Pandemic Era Developments for Postacute Care Networks: Part II CE1

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Pandemic Era Developments for Postacute Care Networks: Part II

Laura Kukral, MBA, LNHA, and Ben Frank, MHA, FACHE

Postacute care networks (“networks”) are changing in response to the impacts of COVID-19. These changes include network structures, size, membership, goals, and use of technology. One of the most notable changes is the inclusion of “super skilled nursing facilities (SNFs)” to provide integrated specialty care modeled after hospital-based service line best practices.

What is a Service Line?

A service line is an organizational and managerial model that follows the patient’s path through the care process to provide and integrate all the services they may need for a medical condition (eg, cardiac care) at a single location or set of locations. Hospital service lines emerged in in the 1990s in response to the demand for integrated care and the need for caregivers to “cut across both institutional and disciplinary boundaries to organize patient care around specific diseases, interventions or populations” (Charns et al., 2001). Before service lines, patients found that hospitals offered a piecemeal system of care with many siloed physicians and departments. When Johns Hopkins Medicine moved to the model, it was described as a sea change in patient care with the expectation that patients could call a single phone number and enter the system at the right place and into a care path that was more efficient and effective (Blum, 2017). Service lines were established as strategic collaborations between physicians and hospital managers, with physicians designing the clinical process and managers providing day-to-day oversight (Becker’s Hospital Review, 2012).

While health systems historically focused on organizing care (and service lines) inside the walls of the hospital, programs such as Medicare’s Value-Based Purchasing Program, Hospital Readmission Reduction Program, and Bundled Payment Care Initiative (BCPI) established incentives for collaboration with providers across the entire continuum of care, notably postacute care providers. Hundreds of hospitals and physician group practices initiated BPCI Model 2 agreements that bundled payments for a Medicare beneficiary’s hospital inpatient stay and all postacute care (CMS, 2022) and gained experience in coordinating care with SNFs. These early collaborations frequently identified preferred providers and created shared care paths. They generally did not result in integrated service lines and strategies because of a variety of obstacles including strategic priorities, organizational culture, and limited understanding of the rules and regulations required at various levels of care as well as disparate data sources, lack of governance and legal structure, and questions about funding, availability of staff and equipment, and costs of care.

Service Lines Across the Continuum of Care

Despite development challenges, specialty programs have a long history in skilled nursing (Marselas, 2021). Notably, the COVID-19 pandemic seems to have created more specialty and service line partnership opportunities for postacute care providers and hospitals, “especially for those who can demonstrate prowess with cardiac, pulmonary, renal failure, sepsis and neurologically impaired patients” (Marselas, 2021). According to PointRight, a data analytics company, the skilled nursing industry experienced a nearly 5x increase in

Laura Kukral, MBA, LNHA, is a consultant in healthcare strategic planning and innovation. She has 30 years’ experience helping health systems, postacute providers, and community-based organizations with growth and innovation planning. She is currently the President of S-gen Marketing, LLC, and is a go-tomarket and innovations advisor for 3AimPartners, LLC, and SciMedi, LLC. She can be reached at LauraK@s-genmarketing.com.

Ben Frank, MHA, FACHE, is Chief Executive Officer at 3AimPartners, LLC, a healthcare consultancy focused on improving patient experience, the health of populations, and cost of care. Ben previously served as the Market President for Chen Medical, System Chief Operating Officer and Chief of Staff for Inova Health System, and System Executive Director of Clinical Operations at the Cleveland Clinic. He can be reached at Ben@3aimpartners.com.

Postacute care networks are changing in response to the impacts of COVID-19. These changes include network structures, size, membership, goals, and use of technology. One of the most notable changes is the inclusion of “super skilled nursing facilities (SNFs)” to provide integrated specialty care modeled after hospital-based service line best practices.

extensive services including isolation, tracheostomy, and ventilation between fiscal year quarter 4 (FYQ4) 2019 (prepandemic) and FYQ4 2020 (Arellano, 2021). The cause of the dramatic rise is thought to be threefold: 1) the high number of frail elderly diagnosed with COVID-19 and receiving SNF care; 2) a heightened preference for home health over SNFs during the pandemic resulting in SNFs caring for the sickest patients; and, 3) financially attractive reimbursements for medically complex care.

