1. The SNF* Readmission Penalty, Post-Acute Networks, and Community Collaboratives
Lindsay Holland, MHA
Director, Care Transitions
Dominique Diaz, BS Quality Improvement Specialist, Care Transitions
Health Services Advisory Group (HSAG)
September 20, 2017
*Skilled Nursing Facility (SNF)

2. Objectives Describe the SNF Value-Based Purchasing (VBP) Program
Discuss the post-acute network model to reducing readmissions.
Discuss the QIN-QIO* community collaborative approach to improving care transitions.
QIN-QIOs in every state and territory are united in a network administered by the Centers for Medicare & Medicaid Services (CMS).
The QIN-QIO program is the largest federal program dedicated to improving health quality at the community level.
*Quality Innovation Network-Quality Improvement Organization

3. HSAG: Your Partner in Healthcare Quality
HSAG is California’s Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO).
QIN-QIOs in every state and territory are united in a network administered by the Centers for Medicare & Medicaid Services (CMS).
The QIN-QIO program is the largest federal program dedicated to improving health quality at the community level.
Committed to improving quality of healthcare for more than 35 years
Provides quality expertise to those who deliver care and those who receive care
Engages healthcare providers, stakeholders, Medicare patients, families, and caregivers
Provides technical assistance, convenes learning and action networks, and analyzes data for improvement

4. Nearly 25 percent of the nation’s Medicare beneficiaries
About HSAG
Nearly 25 percent of the nation’s Medicare beneficiaries
Drives quality by providing technical assistance, convening LANs, collecting and analyzing data for improvement
Works on initiatives to improve patient safety, reduce harm, improve clinical care
Engages healthcare providers, stakeholders, and beneficiaries to improve health quality, efficiency, and value.
HSAG is the Medicare QIN-QIO for California, Arizona, Florida, Ohio, and the U.S. Virgin Islands.

5. INTERACT Overview—Tools to Reduce Readmissions
INTERACT is a quality improvement program designed to improve the care of nursing home residents with acute changes in condition.
In a six month study of SNFs in three states, hospital readmissions were reduced by 17% post INTERACT implementation

6. How Does INTERACT Help Reduce Readmissions?
Preventing conditions from becoming severe enough to require hospitalization through early identification and assessment of changes in the residents’ conditions.
Managing some conditions in the nursing home without transfer when this is feasible and safe.
Improving advanced care planning and the use of palliative care plans when appropriate as an alternative to hospitalizations for some residents.

7. INTERACT Tools Communication Tools Clinical Decision Support Tools
Stop and Watch
SBAR
Medication Reconciliation Worksheet
Clinical Decision Support Tools
Change in Condition
Care Paths
Advance Care Planning Tools
Communication Guide
Tracking Tool
Comfort Care Order Set
Other ACP Tools

8. California Care Coordination Communities

9. The Changing Healthcare Environment
Evolving Future State
Key Characteristics
Patient-centered
Incentives for outcomes
Sustainable
Coordinated care
Systems and Policies
Value-based purchasing
Accountable Care Organizations (ACOs)
Episode-based payments
Medical homes
Quality/cost transparency
Historical State
Key Characteristics
Fee-For-Service (FFS) payment systems
Incentives for volume
Fragmented care
Systems and Policies
Unsustainable
Result: Better care, smarter spending, and healthier people 9
Source: Centers for Medicare & Medicaid Services

10. Doing things the same way… …will NOT reduce readmissions.10

11. California Medicare FFS Hospital Readmission Rates
Calendar
Year
Readmission
Rate
2013
17.6%
2014
2015
18.2%
Q1 2016
17.4%
Q2 2016
17.2%
Q3 2016
18.6%
Q4 2016
Q1 2017
17.9%
0% relative improvement rate
Data files provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

