“The Centers for Medicare & Medicaid Services (CMS) announced this week that Arnie Cisneros, PT, and Linda Alexander, RN, have been awarded for their Model 2 Retrospective Bundled Payment Initiative entitled “Retrospective Acute Care Hospital Stay plus Post-Acute Care” in collaboration with the Detroit Medical Center (DMC). Cisneros, President of Home Health Strategic Management (HHSM), and Alexander of Detroit Medical Center, worked with Detroit Medical Center and The Rehab Institute of Michigan to complete the Model 2 Bundling Application, which consists of CMS and Post-Acute Providers working together to set a target payment amount for a defined episode of care.
DMC is a collection of nine hospitals that is also a Pioneer Accountable Care Organization (ACO) awardee. The Rehab Institute of Michigan, part of DMC, was charged with completing the Model 2 Bundling Application for the ACO project. Throughout the initiative, the DMC contracted with Home Health Strategic Management based on HHSM’s knowledge of post-acute services to create clinical pathways, bundling models, post-acute vendor rosters, and the Model 2 application. Cisneros and Alexander’s proposal included the target price, set by applying a discount to total costs for a similar episode of care as determined from historical data.”
– hcafnews.com – 10/26/12
The Utilization Review program for homecare that is S.U.R.C.H. was the basis of the clinical protocol for LE total joint replacement chosen for the Model 2 Bundling pilot. For progressive Home Health Providers who are subscribers to the HHSM e-Newsletter, this will come as no surprise. S.U.R.C.H. has helped many homecare agencies and clinicians focus care for improved clinical and fiscal results, creating gains under PPS that serve both patient and Provider. And now that we have entered the ACO era, based entirely on wellness, savings, and efficiencies propelled by gain-sharing across the care continuum, S.U.R.C.H. can also open the door for Home Health agencies seeking direction in the new healthcare landscape. By identifying the essence of clinical declines and acuity through Start of Care OASIS data, the S.U.R.C.H. process allows the Provider to develop care programs that are efficient and focused. Furthermore, this progressive protocol defines these care components in Medicare terms, so that compliance and qualification become second-level concerns.
Home Health Changes Ahead in the Bundling Model
Even the most casual observer is aware of the healthcare changes that lie ahead in Home Health. Entitlement concerns, combined with baby-boomer caseloads, an outdated medical model, an in-efficient care continuum, and the funding emergencies of the new world order outline a system with structural concerns that must be addressed. In addition, healthcare evolution offers additional challenges as care delivery is constantly remodeled for contemporary goals. The ACO model seeks to develop methods of delivering care under reduced costs without compromising clinical outcomes. By streamlining the acute episode and eliminating the silo-based nature of the care continuum, ACOs will reduce unnecessary healthcare spending.
The Care Transitions element of the ACO includes the Bundling Model, which is designed to reduce costly hospital readmissions by including Post-Acute care as part of the acute episode. The Bundle, referencing all costs of the acute episode, combined with costs of Post-Acute services, often addresses the 30 day, post-DC period after the patient returns to the community. By making the acute hospital, or health system, responsible for all Post-Acute care costs and outcomes, the ACO places the responsibility of the entire epsiode at the feet of the acute, inpatient Provider. By “Bundling” all care costs and management responsibilities, the ACO reduces the silo effect of the care continuum, i.e., all independent, or “silo-ed”, Providers (IRF, SNF, LTACH, Home Health) producing and delivering care seeking to address their individual business concerns. Any hospital readmission related to the original episode would be considered part of that episode, and the costs of readmission would be the responsibility of the hospital or health system that managed the acute component of the case.
The changes that this model will deliver to the current care continuum cannot be over-stated. By reducing the inefficiencies of today’s model, funding for universal coverage will be obtained, quality outcomes-based care will improve patients at a faster rate, and readmissions will be significantly reduced because that’s where the focus of the re-wired, Bundled epsiode will be. No longer will the Post-Acute phase of the acute episode be considered optional care; the Post-Acute environment will be where the episode is completed. Standard discharge protocols will include the scheduling of the SOC Home Health visit from the acute hospital bed, signaling for all involved that this is how and where the episode ends.
All Acute Medicare Providers will Confront Changes
Hospitals are also headed for changes that will redefine how they operate in the landscape of the future. In the early day of Medicare (the 1960s), hospitals were the only care delivery vehicle available, and that payment scenario continues today under the current fee-for-service model, despite the introduction of PPS. Many healthcare experts predict that over the next ten years, acute-care hospitals will be reduced to intensive care units, with all non-life threatening care moved to less costly environments, and that means the Post-Acute world will be where much of today’s care will occur. The funding and baby boomer challenges referenced above are here to stay, and that means that affordability will be present in the care equation of the future.
What Have You Done so Far?
So with the new care models just over the horizon, now is the time for ALL Medicare Providers to prepare for the future, and there are a number of steps you can begin today. It is clear that the ACOs and Bundling models will require efficient programs, based on best-practice care that is delivered in the most cost-effective manner. This will require an elevated level of clinical management when compared to what we currently deliver in homecare, so now is the time to adopt care and quality controls seen at other points of the care continuum. Clinical rounds for nursing and therapy staff, timely and transparent documentation, fresh staffing for patient programs, OASIS accuracy and programming, and a rush to clinical goals defined by safety; all are examples where attention today will spell success tomorrow.
Examine your OASIS for accuracy on a per episode basis, especially the defendability and inter-reliability of the Functional section. Assure consistent and proportional clinical intensities for both nursing and therapy, reduce or eliminate un-necessary aide assignments, and STOP writing certification period orders of Post-Acute patients when not clinically indicated. There are many more ways to begin to prepare, but these are the first steps that should be underway. Don’t find yourself behind the homecare curve of the future; if you don’t prepare for tomorrow, someone else will.