1. Bundled Payment: 1 Year Later 2014 AAPM&R Annual Assembly

2. Brooks Rehabilitation: System of Care
Inpatient Rehabilitation
157 freestanding IRF beds
3,100+ admissions annually
Skilled Nursing
A new 100-bed SNF that opened July 2013
Management of 35-bed SNU focused on joint replacements
Home Health Care
Covers 6 counties
70,000+ skilled visits annually
Outpatient Therapy
28 locations
225,000 patient visits to over 23,000 patients
Community Programs
Adaptive Sports
Brain Injury Club House
Stroke Wellness
Physician Services
11 employed PM&R physicians
Provide both IP and OP care
Rehabilitation Research
In partnership with the University of Florida
14 active clinical trials
Neuro Day Treatment
Day program for patients recovering from brain injury & other neurological disorders
9/19/2018

3. Brooks Rehabilitation: Where we are
Brooks Rehabilitation Hospital
Brooks Outpatient Locations
Brooks Bartram Crossing (Skilled Nursing)
Brooks Brain Injury Clubhouse
Total Joint Replacement Skilled Nursing Unit
Brooks Contract Services
Brooks Home Care Advantage Service Area
9/19/2018

4. Participation in Model 3 (Includes Post-Acute Only)
Bundled payment program is referred to as CompleteCare internally & externally with its own branding:
Brooks is an “awardee convener” for a Model 3 program covering the following MS-DRG’s:
As an awardee convener, Brooks is financially liable for excess spending owed to CMS based on episodes that initiate in Brooks owned locations for a episode length of 60 days. Conversely, we have a financial opportunity if the total spend is less than the target
Initial target price based on Brooks 3 year historical data ( )
Price adjusted regularly throughout demonstration to account for National trends
Target price is net of a 3% discount guaranteed to Medicare
Risk phase began October 1, 2013
MS-DRGs
Rationale for selecting
Hip Fractures
Generally a homogenous group albeit frail and elderly
Generally predictable path between acute & PAC
Historically, manageable rate of readmissions
Total Knee & Hip Replacements
High degree of homogeneity
Generally healthy
Low readmission rate
Great variability in PAC use, behavior driven vs. scientifically driven
As compared to MS-DRGs covering Stroke, CHF, COPD, etc.
9/19/2018

5. Rationale for Participation in BPCI
Be on the forefront of possible payment reform and healthcare policy changes that might effect post-acute providers
Serve as a catalyst for our businesses to begin working together as a system
Experiment with clinical redesign
Have a stronger “voice” regarding future policy and payment reform changes
Prove that post-acute care providers have the sophistication to take “risk” and play a primary role in the continuum of care

6. Original Expectations
Bundled Payment would be an experiment, a form of “research”
Breakeven financial performance
Would require diversion of patients traditionally seen in Brooks Rehabilitation Hospital thereby challenging belief systems
We would be able to back-fill loss of patients from Brooks Rehabilitation Hospital
Development of the care navigator, we were not sure what it would mean
The need for tools that would facilitate communication between settings – we never envisioned CareCompass
Would we have the ability to self-manage Medicare claims data and Brooks clinical data?

7. What has Brooks changed internally as a result of Bundled Payment?
Four Primary Domains for Change
Areas of Change
1. Assessment Phase
Nurse Liaison uses standardized tool to holistically assess patient for most appropriate first site of care (IRF, SNF, Home Health)
Collaboration with acute care hospitals to better coordinate care transitions and standardize transfer paperwork
2. Care Coordination
Patient assigned a dedicated Care Navigator to coordinate care and educate throughout the episode
Standardized evidence-based assessments used in all settings and across all clinicians at pre-determined intervals
Longitudinal Care Plan developed for each patient by clinical team that spans the episode of care
3. Patient and Caregiver Engagement
Patients made aware of enrollment in bundle program early on and sets expectations
Care Navigator provides patient/caregiver standardized evidence-based education
Care Navigator stays connected to patient post discharge via phone and home visits
4. Information Solutions
One IT tool (Care Compass) that brings information from disparate systems and is a repository for all information; helps monitor patient throughout episode