12. Orange County Medicare FFS Days to Readmission: Q2 2016–Q1 2017
Setting
0–7
8–14
15–21
22–30
Count
Rate
Home
1,218
37.60%
797
24.6%
623
19.2%
604
18.6%
SNF*
860
31.90%
680
25.2%
548
20.3%
610
22.6%
HHA**
792
36.00%
567
25.9%
413
18.8%
419
19.1%
Hospice 19
38.00% 16
32.0% 7
14.0% 8
16.0%
Other
297
42.00%
158
22.3%
122
17.3%
130
18.4%
Total
3,186
35.80%
2,218
25.0%
1,713
19.3%
1,771
19.9%
Data to follow
* Skilled nursing facility (SNF)
** Home health agency (HHA)
35.8% returning within one week of discharge
Data files provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

13. Orange County Medicare FFS Discharge Distribution: Q2 2016–Q1 2017
Group
Setting Discharged to
30-Day Readmit Rate
Readmits to Same hospital
Readmits to different hospital
Orange County
Home
2,195
67.7%
1,047
SNF
1,735
64.3%
963
HHA
1,698
77.5%
493
Hospice 32
64.0% 18
Other
353
49.9%
354
Total
18.0%
32.3%
California
18.9%
68.0%
32.0%
Data files provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare Fee-for-Service beneficiaries.

14. Hospital Readmission Penalties
Penalty Year
Number of
Hospitals Penalized
2013
197
2014
165
2015
153
2016
147
2017
207
2018
221
*Fiscal Year

15. California Cohort C: Readmissions
The number of beneficiaries for each community and the percentage of beneficiaries within the cohort are displayed next to the community name. The data source for the beneficiary counts is the NCC Scorecard.

16. Hospital Readmission Penalties (cont.)
Section 3025 Affordable Care Act of 2010
October 2014
2017: 139 California hospitals were penalized ALL 5 years for excess readmissions
Congestive heart failure
Coronary artery bypass graft
Acute myocardial infarction
Pneumonia
Chronic obstructive pulmonary disease
Total knee and hip arthroplasty

17. Nursing Home Readmission VBP Program
H.R Protecting Access to Medicare Act of 2014
October 2017
Readmission rates go public on Nursing Home Compare
October 2018
VBP program for nursing homes begins
Example: If a hospital’s base operating DRG amount is $1,000 and the payment penalty is 1 percent, then the amount reduced by the penalty is $10 and the payment made to the hospital is $990.
Risk Adjustments: age, gender, comorbidities
Exclusions:
Planned readmissions
Patient self-discharge against advice
Same day admit/discharge
Transfer to another acute care facility
Patients without at least 30 days post-discharge enrollment in FFS Medicare
Patients who died during the index hospitalization
As part of the FY 2015 IPPS final rule, CMS finalized an updated method to account for planned readmissions.
CMS will add readmissions for coronary artery bypass graft (CABG) surgical procedures to the list for FY 2017.

18. SNF Readmission Penalty Timeline
2014
Passed
Oct. 2015
All-cause readmission measure defined
Oct. 2016
“Potentially preventable” adjusted rate
Oct. 2017
Public reporting of SNF readmissions
October 2018
Oct. 2018
2% withhold of SNF payments begin
Incentive/ penalty goes live
$2B Savings/ 10 years
50–70% of the withhold will go to incentive payments to SNFs
30–50% of the withhold will go to Medicare for savings
40% of SNFs nationally will receive a penalty
Passed in 2014
All cause readmission measure defined (by October 2015)
“Potentially preventable” adjusted rate (October 2016)
Public reporting of SNF readmissions (October 2017)
Ranked score provided to SNFs (October 2018)
2% withhold of SNF payments (October 2018)
50-70% of the withhold will go to incentive payments to SNFs
30-50% of the withhold will go to Medicare for savings
Incentive/ penalty goes live (October 2018)
40% of SNFs nationally will receive a penalty
Estimated to save Medicare $2B over next 10 years

19. Nursing Home Readmission VBP Program (cont.)
Reduction amount: 2%
Lowest performers may lose 2% of Medicare funding
Program is designed to save money for CMS
Top performers’ incentive payments 50–70% of the reduction amount (1.0–1.4%)
SNFs will be ranked
Bottom 40% will be in the penalty-eligible range
CMS provides reports on the measure
So SNFs can review and plan for action
Began 10/1/2016
40%
The reduction amount will be 2%, meaning that lowest performers may lose 2% of Medicare funding.
The program is designed to save money for CMS: incentive payments (those for top performers) will be between % of the reduction amount (between 1.0 and 1.4%)
SNFs will be ranked such that the bottom 40% will be in the penalty-eligible range
CMS will provide reports on the measure beginning 10/1/2016 so that SNFs can review and plan for action

