Value-based Purchasing Update and Best Practice Process April 25, 2019 August 27, 2019

Genesis HealthCare The Direction of Healthcare & Value-based Purchasing Hospitalization Avoidance Evidence-based Medicine Hardwiring Effective Clinical Systems August 27, 2019

Direction of Healthcare

The Direction of Healthcare Value-based Care Delivery Alternative Payment Models MSSP CJR BPCI Advanced Payment Reform Patient-Driven Payment Model Value-based Purchasing SNFRM Home Health August 27, 2019

Payment Quality expectations Outcomes Reducing hospitalizations & adverse events

Hospitalization Avoidance

Integrated Practice Drives Better Outcomes Interprofessional Practice Standards Integrated Practice Drives Better Outcomes Established and functioning IDT Risk for Readmission Assessment Post Admission Patient/Family Conference (72 hour meeting, Wellness meeting etc.) the IDT will: Review the risk areas with the patient/family to determine accuracy and identify additional risk areas. Ensure that the Risk for Readmission Care Plan has been completed for patients with a score of 10 or >. Engage the patient in discussion related to: Potential discharge date and plan Patent expectations and goals of care Documentation of the Patient/Family conference serves as the baseline care plan review and care plan meeting note.

THINKING RIGHT|ACTING RIGHT ABOUT PATIENT CARE A consistently used, guided clinical reasoning and problem-solving model that generates a sustainable process for collaborating on clinical care (teaching others, holding staff accountable to the process, new hire mentoring to the process, expansion of the process to other operational endeavors) and that can be implemented easily within existing center processes: Conduct meaningful Clinical Case Review meetings that result in pertinent, efficient, effective, reasonable, and actionable recommendations that are implemented and evaluated in a timely manner Incorporate correct clinical reasoning and problem-solving (Thinking Right) in every situation and interaction related to patient care

An Approach to Collaborative Clinical Reasoning Idaho Centers started implementing the clinical reasoning and problem solving methodology in April 2013. This chart shows 3 years, from April 2013 through May 2016, of 30-day reshospitalizaton data for all Idaho Centers. Note improved, sustained performance. An Approach to Collaborative Clinical Reasoning Findings from a Demonstration of “Thinking Right” All GHC Centers in one state began implementation of the clinical reasoning and problem solving methodology in April 2013. This chart shows 3 years, from April 2013 through May 2016, of 30-day aggregated reshospitalizaton data.

“Change at the Scale of the Whole” Changing the messaging Care transitions from hospital to Center; Center to Community Clinical Capabilities Clinical Reasoning Communication

Evidence-based Medicine

Example: Evidence-based Clinical Specialty Programs

Standardizing Care Delivery Example: HF Pathway

Hardwiring Effective Clinical Systems

Hardwire Effective Clinical Systems/Strategies August 27, 2019

Manor Care Managing Re hospitalization inside the SNF Transition Planning Managing Community Transition with Down Stream Providers

Process From Admission to Discharge Tracking and Trending of Re Hospitalization Data: Focus is on Monthly, Quarterly, and Annual Trends, Admission Diagnosis, Reason for Discharge by System, Decision Maker, Time from Admit to Discharge and Shift, also can trend process steps to identifying opportunity. Upon admission, protocol and care paths initiated by diagnosis ( sepsis , CHF, Stroke, COPD (non bundle) ) Nurse to Nurse transition report with the hospital Point Click Care: POC alerts for change in condition with emphasis on nursing and rehab Utilize the interact flow chart/ flow 02 tool with all change in condition. Completion of SBAR tool before calling physician. In PCC all POC alerts reviewed two times a day, in the morning meeting and at wrap up ( STOP & WATCH, early warning signs )

Process From Admission to Discharge 7. Focused daily rounds held at lunch and or after rehab. Focus is on new admits, targeted diagnosis and anyone with a change Vital signs daily and monitor for change in baseline Utilize respiratory therapy for any patient with a respiratory diagnosis to evaluate and develop plan of care Emergency Department called prior to all patients being sent to the ED. Utilization of either hospital or interact tool for clinical capabilities. Weekly call to review all re hospitalizations, to review process steps, what could we have done differently and facility follow up plan ( interact quality improvement tool )

