an on-going basis

10. Care Transition Managers to Smooth Transitions, Connect Patients with Primary Care Physicians, and Reduce Rehospitalizations
Reducing Gaps in Patient Care through:
Care Managers are paired with patients most at risk for rehospitalization to improve provider coordination with transition to home
Care Transitions Program
Patient/ Caregiver Engagement & Education Across the Continuum
Transition Plan of Care Support & Collaboration
Communication with Patient’s Health Care Provider
Medication Management
Support of Follow-Up Plan of Care
Program Goals:
Reduce readmissions
Increased engagement with patient’s primary care provider
Improve outcomes, key quality metrics, and the patient’s experience
Provide greater continuity of care to and from different care settings
Promote patient engagement in care planning and goal setting
Reduce medication errors
Collaterals to mention:
Job description
Newsletter piece

11. Post Acute Care Tomorrow
Joint quality committees to promote data sharing and communication, improved outcomes, and consistent quality measures across settings of care
Enhanced Physician Collaboration
Care
Managers to Smooth Transitions
Patient-centered care management capabilities that extend across post-acute sites of care and into home to improve quality and reduce costs
IT Linkages and Information Sharing
Health Information Exchange – Connecting electronic medical records to support care management across settings, streamlined reporting of clinical/utilization metrics
Condition-specific clinical programs, care pathways and outcome measures to support episode care management, decision making and learning
Targeted Clinical Programs & Pathways

12. Multiple Communication Elements Drive Success
Post Acute Care Tomorrow: Bundled Payment Collaborative Elements
Multiple Communication Elements Drive Success
Joint Operating Committee (JOC)
Performance Improvement
Physician Communication
EMR Linkage
Monthly meeting composed of administrators, physicians, quality and case management staff
Operates under charter defining objectives of committee, parameters of the relationship, and establishment of a mission
JOC uses performance dashboard including LOS, readmission rates, patient satisfaction, quality metrics (e.g., falls, wounds, infections, wean rates, mortality)
Staff/affiliate physicians provide coverage at Kindred Post-Acute Sites
Medical leadership is actively engaged in JQCs and guide performance improvement initiatives
Setup medical record access to the STACH EMR
Automating movement of H&Ps, progress notes, and discharge summaries 12

13. Operationalization of “The Triple Aim” Post Acute Medicine
Acute/Post Acute Alignment
Improve
Health
Improve Patient Experience
Cost effective care
Care Transitions Programs
Home-Based Primary Care
Risk Stratification

14. HOME-BASED PRIMARY CARE
HBPC as Fulcrum of Care Coordination for High Risk Patients
Patient Facing Tactics
Health risk assessments and patient stratification
Care plan development and tracking; care team
Advanced care planning, including placement
Care transition management, medication reconciliation
Technology usage/tools in caregiving, monitoring
Expanded “HH of the Future”:
Chronic care, disease management
Ongoing monitoring
Intervention algorithms/processes, resources
Other services, including hospice, palliative
Patient education, engagement, data mechanisms
Patient satisfaction surveys and feedback
Provider Facing Tactics
Provider support and education: disease pathways, care plans, care team, placement, protocols
Resources of HBPC network
Network development, including specialists, DME, lab services, radiology, etc.
Support/coordination in patient management
Provider feedback mechanisms
Provider training on tools, IT system, data/analytics
Reporting on cost/utilization and quality/outcomes:
Dashboards
Real-time notifications of hospitalizations, care transitions, alerts/interventions needed, etc.
Capabilities to spot/manage “frequent flyers”
PATIENT
HOME-BASED
PRIMARY CARE
Health Information Technology Tactics
Integrated and complete EHRs for Health Info Exchange across network
Analytics to identify and manage “frequent flyers”: risk pools, placement, care plans, tracking
Real-time reporting on cost, quality/outcomes, patient satisfaction
HBPC-driven care management provides most immediate, impactful care model for high risk PAC users

15. Visiting hospice and palliative care services
Home health and
home therapy
Acute care hospital
LTACH
Subacute
Nursing home
Assisted living
Lab
DME
Outpatient clinics
Private duty home care
Social work
Visiting hospice and palliative care services
Home Based Primary Care

16. Conclusions
The aging and chronically ill population will continue to use increasing amounts of post acute care.
Enhanced focus on reporting of clinical quality and resource utilization can promote increased alignment between acute and PAC sites as well as improved outcomes.
HBPC can be a valuable partner to high PAC users, by providing improved care access, coordination and management.