Facing the music: Providers learning new moves so they can stay in step with new dance partners
McKnight's Roundtable lineup
Much of any future success with bundled payments or integrated care will rely heavily on positioning and analytics. A willingness to show possible partners that efforts are being taken to eliminate missteps will also be critical. That was a common refrain among from long-term care executives taking part in a McKnight's Roundtable in August at the AnalyticsEdge PointRight symposium in Boston.
Operators are eager to see returns on investments from forward-thinking strategies that improve quality, the experts explained. Take hospital readmissions, for example, where many providers have lowered rates. Providers have worked hard on educating their acute care cohorts to understand the full role of a skilled nursing facility. However, many in long-term care haven't necessarily seen the preferred referral rates or additional admissions they hoped for.
“We haven't quite seen the back side of all of this wonderful effort that's been put in up front. That time probably is still to come,” said Steven Littlehale, PointRight executive vice president and chief clinical officer.
Understanding data and analytics continue to be important keys for those tip-toeing into managed care, he added.
Managed care meringue
In Kansas, which has Medicaid managed care through three different large organizations, the major focus is on numbers, according to Medicalodges Chief Operating Officer Fred Benjamin.
“If you're not measuring it, you're not managing it,” he said. The three MCOs under KanCare have a 5% holdback.
“If we can be their partners and help them to get their holdback and get a bonus beyond that, we're the most valuable people that they have to work with,” Benjamin said. “So we're spending a lot of time trying to understand and match our data collection and our quality improvement.”
One change in understanding managed care and accountable care organizations relates to real-time versus historical data, noted PointRight Executive Vice President for Payer Solutions Kili Chivers.
“What we've seen historically is that [ACOs and MCOs] use historical data in the look-back period to try to get ahead of the rehospitalization rates,” she said. One common diagnosis from that data is patients with congestive heart failure, and logic leads the MCO to say, ‘Every time a member has a diagnosis of CHF, we're going to try to manage that member,'” Chivers said.
But analytics have pushed managed care companies to understand it's more important to place the patient in the right facility, she added.
“It's about using a smart network, instead of a narrow network, to guide patients to the best provider to meet their needs,” Chivers explained.
“A CHF patient that is receiving care in a nursing facility that's great at managing CHF will be at lower risk than a diabetes patient receiving care in a nursing facility with a focus on hip replacement rehab.”
Her team also has encouraged MCOs to use a third-party to collect data so that they can have a “true perspective of quality and outcomes. If you're just looking at your patients and you're only sending CHF patients to that particular facility, you may not be getting a true look at their overall outcomes.”
These outcomes could tie into payments as MCOs start to collect MDS assessments on their members in a given nursing facility.
Bundled pay bolero
Bundled payments and integrated care sound simple in theory but are complicated in reality, said Neil Kurtz, M.D., president and CEO of Golden Living, one of the nation's largest skilled nursing chains.
“Right now, sometimes I think the only reason for my existence … is to make the payers richer and the hospitals more money, and I'm not seeing the upside yet,” he said.
Advantage Management Group Vice President Strategic Development Patricia Butler agreed, noting that better data is needed in order to understand not only the amount being paid in reimbursement, but the actual cost of care, especially as acuity levels rise.
“Our systems are not set up to tell us that,” Butler said. “That's one of the critical pieces that we need. We need our systems to be able to put in the data and say this person with these comorbidities … what is the cost to care for that patient?”
Electronic health records may be able to help reduce costs, and adverse events as well, said Agency for Healthcare Research and Quality senior social scientist William Spector, Ph.D.
“It gives the nursing home a lot of advantages if you have a good health system,” he said. “But the electronic health record itself, you still have to figure out how to get a particular piece of information that you need to help clinical decision making. Who do you need to be dealing with to make changes in practice? So we've been working on that for pressure ulcers, falls, preventable hospitalizations and also we have a module that deals with pressure ulcer healing issues, too. We've thought of it almost as an intervention approach.”
When trying to lower rehospitalizations, it's important to remember it's not just about quality measurements, Spector said. SNFs should look at what areas they can change.
“Avoidable hospitalizations or preventable hospitalizations, something that the nursing home can actually do, is only about half of the total rehospitalizations,” he said. Focus on infection rates, he advises: “That's about half of the half and so the first thing is what are you doing about infections, and sepsis is the biggest one.”
Rehospitalization rates also can vary by region and specific illness, making it important to understand what local partners are doing.
While Golden Living is a national chain with 300 facilities in 20 states, Kurtz reminded the panel that healthcare remains “intensely local.”