Target Diagnosis Stroke F A S T assessment Assess stroke deficits upon admission / continue assessment for acute neurological changes Asses Vital Signs and Pulse Oximetry Assess for dehydration Check Blood Glucose Assess Mobility / Pulmonary Status Implement blood thinners, statins Rehab (assess eating, swallowing, communication, muscle tone and provide daily rehab) Nursing ( assess bowel and bladder, fall risk, psychosocial impact)

Target Diagnosis Sepsis / Infection CHF Implementation of Antibiotic Stewardship Program Patients admitted with history of infection / sepsis are recommended for ADM consult Patient who exhibit any 2 symptoms (3 100’s - temp >100, BP <100, heart rate >100) temp 99, chills, altered mental status, decrease in appetite, hypotension, decreased urine output or concentrated dark urine, cool extremities or mottling of skin ) should signal a change in condition with potential infection Review advance directives with change in condition, ADM can assist Facilities Capabilities completed and reviewed with medical director to determine facilities ability to treat sepsis in the center. CHF Medication Management ( IV Lasix ) Daily weights Diet education Functional performance in rehab, areas to monitor

Target Diagnosis COPD Gold Criteria for COPD Assessment completed by respiratory therapy Respiratory protocol and equipment utilized based on their rank from mild to severe, based on their performance in rehab. Assess breathing daily in the AM prior to rehab

Palliative Care (ADM) / Hospice Discussion of POLST form on all admission and is part of the assessment process Initiated consult with chronic disease Cancer Heart Disease Pulmonary Disease Kidney Disease Alzheimer’s Disease Parkinson’s Disease Combination of diseases resulting in a disabling or debilitating status

Palliative Care (ADM) / Hospice Advanced Disease Management ( ADM ) Screening Tool used to discuss either palliative care or hospice Team members involved in palliative process Patient Family Collaborative Physician Nurse Practitioner Helps avoid re hospitalization when someone advances to the chronic disease management ADM / NP evaluate pts for advance care planning.

Transition Planning Transition Program Transition Assessment Pre admission 24- 48 hrs Week 1 to discharge week Discharge week Week after discharge Transition Assessment Plan A and B Evaluate community environment Chronic Disease – assess for training needs and home support Evaluate ADL function to home ( develop plan for transition )

Transition Planning 3. . 24 to 48 hours Utilization of DVACO Preferred Home Health Providers whenever possible Identify home care prior to discharge Transition Assessment and facility diagnosis protocols 4. Week 1 to Discharge - education to patient and family Focus on medication management Utilize zone programs for chronic disease education program ( education to patient / family / staff ) CHF/ COPD / Sepsis / Stroke zone programs ( poster Identifying how a patient feels and helps to educate the family and patient to help improve change in condition communication, so that we have consistent care for the patient) Track every patient on the program using a tracker. We participate in this program with MLH

Transition –Planning 5. Discharge Week 6. After Discharge Risk Assessment – nurse to nurse report hand off Involve the assigned Ambulatory care coordinator from DVACO / Abington Jefferson Hospital with discharge process My transition home packet sent to PCP and home care 6. After Discharge Home Care and facility communication calls through out their stay with home care Follow up calls 48hrs post transition home / PCP appointment made prior to discharge

Managing the Community Transition with down stream providers Home Health Community Transition - Transition Planning Worksheet is completed on all new admissions - Home Health is notified of referral - Home Health attends weekly Medicare skilled meeting - Weekly rounds are completed of patients referred with facility and home health liaisons - Hand off to home care before transition to community and a risk assessment is completed. High risks are communicated to nursing at home health following the guidelines for nurse to nurse report

Managing the Community Transition with down stream providers - Facility does follow up at 48-72hrs after community transfer and around PCP appointment - Weekly call is established reviewing 100% of all patients referred following tracking form - Patients at risk for hospitalization are evaluated to return to the skilled facility - All patients admitted to the hospital are reviewed and tracked - All patients receive a follow up call from the home health, 48 hrs after service ends for health check

Managing the Community Transition with down stream providers Non skilled home care - Liaison meets with patient and family - Interact with home health - Work in conjunction with home health - Follow up 60 to 90 days post home health - Provide non skilled home services

Open Discussion August 27, 2019