Bundle Payment Care Initiative Advanced Update Heather Peiritsch MSN, RN Bundle Payment Program Manager Abington Jefferson Health Heather.Peiritsch@jefferson.edu

Affordable Care Act (ACA) Accountable Care Organizations (ACO Hospital Readmissions Reduction Program Bundled Payment Care Improvement (BPCI) Bundled Payment Care Improvement Advanced (BPCI-A) 2012 2012 2012 2018 Provider led organization, takes on full responsibility for the overall cost and quality of care delivered to a defined patient population Risk adjusted readmissions within 30 days of discharge: AMI, CABG, COPD, Elective THA/TKA, HF, PN Payments linked for multiple services beneficiaries receive during an episode of care. Include financial and performance accountability New iteration of bundled payments, align incentives for reducing expenditures and improving quality of care. Qualifies as an APM. Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners – allowing them to work closely together across all specialties and settings. 2012: Accountable Care Organizations (ACO) Integrated health systems Linking payment to quality outcomes – shift healthcare payments away from fee-for-service toward value-based reimbursement 2012: Hospital Readmissions Reduction Program Risk-adjusted readmissions within 30 days of discharge Initially AMI, HF, PN, now expanded to include others 2014: Bundled Payment Care Improvement (BPCI) Episodes of care bundled together – financial and performance accountability example: Acute care admission plus 30/90 days post discharge Focus on high-cost episodes Precursor was HMO (1980’s) – unpopular; incentivized providers to limit services According to CMS https://innovation.cms.gov/initiatives/bundled-payments/index.html - BPCI models lead to higher quality and more coordinated care at a lower cost to Medicare – yep, that’s true – but higher cost to discharging organizations https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program.html https://innovation.cms.gov/initiatives/bundled-payments/  

Jefferson Hospitals Heart Failure and Sepsis Abington ONLY—Stroke Best Practice Protocols/Policies Streamlining Education Analytics Preferred Providers Nurse Navigation

The IHI Triple Aim Improve the health of the population Reduce or control the per capita cost of care Enhance the personal experience –quality, access and reliability . In the current healthcare landscape, no one is held accountable for all three dimensions of the IHI Triple Aim. To optimize the health of a population, all three Triple Aim dimensions need to be addressed at the same time. http://www.ihi.org/Engage/Initiatives/TripleAim

Navigation Program Goals Cost Readmission Reduction SNF placement and SNF LOS Patients will go to the safest, lowest level of care as soon as medically stable Quality Care Redesign Patient satisfaction and Engagement Patients will have a great hospital experience Coordination Acute and post-acute provider alignment Patients will have excellent care coordination

Post Acute Partners

Benefits of a Post Acute Network Patient-centered care Development of new relationships amongst healthcare providers, homecare agencies and facilities Decreased variation in care practices Decreased 30 and 90-day readmission rates Increased education and quality of care ENHANCED COMMUNICATION Application 2015

Networking a Pathway to Quality Physician Practice Patient Coordination of Care Zone Management Education Specialized teams Goals of Care Readmission Review Tele-monitoring Practice Care Managers Pharmacist Behavioral Health Specialist Health Coach Social Work Same day sick appointments Advanced Care Planning Monthly leadership meetings Best Practice Guidelines Weekly patient updates Home Care Inpatient Facilities

Advanced Care Planning

Quality Metrics for BPCI-A Heart Failure, Sepsis and Stroke BPCIA Quality metric: Advance care planning Quality Metrics for BPCI-A Heart Failure, Sepsis and Stroke CMS has selected seven quality measures for the BPCI Advanced Model. Two of them will be required for all Clinical Episodes. The other five quality measures will only apply to select Clinical Episodes. The two measures that apply to our Bundles are: All-cause Hospital Readmission Measure (NQF #1789) Advanced Care Plan* (NQF #0326) (QPP #47)

Advanced Care Plan (NQF #0326): Care Plan- Communication and Care Coordination Domain Rationale: The patient’s wishes regarding medical treatment need to be established prior to incapacity. Performance period: is 1 year- beginning 9 months prior to the initiating anchor stay/ hospitalization and ending day 90 of the bundled payment episode Appropriate use: ALL healthcare settings (e.g., inpatient, nursing home, ambulatory) except the Emergency Department. Physicians (MDs and DOs), nurse practitioners (NPs),and physician assistants (PAs) Provider can use these codes if they perform an initial service and a non-billing team member (e.g., registered nurse, social worker) helps deliver part of the service, with ongoing direct supervision and involvement of the billing provider.

Coding Summary CODE TYPE Measure Description 99497 CPT BPCIA Quality metric: Advance care planning CODE TYPE Measure Description 99497 CPT Advance Care Directive Advance care planning including explanation and discussion of advance directives such as standard forms (with completion of such forms) when performed by the physician or other qualifying health care professional; first 30 minutes, face to face with the patient, family member(s), and/or surrogate. This services carries an eligible charge, and also a co-payment for the patient unless performed as part of the Annual Wellness Visit. 99498 Each additional 30 minutes (list separately in addition to code for primary procedure) 1123F CPT II Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record 1124F Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

Readmissions

Providing Warm Handoffs Nurse Navigator to Care Practice Manager Nurse Navigator to Home Care Nurse Facility Nurse to Nurse Navigator Hospital Physician to Facility Physician Hospital Nurse to Facility Nurse

Jefferson Health Educational Sessions (adopted from MLH thru the DVACO) Goal: Implement a set of tools to optimize the care of residents with Heart Failure, COPD and Sepsis to improve outcomes and prevent hospital readmission. Heart Failure/COPD Sepsis HF/COPD Admission Order Sepsis Nurse and CNA education HF/COPD Consent to treatment Stoplight tool education HF/COPD nurse and CNA education SBAR tool for a change in condition Stoplight tool education SBAR tool for a change in condition

What YOU Can DO

BPCI Original October 2015-September 2018 Heart Failure CMS Baseline: 57.6% 2016: 43.8% 2017: 43.8% 2018: 43.3% Stroke CMS Baseline: 31.5% 2016: 27.7% 2017: 28% 2018: 26.7%

Abington Residential Care (ARC) Group Affiliated with Jefferson Medical Group Team of Nurse Practitioners and Physicians delivering care to patients in their own home environment Visit in the patient’s home Lab work and Xray’s Arrangement for Home Care services Timely medication refills Prevention of Readmissions