20. Nursing Home Readmission VBP Program (cont.)
One measure: an all-condition, risk-adjusted, potentially avoidable hospital readmission rate
Payment differentials begin FY 2019
Payments on or after 10/1/2018
Calculation of VBP amount will use the “achievement/improvement” methodology used for hospital VBP
Rates will be compared to thresholds and benchmarks
SNFs will be awarded points for either achievement or improvement, whichever is higher
One measure, an all-condition, risk-adjusted, potentially avoidable hospital readmission rate
Payment differentials will begin with FY 2019 (payments on or after 10/1/2018)
Calculation of VBP amount will use the “achievement/improvement” methodology used for hospital VBP
Rates will be compared to thresholds and benchmarks
SNFs will be awarded points for either achievement or improvement, whichever is higher.

21. 30-Day All-Cause SNF Readmission Measure (SNF-RM)
FY 2016 SNF Prospective Payment System (PPS) final rule, CMS adopted the SNF-RM as the first measure for the SNF VBP Program.
The measure is the risk-standardized rate of all-cause, unplanned hospital readmissions of Medicare beneficiaries within 30 days of discharge from their prior hospitalization.
Hospital readmissions are identified through Medicare hospital claims (not SNF claims).
Readmission data is not collected from SNFs and there are no additional reporting requirements for the measure.
Fiscal Year (FY) 2016 SNF Prospective Payment System (PPS) final rule, CMS adopted the SNF-RM as the first measure for the SNF VBP Program.
The measure is the risk-standardized rate of all-cause, unplanned hospital readmissions of Medicare beneficiaries within 30 days of discharge from their prior hospitalization.
Hospital readmissions are identified through Medicare hospital claims (not SNF claims)
Readmission data is not collected from SNFs and there are no additional reporting requirements for the measure.

22. 30-Day All-Cause SNF-RM (cont.)
Readmissions to a hospital within the 30-day window are counted if:
The beneficiary is readmitted directly from the SNF, or
After discharge from the SNF
As long as the beneficiary was admitted to the SNF within 1 day of discharge from a hospital stay
Excludes planned readmissions
Is risk-adjusted based on:
Patient demographics
Principal diagnosis from the prior hospitalization
Comorbidities
Other health status variables that affect probability of readmission
Readmissions to a hospital within the 30-day window are counted if
The beneficiary is readmitted directly from the SNF OR
after discharge from the SNF as long as the beneficiary was admitted to the SNF within 1 day of discharge from a hospital stay.
The measure excludes planned readmissions
The measure is risk-adjusted based on:
patient demographics
principal diagnosis from the prior hospitalization,
Comorbidities
other health status variables that affect probability of readmission.

23. 30-Day SNF Potentially Preventable Readmission (SNF-PPR) Measure
July 29, 2016, CMS adopted the SNF-PPR measure for future use in the SNF VBP Program
The SNF-PPR measure assesses:
Risk-standardized rate of unplanned, potentially preventable readmissions
Medicare FFS SNF patients
Within 30 days of discharge from a prior hospitalization
On July 29, 2016, CMS adopted the SNF-PPR measure for future use in the SNF VBP Program.
The SNF-PPR measure assesses the risk-standardized rate of unplanned, Potentially Preventable Readmissions (PPRs) for Medicare Fee-For-Service SNF patients within 30 days of discharge from a prior hospitalization.

24. 30-Day SNF-PPR Measure (cont.)
The key difference between the SNF-RM and SNF-PPR measures:
CMS will replace the SNF-RM with the SNF-PPR “as soon as practicable.”
SNF-RM All-Cause
Readmissions
SNF-PPR
Potentially Preventable Readmissions
The key difference between the SNF-RM and SNF-PPR measures is that the SNF-PPR focuses on potentially preventable readmissions rather than all-cause readmissions.
CMS will replace the SNF-RM with the SNF-PPR “as soon as practicable.”