8. Care Compass
- Assists clinical team in prioritizing patients, predicting future needs, and alerts of declining status
- Updates every 2-4 hours with key metrics

9. General BPCI Volume Statistics
Cases triggering a Brooks Model 3 bundle since going live October 1, 2o13 through August 31, 2014
Joint replacement cases = 665
Hip fracture cases = 182
Total cases = 847

10. First Site of Care is Shifting
SNF
SNF
SNF
Historical Source: Jan 2009 – June 2012; CMMI Claims Data File
Actual Source: Oct – Aug
9/19/2018

11. 60 Day Readmission Rates
Period: Oct – August 31, 2014; cases completed
9/19/2018

12. Patient Specific Functional Scale Results
The Patient Specific Functional Scale (PSFS) is a self-reported, patient specific measure, designed to assess to functional change over an episode of care
Patients asked to identify important activities they were unable to perform or having difficulty performing
Rating on an 11-point scale:
Score of “0” reflecting no ability to perform activity
Score of “10” reflects full ability to perform activity
Results:
Time Period: 10/1/2013 – 5/31/2014
9/19/2018

13. Financial Results
Diagnosis
Episodes
Savings per Episode*
% Savings
Joint Replacement
665
$2,616
17.2%
Hip Fracture
182
$4,902
17.0%
Total
847
$3,107
*Episodes beginning between Oct 1, August 31, 2014
*Before Administrative costs of $644 per episode
*Before shared savings payout to two acute care hospitals
*Savings estimated with a blend of actual Medicare reconciliation for 2 quarters and conservative projections based on actual 1st site of care and historical costs.
Cost savings focused on diverting** certain IRF patients to SNF & reducing acute readmissions
**Diversion focused on patients who meet a specific profile and where a SNF placement is highly predictable
9/19/2018

14. Overall Performance
Financial performance has far exceeded expectations
It is extremely difficult to make large meaningful improvements in hospital readmissions rates – we have barely scratched the surface of the work we need to do
Patient self reporting of their functional improvements is extremely strong
Patient experience matches our overall high performance of our individual businesses
We have gained tremendous experience managing Medicare claims data and internal clinical data
Savings is very asymmetrical across our different referral partners

15. Lessons Learned What we did well What we wished we did better
What we are learning as we gain experience
Communication with staff
Better, more rapid feedback loop with clinical staff
Learning to manage the Medicare claim files
Blank slate
Addressing legacy behaviors
Outmigration of patients / market dynamics
Ability to live in the grey
Role confusion
What was the final DRG?
Commitment to developing IT application specific to PAC
Management of internal administrative costs
Trend factors and reconciliation
Investment in Care Navigators
Multi-faceted complexity
Decision to manage data in-house
Revelations about how many opportunities there are to improve patient care
Information sharing with acute care hospital partners

16. Next Steps for Brooks Rehabilitation
Evaluate BPCI expansion to other diagnoses
Possibilities include CHF, Stroke, and Spinal Fusions
Would go at risk for the new episodes on April 1, 2015
Use CompleteCare To Serve as the Brooks “System of Care Roadmap (regardless of BPCI participation)
Use learnings with other patient populations as best practice model
Begin adoption of the Complete Care Clinical Model With Other Inpatient Populations
New thinking and training for clinicians
Standardization in clinical programming
Competencies in care planning and coordination
Longitudinal care planning - Thinking beyond own setting

17. Observations and Possible Future Implications for Post-Acute Providers and Physicians
Post Acute represents a large portion of the cost of an episode of care and the increased scrutiny of PAC utilization will continue
Will lead to a decline in utilization of high cost settings
Less IRF admissions
Will require IRFs to develop new programs to offset loss of volume
Increased attention on physician driven metrics which drive costs
LOS, Discharge settings, Readmission rates
Physician gain sharing opportunities
Dramatic shifts in physician referral patterns
Physician differentiation based on being a high quality low cost provider
Close coordination and buy in from surgeons and PM&R physicians is a key success factor