For more information contact: Slideshare@marcusevans.com Presentation delivered by Josh Luke, PhD, FACHE, Founder, National Readmission Prevention Collaborative, Interim Chief Executive Officer, Memorial Hospital of Gardena at the marcus evans ACO Payer Leadership Summit Spring 2015 held in Las Vegas, NV

1. The Health System of the Future:
Effectively Managing Bundled Care Payment in the ACOy g g y
Environment
Josh Luke, Ph.D., FACHE
Founder, National Readmission Prevention Collaborative
Interim CEO, Memorial Hospital of Gardena
Executive Faculty, CSULB Healthcare Administration Department
Author, Readmission Prevention: Solutions Across The Provider ContinuumAuthor, Readmission Prevention: Solutions Across The Provider Continuum

2. Josh Luke, PhD., FACHE
• Hospital CEO• Hospital CEO
• Memorial Hospital of Gardena
• Western Medical Center Anaheim
• Anaheim General Hospital
• VP, Post Acute at Torrance Memorial Health System
• Home Health and Hospice oversight
Developed award winning Post Acute Network• Developed award winning Post Acute Network
• CEO for HealthSouth Las Vegas Rehab Hospital
• SNF Administrator/ALF Executive Director
• Home Kindred
• Windsor/SNF Management
• California Friends Homes

3. Health Administration Press
American College of Healthcare Executives

4. Presentation ObjectivesPresentation Objectives
• The delivery model of the future: “Discharge Home”
• Bundled payments• Bundled payments
Let’s get off the starting line and skate to where the puck
will be!
Its time to innovate and transform!

5. 1998…….It was a very goody g
year

6. 1998 It d1998…….It was a very good year

7. Grandma BelvaGrandma Belva
March 1920 – July 2002
Congestive Heart FailureCongestive Heart Failure
The Summer of 2002
Home $0
Hemet Valley Medical Center
LTACH
Nursing Home
Home ith Home Health
$
$48,000
$52,000
$12,000
$4 000Home with Home Health
* Hemet Valley Medical Center
Nursing Home
Assisted Living with Home Health
$4,000
$36,000
$18,000
$4,000
*Hemet Valley Medical Center
Nursing Home
*Hemet Valley Medical Center
$42,000
$24,000
$58,000
* Readmission $298,000

8. Who got paid?Who got paid?
We must coordinate care
The Affordable Care Act is not a request, but a
mandate with significant penalties if we do not.
Wh t d thi f th t h it l t ?What does this mean for the acute hospital sector?

9. Are you Ready for the
truth?
The goal is to find a better way for individuals to• The goal is to find a better way for individuals to
age and heal at home.
Th t th i th t j b i t t t h h t• The truth is that my job is not to teach you how to
prevent re-admissions, its to teach you to
prevent….Admissions.
• Welcome to the world of…
ADMISSION PREVENTIONADMISSION PREVENTION

10. What does this mean for
you?
• Hospitals = Last resort
• SNF = Second to last resort; increase capability to
handle med surg level patients
• Home health = Networks will be narrowed
• Patients will be directed to lower levels of care
and care paid privately (ALF, home care, remote
monitoring)

11. Winning!Winning!
S h i i i ?• So who is winning?
• Home Care
• Private duty nursingPrivate duty nursing
• Assisted living
• Who can position for success?• Who can position for success?
• Health systems designed so that hospital is truly the
last resort
• SNF’s who are willing to push for shorter LOS

12. Tommy Olmstead v LC
US Supreme Court Decision, June 1999
Th US S C l d dThe US Supreme Court concluded:
“Patients in an acute hospital have the right to be
discharged to the least restrictive environment when
the care team determines that community placement
is appropriate and the patient does not oppose to thepp p p pp
transfer.”
“Continued institutionalization of patients who mayp y
be placed in less restrictive environments often
constitutes discrimination based on disability.”

13. Tommy Olmstead v LC
US Supreme Court Decision, June 1999
Th US S C l d dThe US Supreme Court concluded:
-Operationally, this means that both physicians and
fhospital case managers must first rule-out the least
restrictive environment as a safe discharge before
considering institutionalizing a patient for post acuteg g p p
services.”
- What do you think CMS would say about this?y y
MSPB?

14. Transitional Care Wellness & Revenue StreamsTransitional Care, Wellness & Revenue Streams
Everyone is being incentivized to avoid the
hospital
• Direct to SNF transfers
from the ED Homefrom the ED
• Remote monitoring at
home and in SNF
Home
• Home visits
• Expansion of Home
H lth t A b l t
Dr.
Office
SNF
Health to Ambulatory case
managers
Home
Health

15. Obama Alaska
Hypothetical New City
Health System
Home
Doctors officey
of the Future
Wellness clinic/gym
OP/Ancillary Services
Assisted Living
SNF
Hospital

16. Obama Alaska
Th S t f Old Th F F S i F fThe System of Old – The Fee-For-Service Free-for-
All
Home
Doctors office
Hospital
Wellness clinic/gym
OP/Ancillary Services
Assisted Living
SNF
Insert Hospital Here!

