1. The Big Puzzle Evolving the Continuum of Care

2. Agenda Goal Pre Acute Care Intra Hospital Care Post Hospital Care Grading the Value of Post Acute Providers Medicare Spending Per Beneficiary (Opportunity) Focused Efforts with Major Joints and Pneumonia patients Implementation Strategy Recommendations on Next Steps

3. Goal To provide excellence (quality/cost = value) in health care services for our community across the continuum of health care providers

4. Excellence in Care

5. Pre Hospital Care Provide a solid foundation of patient’s expectation of the care to be delivered  Physician’s Office  Joint Camp (3 day stay, with possible use of post-acute providers)  Pre-admission evaluation and education (Reduce the potential for SSI)  HbgA1C  MRSA screening  Antibiotic use  Obstructive Sleep Apnea  Smoking Cessation  Personal Hygiene  ER case manager assigning the patient status on all patients  Readmission prevention process

6. Intra Hospital Care Foster a transparent flow of information exchange to coordinate care/discharge planning among hospital departments  Case management/supportive/rehab assessment/stratification of patients  Develop plan for discharge or identify barriers  Set consistent expectations for patient and family along with clinical providers  Seamless information from post-acute providers regarding DAILY availability of beds, clinical ability, insurance coverage restrictions

7. Population Health / Chronic Disease

8. Post Hospital Care Supportive Care/Heart Failure Clinic (Advanced Illness Management) Supportive Care – Post Discharge Navigator (phone calls): Patient population defining as high risk (LACE >11 Heart Failure, COPD, Diabetes, Stroke) Disease Prognosis is defined and communicated to patient/family prior to discharge Post discharge medication reconciliation Heart Failure Clinic Provide follow up care prior to patients first visit to specialist (Heart Failure, COPD, Diabetes, Stroke) Contact Specialist/PCP/APN to coordinate intervention Visits are made to LTACH/SNF facilities to complete the Heart Failure clinic process to decrease readmissions Education provided to diabetic/Heart Failure patients on managing disease Provide 30 day Diabetic Supply Kit to uninsured patients

9. Post Hospital Care Case Management Impact Ensure patients have means of transportation Provide medication assistance as needed Ensure every patient has a follow up appointment with PCP Establish PCP for patients without a PCP Follow up phone call for disease specific patients to ensure appropriate use of medicine and follow up appointments New onset cancer Cardiac with LACE score <11 New respiratory conditions Follow up with Post Acute Agencies related to readmission to improve care

10. Post Hospital Care Create a network of health care providers which optimize the value to our patients and the care continuum  Ensure patients receive the appropriate level of care  Provide quality outcomes (metrics)  Provide excellent patient satisfaction  Maintain cost within US averages

11. Measures of Success with Our Community Partners Objectives- Ensure Post-Acute Providers assist in development of and ensure consistent application of clinical pathways to promote excellence in care across the continuum Scoring will be based on nationally available data Scorecards will be updated quarterly Scorecards will be used to elevate the consistency of care Scorecards will be used to enhance public opinion of post-acute providers Scorecards will be utilized to educate patients, families, and providers on outcomes Goal is to be inclusive of all willing participants

12. LOS Cost of Care per Patient Overall Rating Re- admissions Quality of Care Skilled Nursing Home Scoring

13. Cost LOS Overall Care from the HHA (Patient Perception) Re- admissions % Better with Functional Mobility Home Health Scoring

14. Cost

15. Medicare Spending Per Beneficiary (Opportunity) United Regional’s Post Acute Utilization versus US Average (overall $6.0 million more) Ortho related procedure ($2.8 million) Inpatient Rehab Renal Failure ($704K) Inpatient Rehab Stroke ($690K) Inpatient Rehab Urinary Tract Infection ($348K) Inpatient Rehab Pneumonia and Respiratory infection ($416K) Inpatient Rehab & ($492K) Skilled Nursing Facility Cardiac Arrhythmia ($339K) inpatient Rehab ($361K) Skilled Nursing Facility Amputation ($808K) Long Term Acute Care

16. Focus Efforts on Specific Patient Populations Selected Groups Major Joint Surgery (procedural) Pneumonia (medical) Opportunities Length of Stay Major Joints (4.0 actual vs. 3.1 Medicare GMLOS) Pneumonia (3.5 actual vs. 3.0 Medicare GMLOS) Post-Acute Utilization Major Joints ($2.8 m higher than US Average for Inpatient Rehab case) Pneumonia ($416K higher than US Average for Inpatient Rehab) ($492K higher than US Average for Skilled Nursing Facility)

17. Building Value with Major Joint Surgery DRG 470 – Major joint replacement of lower limb URHCS National Average

18. Building Value with Pneumonia DRG 177, 178, 179, 193, 194, 195 URHCS National Average

19. Implementation Strategy Physician Collaboration Care Coordination Management of Patient Expectations Quality Metrics

20. Implementation Strategy (Physician Collaboration)  Educate/Communicate with physicians the need for change  Ensure confidence in care being provided to their patients (outside of the Inpatient Rehab)  Provide quality metrics as a measurement for care (not “one offs”) to measure care  Enlist a physician champion on Joint Procedures and Pneumonia

21. Implementation Strategy (Care Coordination) Stage 3 & 4 diagnosis, End of Life, Not able to self manage independently Need assistance with self management, Post acute care resource to assist with maximizing health post acute Self managed patients, Low acuity, able to independently care for self Patients with no needs

22. Implementation Strategy (Management of Patient Expectations)  Physician’s Office  Joint Camp  Pre-Admission evaluation and education  ER case manager assigning patient status  Readmission Prevention Process (to be more focused with the addition of 4 fte’s)

23. Implementation Strategy (Quality Metrics)  Patient Satisfaction (After changing referral patterns – Joint and Pneumonia)  Medicare Spending Per Beneficiary (Placement of patients – Reduction of Inpatient Rehab referrals)  Readmission  Length of Stay (inpatient and observation)  Scorecard of Post Acute Providers (grading )

24. Common Goal: Getting everyone to work as a TEAM!

25. Thank you