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Center Connects the Dots from Hospital to Home or Post-Acute Care
The post-acute care continuum traditionally has been structured in silos, with each service run as a separate entity and little communication between hospitals and skilled nursing facilities (SNFs), hospice, home healthcare and others.
As healthcare moves from a focus on volume to one of value, the approach to post-acute care (PAC) needs to change, says Eiran Z. Gorodeski, MD, MPH, FACC. In response to that need, Cleveland Clinic opened its Center for Connected Care early 2013, says Dr. Gorodeski, who is Director of the Center.
“The goal of our Center for Connected Care is to keep our patients connected to the highest quality of care as they transition from the hospital to home or a post-acute care facility,” Dr. Gorodeski explains. The Center, which includes more than 500 multispecialty caregivers providing daily care to approximately 3,500 patients, brings together all of Cleveland Clinic’s home and transitional care services, such as:
- home care
- mobile primary-care physician group practice
- home infusion pharmacy
- home respiratory therapy
- facility-based physician group practices —clinical staff are embedded at eight area SNFs
- home palliative medicine and
- emerging transitional care programs.
“Value-based healthcare is exciting because this is a brave new world where post-acute care is more important than ever,” Dr. Gorodeski says. “The way we view post-acute care within the Center for Connected Care is at a high level. We’re interested in bringing together the entire menu of PAC for patients in a holistic and integrated way.”
He adds: “Through our Center, we strive to provide a full continuum of care so that patients can recover from illnesses or injuries in the best location for their individual needs, with Cleveland Clinic caregivers at their side.”
Helping patients through the PAC maze
Traditionally, when patients leave the hospital, they “enter a complex and potentially dangerous maze,” Dr. Gorodeski says. For example, a hospitalized patient may be discharged to a SNF for short-term care, then to home with home healthcare, only to be readmitted to the hospital and discharged again — this time to long-term acute care (LTAC) — and ultimately into hospice.
“The patient in this example just experienced five different venues and services along the post-acute care continuum, and what happens during that time can be highly variable — the quality of care, how the entities communicate, and the cost,” he says.
The Center for Connected Care’s goal is to reduce variability through an integrated, standardized approach — and to carefully guide the patient through the PAC maze. “We’re striving to coordinating care in a seamless manner, to achieve better outcomes, increase patient satisfaction and reduce costs,” Dr. Gorodeski says. “We’ve thought carefully about how the dots are connected and how they work together in order to develop this progressive model for post-acute care. Within the center, the leaders of each of the PAC areas work together on a daily basis to ensure continuity and integration.” He adds: “It’s important to innovate and operationalize care as the healthcare system changes and to stay a step ahead. There’s no book you can read to tell you what the post-acute care continuum will look like tomorrow, let alone in the next 10 years.”
Improving quality while reducing costs
While quality of care is always the highest priority, providers operating in an environment in which reimbursement mechanisms for PAC are eroding must be more cognizant than ever of cost considerations.“In today’s value-based healthcare environment, where we follow patients indefinitely with the goal of reducing costs during their entire lives, metrics such as hospital utilization rates and the cost of post-acute care are more important than ever,” Dr. Gorodeski says.
Traditional home healthcare reimbursement rates are dropping and hospice requirements are tightening, he says. “We now have a huge opportunity to standardize post-acute care, demonstrate better outcomes for populations, reduce costs, and achieve a financial win while also improving quality.”
Pilot Program Guides Patients to Higher Value SNFs
Deficiencies in the quality of care frequently occur due to fragmentation, and the transition from hospitalization to post-acute care (PAC) is often a major factor, says Nirav Vakharia, MD, of Cleveland Clinic’s Quality and Patient Safety Institute.
“Cleveland Clinic’s Center for Connected Care adds a bridge into the post-acute care world where there’s never been a connection before,” says Dr. Vakharia, who is board-certified in internal medicine.
When a patient needs a skilled nursing facility (SNF) following discharge, a smooth transition and coordinated care help ensure quality, he says.
The Center for Connected Care’s PAC program includes two innovative initiatives with a special focus on SNFs:
SNF Connected Care Program: Cleveland Clinic now has affiliations with eight different SNFs in the region, all privately owned, where Cleveland Clinic physicians and nurses are embedded. Within this network of SNFs, the clinicians see patients on a daily basis and document their care in the health system’s electronic medical record system (EMR), which keeps their primary care physicians, specialists and surgeons updated on their conditions.
“Continuing the care of our patients outside of our facilities is yet another way to ensure continuity and quality,” says Eiran Z. Gorodeski, MD, MPH, FACC. “This new model is already helping to significantly lower readmission rates and length of stay in SNFs.”
The Cleveland Clinic staff and SNF operators belong to joint quality councils that meet regularly and are constantly striving to move the needle on quality, Dr. Vakharia says. “They are making a difference and they are ensuring that patients get the right care at the right place at the right time.”
Pilot program to drive patients to higher-quality SNFs: Historically, when a patient is discharged from the hospital and in need of a SNF, a case manager provides the patient and their family with a long list of facilities based primarily on geography.
“Basically, it’s a laundry list based on zip code,” Dr. Vakharia says. “We realized that patients needed guidance in addition to geography — specifically as related to the quality of the facilities and their ability to meet the patient’s individual needs.”