“Even within a state, within a county, you have to be very careful about any kind of broad generalizations. So again, what gets you a seat at the table, it really is about knowing your community and knowing the needs of your community,” he said. “A lot of this is on a personal level. It's people knowing each other and trusting each other.”
Data has the danger of feeling generalized, rather than local, Littlehale noted.
“It is important you show up with rehospitalization rate, length of stay, all that good stuff,” he said. But it also has to be specific to the market, he added.
“You have to hope that your data conversation is so specific and regionalized that you're going to immediately trump your competition because they're just not going to have it, right? They just don't have it.”
Kurtz said the challenges around who leads the models for payment programs are no less than battlegrounds.
“If SNFs cannot be the convener, we're in trouble,” he said. “It's the Golden Rule: Whoever holds the gold is going to make the rules. And let's not kid ourselves: A lot of what is going on here is preserving revenue stream on the part of hospitals, and until we kind of truly form a partnership and see it as equal partners, which I don't think we're there yet, this is going to be a challenge. And so I do think making sure that SNFs are conveners is really important.”
Massachusetts may be leading the way in convening, with Boston the site for many Pioneer ACOs, Littlehale noted.
The state is a place where “ACA initiatives are a bit more mature,” said CareOne Chief Strategy Officer Tim Hodges. “I'm finding things are coming more full circle.” That includes understanding risk in the care continuum, he noted.
Care continuum cha-cha
In Massachusetts, there is better understanding of how skilled nursing facilities often take the highest-risk patients, Hodges said.
“The days of focusing on joint replacement rehab are well over, and where we really could add value in the continuum is for the more medically complex step-down acute care patients,” he said. “So when we have conversations about the needs of those patients, the benefits, and become very transparent in managing, co-managing those patients for that 90-day episode whether it's a bundle or not, I think that collaboration is really [getting through].”
Care transitioning in Detroit has involved educating hospitals about skilled nursing facilities, Butler said.
“We feel that our hospitals, at least in metro Detroit, are starting to understand about skilled nursing facilities,” she said. One of the offshoots of that has been working with hospital systems to use their first-dosing program, which provides the first three days of medications from a pharmacy for a patient.
“It comes over with the patient from retail, and that has allowed us to reduce pain and reduce some hospitalizations right there,” Butler explained.
Medication safety is one of the focuses of care transition coordinators, noted Nathan Niles, CEO of Reliant Senior Care. The company runs 22 facilities in Pennsylvania.
“The coordinators are making sure residents are being safely discharged, with someone who knows how to open the pill bottle and to make sure the right pills are taken,” he explained.
They also do follow-up calls five and 25 days after discharge to ascertain whether residents are taking pills, visiting the physician or voicing concern.
“It's improved care because we're in the business of caring for people and we should always look to improve what hospitals or the ACOs want us to do,” he said.
Niles also zeroed in on the need to find the right workers to thrive in a modern nursing home.
There's a dearth of employees going into long-term care, especially in nursing, yet Reliant has added positions.
“We've now added a case management department to work with the managed care companies, and we do have to have specializations that we didn't necessarily have before,” Niles said.
Kurtz noted it is hard to find exceptional staff who can juggle direct patient care and a medically complex patient population.
“One of the biggest challenges in our industry is talent acquisition and then talent retention,” he said. “We have far too much turnover in the ranks of CNAs and nurses. I would say the top priority of the company right now is retention. ”
Retention is not easy when managed care companies are hiring hundreds of managers with long-term care experience, Chivers added.
“The first place they are look are long-term care facilities,” she said. “The plan in Florida I was speaking to, they have 530 care managers they had to hire in a six-month span and they're starved for long-term care experience.”
The industry should push investment in employees, create joint training programs and spread the word about the benefits in long-term care employment, Benjamin argued.
“Nursing in long-term care is one of the few parts of our entire economy where there is a pathway from being poor to the middle class. You start a CNA, they can use tuition support for them to become an LPN — a doubling of salary. From LPN to RN, a doubling of salary. RN to BSN, another significant increase,” he said.
There also needs to be a focus on facility leadership retention, panelists agreed. Many providers are setting very specific retention goals and focusing on the future of staffing.
Another question in the short-term is whether skilled nursing facilities will be recognized for their value, Kurtz said.
“What worries me is we do not have enough political clout to get to the table on equal footing as the hospital,” he said.
Consumers also will be increasingly evaluating value, Niles added.
“I could give great care, but I look at our buildings and I say, ‘Well, we have a lot of buildings that were built in the '60s and '70s. They may not be appealing to consumers.' They [also] want a single room.”
Providers can't underestimate the power of the consumer, Hodges agreed. And, he added, they should remember that there's value in talking to peers headed to the same ballroom floor.