25. Performance Scoring
CMS has adopted these scoring methodologies to measure SNF performance that includes levels of achievement and improvement:
Achievement scoring
Compares an individual SNF’s performance rate in a performance period against all SNFs’ performance during the baseline period
Improvement scoring
Compares a SNF’s performance during the performance period against its own prior performance during the baseline period
CMS has adopted these scoring methodologies to measure SNF performance that includes levels of achievement and improvement:
Achievement scoring
Compares an individual SNF’s performance rate in a performance period against all SNFs’ performance during the baseline period
Improvement scoring
Compares a SNF’s performance during the performance period against its own prior performance during the baseline period

26. Definitions for SNF VBP Program
Term
Proposed Definition
Achievement Threshold
The 25th percentile of national SNF performance on the quality measure during CY 2015
Benchmark
The mean of the best decile of national SNF performance on the quality measure during CY 2015
Improvement Threshold
The specific SNF’s performance on the measure
Performance Period
CY 2017
Baseline Period
CY 2015

27. Performance Standards
2013
2014
2015
25th Percentile
20.8%
20.54%
20.41%
Threshold
79.2%
79.46%
79.59%
Mean of the Best Decile
16.76%
16.6%
16.4%
Benchmark
83.24%
83.4%
83.6%

28. SNF VBP Scoring Methodology Achievement Scoring
Achievement Score: For FY 2019, points awarded by comparing the facility’s rate during the performance period (CY 2017) with the performance of all facilities nationally during the baseline period (CY 2015)
CY 2017
Performance Period
CY 2015
Baseline Period
Time
Achievement Score: Points awarded by comparing the facility’s rate during the performance period (CY 2017) with the performance of all facilities nationally during the baseline period (CY 2015)
Rate better than or equal to benchmark: 100 points
Rate worse than achievement threshold: 0 points
Rate between the two: 1–99 points, awarded according to the formula described in the final rule.
Rate better or equal to benchmark
100 points
Rate worse than achievement threshold
points
Rate between the two (formula in final rule)
1–99

29. SNF VBP Scoring Methodology Improvement Scoring
Improvement Score: Points awarded by comparing the facility’s rate during the performance period (CY 2017) with its previous performance during the baseline period (CY 2015)
Me!
CY 2017
Performance Period
CY 2015
Baseline Period
Time
Awarded according to the formula described in the final rule
1–89 points

30. Additional Information
For more information about the SNF VBP Program:
Initiatives-Patient-Assessment-Instruments/Value- Based-Programs/Other-VBPs/SNF-VBP.html
Refer to: FY 2016 SNF-PPS final rule and FY 2017 SNF-PPS final rule
For additional questions,

31. Putting It All Together

32. Doing things the same way… …will NOT reduce readmissions.32

33. Successful Partnerships33

34. Shared Accountability
Transition is a period of shared accountability
Receiving provider
has to understand and execute a care plan based on the key information received
Sending provider
has to ensure that key information has been appropriately received and acknowledged by the receiving provider
National Transition of Care Coalition

35. Elements of a Successful Hospital and SNF Partnership
Utilizes, trends, and tracks readmission data
Conducts root cause analysis
Meets consistently
Improves communication processes
Reviews case studies
Provides training/education
Uses scorecards/dashboards
Develops multi-faceted strategy
Interventions to Reduce Acute Care Transfers (INTERACT)

36. There is Never One Reason for Readmission
Study reviewed over 500 readmissions across 18 Northern California Kaiser Permanente hospitals
250 (47%) deemed potentially preventable
An average of 9 factors contributed to each readmission
Evaluated factors related to 5 domains
73%—care transitions planning and care coordination
80%—clinical care
49%—logistics of follow-up care
41%—advance care planning and end-of-life care
28%—medications
250 readmissions identified 1,867 factors
Feingenbaum et al Medical Care 50(7): July 2012

37. Thank you!
Dominique Diaz Quality Improvement Specialist, Care Transitions, HSAG 37

38. This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C