Historically, health systems focused on organizing care (and service lines) inside the walls of the hospital and among its physicians. However, payer policies and programs such as Medicare’s Value-Based Purchasing Program and Readmission Reduction Program incentivized hospitals and accountable care organizations to extend their efforts to coordinate care and collaborate with postacute care providers. Although, many of these collaborations engaged specialty physicians and identified preferred providers and care paths, they generally did not result in clinically integrated service lines between hospitals and postacute care providers. The silos still exist.

The lack of integration across the continuum impacts patients and providers in several ways. From the patient’s perspective, when they leave the hospital for postacute care a breach can occur in the patient-centered care approach that the service line model intended to address. Patient compliance with the plan of care for rehabilitation, medications, or other services necessary to recover and avoid rehospitalization is at risk as soon as the patient leaves the hospital setting. From the postacute care providers’ perspective, alignment with service line care paths is more difficult when presented as a hodgepodge of orders without the umbrella of knowledge and tools that service line integration offers them. As acuity increases, SNFs face higher staffing demands, training needs, additional compliance requirements, and an increased need for agreed-upon care paths, shared electronic health records, and data. Health system service line integration is increasingly critical if valuebased goals are to be achieved and sustained.

The Super SNF Approach

Hospitals and payers often distinguish service lines as Centers of Excellence when they consistently deliver high value (superior quality, cost, and patient experience). Likewise, “super SNFs” are high performing SNFs overall and provide one or more types of high acuity specialty care. To identify examples, the authors looked for SNFs consistently rated four or five stars overall by the Centers for Medicare & Medicaid (CMS) that had high-skilled care volume and a regional draw area as well as preferred status in payer and health system networks, low readmission rates, and at least one high-performing specialty service. These facilities became a critical resource, particularly during the pandemic, because they provide near hospital-level care facilitating regional inpatient acute capacity and service-line specific outcomes (Kukral & Frank, 2022).

One example is Andover Village Skilled Nursing & Rehabilitation (SNR), a five-star rated facility located in rural Ashtabula County, Ohio (Kukral & Frank, 2022) (Figure 1). It meets the author’s criteria for Super SNF status and draws patients from a broad geographic area including Cleveland and Columbus, Ohio as well as Pittsburgh, Pennsylvania. More than half (52.4%) of the facility’s skilled nursing admissions between Q3 2020 and Q2 2021 originated from outside of its home county (Ashtabula, OH). In addition to its referral partnerships with Ohio hospitals, patients were admitted to the facility during the reporting period from eleven hospitals in Pennsylvania and one in New York State.

Andover Village Skilled Nursing & Rehabilitation differentiates itself by colocating ventilator services with a freestanding dialysis center operated by DaVita. Its average hierarchical condition category patient risk score is defined as very high at 3.73, its 30-day overall readmission rate based on 2 years of discharges from skilled care is 14.08%, and its most recent year Medicare length of stay is 21 days.

The facility’s quality is driven by its respiratory care program which, despite its very high acuity and vent-dialysis program, has a lower 30-day respiratory readmission rate (17.14%) than the Ohio average (18.54%) for SNF patients in the respiratory diagnostic group based on CMS data reported between Q3 2020 and Q2 2021. The average Medicare length of stay for respiratory care patients is 27 days, with a 16-day median length of stay, which is also lower than the Ohio average length of stay for respiratory care (25 days) and the 19-day median length of stay. Other respiratory

FIGURE 1 ANDOVER VILLAGE SKILLED NURSING & REHABILITATION: Patient Acuity by Diagnosis-Related Group

Respiratory System Skin Diseases Nervous System Injury & Poisoning Infectious Diseases Genitourinary System Endocrine & Metabolic Digestive System COVID-19 Circulatory System

0 10

Low Acuity Medium Acuity High Acuity 20

Patient Count 30 40

quality indicators include a ventilator-associated pneumonia rate for the most recently reported period of zero (Ohio Department of Medicaid, 2020). The facility’s acuity (Table 1) is reflective of its ventilator and hemodialysis programs. About 35% of skilled nursing patients are admitted to Andover Village SNR with a respiratory diagnosis, compared with a state average of 10% during the same period (Trella Health, Atlanta, Georgia).

