Are you ready to go “At Risk” for Readmissions?

The Affordable Care Act (ACA) will define the healthcare management, production, and delivery processes of the future by rewiring the philosophies and financial incentives in the current care continuum. Health systems across the country are beginning to internalize and address the challenges they will confront as a result of the ACA care models, and Post-Acute Providers would be wise to do the same. Industry reports that Pioneer Accountable Care Organization (ACO) enrollment is decreasing are punctuated by ongoing announcements of newly formed ACOs elsewhere across the country, while media reports, fueled and advanced by politically-charged reporting, outline struggles with the new care models despite the relative infancy of the pilot programs. Meanwhile, healthcare leaders feel the ACA, with its’ ACO-centered episodic care model, is here to stay. Quoting a representative of a leading national hospital chain speaking at the 2014 Home Health Financial Managers Association Conference in July; “Even if the ACA is defeated politically, we feel the ACO care model will survive; at this point, the payers will demand it.”

The underlying message of the above quote is that payers have realized they are paying more than is necessary to achieve desired clinical programming via the current silo-based care continuum. Concerns that are confronted daily in Post-Acute care, whether in SNF or Home Health patient programming, represent in-efficient care episodes that are marked by compromised clinical results or un-necessary delivery costs. Focusing on the areas of inefficiencies that define the level of disconnect currently present between care sites, the ACO-based episodic approach seeks to minimize these clinically and fiscally compromising practices. The result is a streamlined, more efficient acute care episode where silo-based activities are eliminated or reduced, and billing totals reflect the quality of care delivery by Providers involved in the case.

The net result for Providers of all types that are included in the ACO-based episodic care approach are significant changes in their patient programs; in terms of length of stay (LOS), coordination and communication responsibilities, and care content requirements regarding value and delivery specifics. In short, the care programs of tomorrow will differ wildly from those we develop and manage today, and signs that the future is closer than many might think are appearing all across the care landscape.

A quick review of the 2015 PPS Home Health Proposed Rule reveals just one example of this as it applies to homecare changes we will expect to see as the ACA matures. In the Value-Based Purchasing programming proposal outlined in the Rule, the Home Health reimbursement rate would be reduced in an across-the-board manner (5-8%) for all patient episodes. Agencies who meet objective standards in terms of clinical patient outcomes would receive performance bonuses that would essentially replace the rate reduction. The underlying premise of Value-Based programming should not be lost on any Home Health Provider; in the future, effective reimbursement will be attached only to those patient programs where we actually achieve our goals. The implications of this approach to care outcomes will be felt in many areas of today’s standard Home Health programming. How will we handle non-compliant patients, delayed care admissions or missed visits, refusals of needed services, clinician-managed schedules or un-involved caregivers? This ongoing list of care challenges exists today, but when these items are directly related to payment levels, we will see them in an entirely different light.

The evolution of care that we will see in the ACO-managed episodic approach will mimic the industry changes that were seen as the DRG process reduced hospital LOS stats by more than 75%. Care programs will become more focused as they are increasingly individualized. Program efficiencies, and the factors that affect them, will be the primary concern as program value moves to the forefront of the delivery model. Clinical staff management and control will increase, including; schedule management, productivity control, readmission tracking by clinician, adapting care to in-episode progress, and much more. Basically, the introduction of the Value-Based Purchasing program, especially as outlined in the Proposed Rule, creates a scenario where Home Health Providers will essentially be betting program solvency on the performance of their front-line clinical delivery staff. Are you prepared to do that today; trust your clinical staff to produce care programming that directly defines your financial outcomes?

Most Home Health Providers are not prepared to assume this level of care responsibility. In fact, brief conversations with homecare management reveals they possess a varying degree of confidence regarding the clinical IQ or directability of specific members of their clinical staff. Statements along the lines of “She could treat my mother” or “I wouldn’t let him near one of my family members” reveal underlying cracks that exist in our care and delivery quality. Considering that the ACO, acuity-based, episodic programs will be based on the ability to identify clinical specifics, process a morphing clinical response to those specifics assuring compliance and caregiver involvement, communicate those elements via visit-based clinical reporting through inter-connecting ACO software, and lose the patient to outpatient or chronic programming in response to directives from ACO-based UR control; clinical staff management and control will be paramount for success. The Post-Acute Provider seeking success in the new care landscape should address these issues today in the same manner that acute care hospitals resolve these types of concerns, since these acute care systems will be the ACOs of the future managing both the Post-Acute Bundles and the Population Health chronic care programming.

But many in the Post-Acute world, including both SNF and Home Health Providers, are jumping ahead of the curve by addressing the concerns of the new care models before the 1/1/18 Bundling start date marks the onset of the episodic approach. By relating programming to the concerns their referrals sources must address, these progressive Post-Acute Providers are willing to go “At Risk” financially with their care product. Acute Care hospitals, who have faced readmission penalties exceeding a half billion dollars over the last three years, are focusing on limiting readmissions of recently discharged patients to minimize these penalties, which will increase steadily until readmissions become the effective responsibility of the ACO managing the Bundled episode. By internalizing these changing programming concerns of referral sources, these Post-Acute Providers are willing to bet portions of their care payments on the actual accomplishment of programming goals, in this case, readmissions.

By going “At Risk” for readmissions, Providers align care with goals that extend beyond their own traditional processes to address the delivery needs of the episode itself. In doing so, they commit themselves to manage and modify clinical programs, and the staff that deliver these programs, as they move their care and staff forward in the care environment of tomorrow. Through this approach, these Post-Acute Providers are able to achieve a number of important goals; 1) They are moving closer to the care development and delivery of tomorrow, 2) They are reducing the silo-based activities their staff must address as they evolve their care, 3) They are willing to adopt risk related to their care (the basic premise of the ACA), and most importantly, 4) They are distinguishing themselves from their competitors on the care path of tomorrow.

So in summary, are you willing to go “AT RISK” for readmissions in the delivery of your post-acute care programming, and if not, why not? This simple question summarizes nearly all the challenges of the future for those Home Health Providers who need to rewire their programs for better care at a better cost, improved clinical outcomes, and transparency in care value and delivery realms. Industry predictions identify a significant loss of Provider numbers in the next 5-10 years despite the addition of baby boomer numbers to our target population. Those Home Health Providers seeking to survive this industry contraction should consider reaching outside their current care comfort zones, just as those going “AT RISK” for readmissions have. Now is the time to prepare for tomorrow if you hope to treat the patients of the future though the programs of the future.