17. Story Timey
Once Upon a time…
Old Hospital = 290 bedsOld Hospital = 290 beds
New Hospital =
249 beds
Hospital Bed
Capacity
The Fee For Service Post ACA Era
Free-for-All Era

18. Seven Reasons to Coordinate CareSeven Reasons to Coordinate Care
1. ACO’s (MSSP incentive)
2. Bundled Payment Initiatives
3. Value based Initiatives
4. Readmission Penalties
5. RAC Audits
6. MSPB
7. HHS Announcement January 2015
• 30% ACO by 2016; 50% by 2018
• 90% of FFS reimbursement tied to quality

19. Connectivity and Care PlanningConnectivity and Care Planning
• Hospitals must be connected to their post acute
providers and innovate
• Risk stratification software & post acute connectivityRisk stratification software & post acute connectivity
• Remote monitoring units
• Formalize relationships for Care Planning support• Formalize relationships for Care Planning support
to reduce workload and provide ambulatory case
management services
• Care Patrol Community Integration Model: Designed
Specifically to Assist Hospitals with MSPB
• Care Centrix HomeStar: Home Health managementCare Centrix HomeStar: Home Health management

20. IMPACT
Here Comes Reason #7 to Coordinate Care
Improving Medicare Post-Acute Transformation Act of
2014
IMPACT Act of 2014 takes a crucial step toward the
modernization of Medicare payments to post-acute care
(PAC) providers
Who wins? Maybe no one: It appears to be more
documentation to prove medical necessity

21. Post Acute ExpectationsPost Acute Expectations
1. POLST
2. SBAR
3 S d W h3. Stop and Watch
4. Return to Acute Log (Emergency Dept)
5 Return to ED Root Cause Analysis5. Return to ED Root Cause Analysis
6. Predictive software/electronic quality data *
* Only tactic requiring investment; small price to pay
to be preferred provider

22. Four examples of
Value-Added Innovation
• Risk Stratification in acute and post acute connectivity
• Software such as RightCare Solutions (UPenn) identifies &
connects
• Vree Health Population Health management
• Care Management
• Community Integration Model
• Home Based Transition programs
• Home Instead transition program• Home Instead transition program
• Predictive software (Coms Interactive and Medline) in SNF’s:
• Trains nurses when red flags arise and how to react toTrains nurses when red flags arise and how to react to
warning signs

24. Bundled Payment ModelsBundled Payment Models
Early Learnings
• Must have semi-sophisticated EMR to identify thosep y
in bundle early in the admission
• Must “rule-out home” as an option before considering
LTACH IRF or SNFLTACH, IRF or SNF
• Must have post acute providers with leadership not
incentivized to extend length of stay
• Risk stratification software

25. Bundled Payment ModelsBundled Payment Models
Early Learnings
• “Graying” of home based servicesy g
• Home health
• Home care/private duty
Wellness efforts• Wellness efforts
• Support services in the home are key
• Telehealth
• Remote monitoring
• Narrowing of Post Acute Network

26. A Bundle Key - The Super SNFA Bundle Key - The Super SNF
• Stop looking at competitors within the SNF
industry for the answers and start innovating
H it l b d SNF’ ithi il f f ilit• Hospital based SNF’s within a mile of your facility
get paid $800-$1100 a day for SNF patients; why
don’t you?

27. Post Acute Bundle ConvenersPost Acute Bundle Conveners
• Signature Healthcare
• 113 Communities
• 9 states
• 21 SNF’s (in Kentucky alone)
• 1 Critical Access hospital

28. Key Action ItemsKey Action Items
I t d Diff ti t• Innovate and Differentiate
• Readmission Tool Kits
• Providers Must Become Certified to Stand Out• Providers Must Become Certified to Stand Out
• Fellow in Readmission Prevention
• Certified Readmission Prevention Partner program
• Outreach to your referral partners consistently
• On the 15th of each month: Share the tools above!

29. My Legacy: Going Purple for My
Mom
Values
• PassionPassion
• Empathy
• Fight
• Use your giftsy g
• Legacy

30. Go Purple to fight Alzheimer’s
Disease!
Josh Luke, Ph.D., FACHE
• Founder, National Readmission Prevention Collaborative
• Interim CEO, Memorial Hospital of GardenaC O, p G
• Executive Faculty, CSU Long Beach
• Author: Readmission Prevention: Solutions Across the Provider
Continuum
JoshLuke@NationalReadmissionPrevention.com
NationalReadmissionPrevention.com