Although many SNFs offer high quality overall, superior outcomes for specific diagnosis-related groups (DRGs) are what makes them “super” for patients needing a particular type of care. Readmission rates for DRGs are of interest to network curators because the overall readmission rate does not address underlying variation in SNF performance by DRG (Oruongo et al., 2020). In other words, a high-performing postacute care provider overall may not be high performing in dialysis care, ventilator care, or some other DRG. Research using Medicare claims data and grants supported by multiple organizations including the Health Innovation Program and the UW School of Medicine and Public Health reflect considerable differences in readmission rates across SNFs by DRG category despite similar overall readmission rates (Oruongo et al, 2020). The investigators suggest that hospital discharge teams be equipped with SNF readmission rate by DRG categories so they can direct patients to facilities with high-quality care specific to their conditions (Oruongo et al., 2020). They go on to add, “policy makers could better identify opportunities for increased value by encouraging specialization and innovation among SNFs” (Oruongo et al., 2020).

The Care Manager’s Role

Care managers may first want to use internal data to evaluate the performance of preferred networks by the types of patients being discharged, the discharge level of care, and the performance of specific network members. They may also want to inventory and evaluate the capabilities and performance of network members for DRGs.

According to a Healthcare Financial Management Association article, one reason health systems are well positioned to improve the value of postacute care is because

TABLE 1 READMISSION AND LENGTH OF STAY FOR ANDOVER VILLAGE SKILLED NURSING & REHABILITATION VS. STATE OUTCOMES.

All Diagnosis All Respiratory High Acuity Respiratory Ventilator > 96 Hours Facility State Facility State Facility State Facility State

Readmissions (30-day Medicare fee for service) 14.08% 16.18% 17.14% 18.54% 18.75% 19.44% Insignificant 33%

Length of stay (average Medicare days) 21 26 27 25 NA NA 50 35

A service line is an organizational and managerial model that follows the patient’s path through the care process to provide and integrate all the services they may need for a medical condition (eg, cardiac care) at a single location or set of locations.

they play a central role in organizing service offerings (Maksimow & Samaris, 2018). The investigators go on to identify four health system activities that are critical to effective network operations including market needs assessment, network evaluation, network design, and alignment options (Maksimow & Samaris, 2018). Given the underlying variation in postacute care performance by DRGs mentioned earlier in this article, we suggest a DRG-based analysis using all four of these steps to identify service line alignment and development opportunities. Care managers are uniquely qualified to contribute to all steps.

During the market needs assessment, care managers can be a critical resource to identify: • The strategic framework for the postacute care strategy including the latest problems to be solved • DRG-based opportunities for improvement in readmissions, costs of care, and patient satisfaction, if any • Data sources (both internal and external) including those for DRG-based assessment of post-acute problems and needs • Network alignment and service line opportunities to evaluate further • Key considerations for the scope, approach, and methodology to be used by planners to assess and determine the postacute care market strategy • Operational considerations such as past issues with postacute care access by setting and location

Service line development opportunities should be explored for high-acuity DRGs such as ventilator care, dialysis, sepsis, neurological rehabilitation, cardiac rehabilitation, behavioral health, and any of the organization’s high-volume service lines. Once needs for DRG-based outcomes improvement are identified, care managers can contribute to the development of specialty programs across the continuum of care by facilitating: • The goals and measures that postacute care specialty programs would be expected to accomplish • Referral pathways for appropriate levels of care and key clinical condition

TABLE 2 ROLES AND RESPONSIBILITIES IN INTEGRATED SERVICE LINE DEVELOPMENT

CARE MANAGERS POSTACUTE CARE PROVIDERS PLANNING OFFICE/STRATEGY

Identify:

Problems to be solved

Problems to be solved, projections Enterprise prioritization DRG-based improvement opportunities Specialty care capacity Projections Data sources Data sources Data sources Service line opportunities for postacute care alignment Business case analysis for specialty care development and integration Business case analysis for specialty care development and integration

Operational considerations

Facilitate:

Goals a postacute care specialty program should accomplish Operational considerations

Compliance standards Consideration of options for build/buy/ partner

Designation of work plan leadership, accountability, and participants

Referral pathways

Postacute care best practices Engagement from service line experts Clinical input Protocols for placements and communication Protocols for admission and communication Status reports

Project management support including medical directorship and training Implementation: Staffing, equipment, licensure Project oversight

Care managers may first want to use internal data to evaluate the performance of preferred networks by the types of patients being discharged, the discharge level of care, and the performance of specific network members. They may also want to inventory and evaluate the capabilities and performance of network members for diagnosis-related groups.

• Engagement from service line experts including medical directors, executive directors, hospitalists, SNFists, and telehealth clinicians as well as business analysts and strategists • Protocols for patient placement, communication with postacute care partners, patient communication, and public or other cobranded communication • Project management office oversight for shared work plans across the continuum, resource acquisition, status reports, and obstacle resolution

Regardless of where they work (hospital, postacute care, or other level of care), care managers should seek support from their enterprise-level strategy office and/or project management office. The strategy office and project management office functions are responsible for enterprise priorities, timing, and resource allocation. These teams are skilled at forecasting and can help evaluate the return on investment of specialty care integration with postacute care providers. They will consider such things as potential improvement in value (costs/quality/experience), how much time the hospital’s clinical staff will invest in meetings, out-ofpocket costs, legal risks and mitigants, and more. In addition, the strategy office is often tasked with considering a range of options including “build, buy, or partner” that care managers may not be empowered to explore. Likewise, the project management office offers tools and resources to ensure proper governance if a project ensues and can provide work plan leadership and oversight.

Care managers should also anticipate significant contributions and leadership from postacute care providers in specialty care program development and integration. Prospective partners most likely have existing specialty care programs and can offer compliance expertise specific to the postacute level of care, best practice guidance, and data about their operations. SNFs have long made specialty care investments based on market needs and can likely bring DRG-based information to the conversation for a regional area including patient need forecasts, costs and reimbursement trends, and DRG-based outcomes like length of stay, readmissions, and Medicare Spending Per Beneficiary.

Health systems are pursuing a variety of postacute care, service line, and population health strategies that must be coordinated and prioritized at the enterprise level. Networks evolve and should reflect market needs. Toward this end, care managers can offer expertise, facilitate relationship building, and encourage flexibility in the design of high-performing postacute care partnerships and service lines that are as effective across the continuum as they are within the hospital ecosystem (Table 2). CE1

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References

Arellano, M. 2021. Do Increases in Patient Acuity Present a Problem for SNFs? PointRight. https://pointright.com/increases-in-patient-acuity-aproblem-for-snfs/ Becker’s Hospital Review. 2012 June 14. Structuring Hospital Service Line Management for Success. https://www.beckershospitalreview.com/hospitalkey-specialties/structuring-hospital-service-line-management-for-success. html

Becker’s Hospital Review. 2021 April 30. The rise of home-based care: How Jefferson Health is engaging more patients at scale. https://www.youtube.com/ watch?v=uZBnaq0Kb6Y Blum, K. 2017 May 8. Service Lines Put the Patient First. Johns Hopkins Medicine News & Publications. https://www.hopkinsmedicine.org/news/ articles/service-lines-put-the-patient-first Centers for Medicare and Medicaid Services. 2022 January 18 (Last updated on). Bundled Payments for Care Improvement (BCPI) Initiative: General Information. https://innovation.cms.gov/innovationmodels/bundled-payments Charns MP, Wray NP, Byrne MM, Meterko MM, Parker VA, Pucci LG, Fonseca ML, & Wubbenhorst WH. 2001 April. Service Line Management Evaluation Project Final Report. The Management Decision and Research Center, Houston Center for Quality of Care and Utilization Studies. https://www.research.va.gov/resources/pubs/docs/service_line.pdf continues on page 38