When looking for opportunities to improve efficiencies in Medicare Spending Per Beneficiary (MSPB) episodes, focusing on the ‘low-hanging fruit’ might make sense, but it’s important to not miss the other big pieces that require more of a stretch to grab.
Medicare attributes 43 percent of episode spend to post-acute care (PAC), which continues to increase 5.4 percent per year. Post-acute spend also explains 73 percent of variation in total Medicare spend. Optimization of PAC resources is key to improving efficiencies for MSPB episodes, but most hospitals find improvement in this area complex since the MSPB episode spans the continuum of care, which includes the three days pre-index admission through 30 days post discharge.
A recent Vizient Performance Improvement Collaborative was designed to assist members with improving utilization patterns of skilled nursing facilities (SNFs), home health, inpatient rehabilitation and readmissions as key drivers to improve MSPB performance.
Nicole Spatafora, director of programs, performance improvement collaboratives at Vizient notes, “Improving in this area isn’t necessarily about just reducing PAC episodes. There are going to be patients where it’s definitely appropriate for post-acute care, whether that’s a SNF or home health services. What hospitals really need to work on is managing that PAC portion of the episode and that requires creating strategic partnerships.”
Creating a foundation for strategic partnerships
To establish strategic partnerships with PAC providers, a strategy needs to be developed and senior level commitment is critical. When evaluating performance and partnerships, hospitals can leverage CMS ratings, e.g. quality, star and nursing. In addition, different outcome metrics should be checked, such as the number of readmissions and ED visits pertaining to a particular PAC facility. High referral volume and length of stay (LOS) are primary indicators to review, as is location. In evaluating this, the hospital is not only reviewing cost, but PAC resource management.
As partnerships form, the hospital needs to take the initiative to provide education on the CMS Value Agenda, identify common goals, performance metrics and assess commitment of its PAC providers. By establishing a partnership with the PAC provider, hospitals can start to build a culture of shared ownership as the entities work together to advance care coordination strategies, improve quality and prepare for a transition to a value-based agenda.
The next step is gaining access to relevant patient data from the PAC providers. A mutual understanding of what indicators and metrics must be measured helps the hospital and PAC providers determine if their collaborative efforts are reducing the overall MSPB score.
“Readmission and ED visit rates back to the hospital are relatively easy to capture, but tracking data like LOS in a SNF or the number of home health visits a patient has is difficult because the hospital and PAC facility are often not on the same electronic health record platform,” Spatafora said. “The hospital must rely on the PAC facility to provide the other necessary data.”
Ensuring the right care in the right setting
“Optimizing PAC resources not only ensures that patients get to the right setting of care, but it also requires alignment of that care with the patients' needs.” Skilled nursing utilization may not be the appropriate care setting for every patient. Patients without comorbidities or who have support at home could be fine if discharged with home health serving as their method of PAC. Partnering with SNFs and home health agencies to align LOS and visits with patient need can reduce episode spend and drive the value agenda. “This is challenging because payment incentives are not always aligned. A PAC facility payment has been volume driven, and hospital payment is value driven," said Spatafora.
An innovative strategy is to assign clinical resources such as a SNFist – a hospitalist or physician embedded in the SNF – or a nurse navigator to better manage care across the continuum to reduce LOS, unnecessary ED visits and readmissions. These clinicians help solidify the strategic partnership by working with the PAC provider to coordinate care, assist with discharge planning and resolve issues that could have otherwise resulted in an ED visit and/or readmission to the hospital.
“Looking at the PAC space and finding ways to improve efficiencies is a key component of the CMS Value Agenda. To be successful in this agenda it will require hospitals to closely measure and manage the episode,” said Spatafora. “The payoff is as organizations begin to optimize PAC resources, they will see reduced spend per episode and improved MSPB performance.”
For more information on how your organization can leverage the findings of this particular collaborative, contact Nicole Spatafora.