As a result, the Quality and Patient Safety Institute and Center for Connected Care launched a pilot program in July focused on guiding patients to higher-quality SNFs and tracking related metrics. The SNF information provided to patients and families is now much more comprehensive: It includes quality measures based on Medicare’s 5-star quality ranking system, as well as details on specialized services such as orthopedic rehabilitation or post-stroke care.
“We’re assessing the proportion of patients who go to higher-value SNFs and tying outcomes to where they go,” Dr. Gorodeski says. “The pilot is still underway, but we are already seeing fewer readmissions and better outcomes in patients who go to the higher value SNFs.”
Specifically, the pilot is assessing patient outcomes as related to the Medicare quality rating of each SNF (4- or 5-star vs 3 stars or below), with additional analyses based on whether the patient selects one of the eight Connected Care facilities -- all of which have 4-star or above ratings.
“We believe that by giving patients access to this information on SNF quality and specialized services, they will be able to make more informed decisions,” Dr. Vakharia says. “This will smooth the care from the hospital to the SNF and increases the likelihood that patients will be able to remain in the facility without a worsening of their condition and an unplanned return to the hospital.”
The Center for Connected Care is developing tools to help educate patients about their options for high-quality Skilled Nursing Facility care. These tools will give patients access to an online library of more than 15,000 SNFs with information about Medicare’s Nursing Home star rating while highlighting the SNF Connected Care sites. The SNF star ratings included in the database are updated monthly based on the Centers for Medicare & Medicaid Services (CMS) information on the Skilled Nursing Home Compare website, www.medicare.gov/nursinghomecompare/search.html.
Bundled Care for Orthopedic Surgery Could Mean Lower Costs, Higher Satisfaction
There’s a lot of room to improve upon Medicare’s fee-for-service system of payment for total hip and knee replacements, says Mark Froimson, MD, MBA, orthopedic surgeon and former president of Euclid Hospital, one of the key drivers of the Bundled Payment for Care Improvement (BPCI) pilot with CMS for total knee and hip replacement at Euclid Hospital. In his role, Dr. Froimsom led the development, implementation and ongoing operation of a program that has realized improved clinical and financial outcomes of care.
“The current system emphasizes episodic, fragmented care and doesn’t include the right incentives to optimize resource utilization or to improve outcomes and patient satisfaction,” he says.
That’s why Cleveland Clinic’s Euclid Hospital is participating in a Centers for Medicare & Medicaid (CMS) pilot project called the “Bundled Payments for Care Improvement,” which pays a set fee for total hip and knee replacements for Medicare patients as an alternative to fee-for-service. The pilot, which bundles payments for acute and post-acute care (PAC), is part of a provision under the Affordable Care Act (ACA) that created the Center for Medicare and Medicaid Innovation to develop ways of improving Medicare.
Cleveland Clinic is ranked as one of the nation's top hospitals by U.S. News & World Report.
Doing what’s best for patients
“Medicare developed this program to help change the way that incentives align with what’s best for patients,” Dr. Froimson says. “We’re doing it because it’s the right thing for patients.”
The partnership between the Orthopedic & Rheumatologic Institute and the Center for Connected Care, which emphasizes continuity along the PAC continuum, has ideally positioned Cleveland Clinic for the pilot. “A total joint replacement should be viewed as an entire episode and a complete experience, from the initiation of care all the way through complete recovery,” he says. “We call our program ‘complete care,’ which means that we are making a promise to patients that we’re going to stand with them as partners during the entire process.”
Bundled payments work in part by aligning incentives for providers — hospitals, PAC providers, physicians and other practitioners — allowing them to work closely together across all specialties and settings. “This payment structure rewards the quality of care furnished rather than the quantity of services,” Dr. Froimson says.
Cleveland Clinic began participating in the three-year bundled care pilot in October 2013 and is already seeing significant improvements in:
- PAC facility utilization —75% of patients (vs 39% at baseline) now go home with home healthcare/physical therapy (PT) rather than to SNF or rehab;
- Cost of care — the total cost of acute and PAC has decreased by 10% compared with episodic, fee-for-service care;
- Readmission rates and patient satisfaction — readmission rates have decreased by 3.4% and patient satisfaction scores (HCAHPS) have improved and are nearing the 90th percentile;
- Lengths of stay (LOS) — the three-day LOS requirement prior to SNF admission is waived for the pilot, and hospital LOS has decreased from 3.4 days to 2.6 days; in addition, when patients are admitted to SNFs for rehabilitation, their LOS also has significantly decreased.
The increase in patient satisfaction while cost drivers decrease is no coincidence, Dr. Froimson says. “Our mantra is that patient engagement and quality improvement drive cost savings,” he explains. “Patients don’t want unnecessary care. They don’t want to be away from home longer than needed. They don’t want unnecessary days in the hospital. An engaged and well-informed patient is our best asset.”
The importance of PAC
The partnership between the Orthopedic & Rheumatologic Institute and the Center for Connected Care has provided valuable perspectives and resources when determining the appropriate PAC venue and care level for Medicare patients discharged from the hospital following total joint replacements.
“We worked with Connected Care to identify protocols that would allow us to send patients home with home healthcare who would have otherwise been using rehabilitation centers or skilled nursing,” Dr. Froimson says. “Our partnership with Connected Care has helped make the reduction in SNF/rehab facility utilization possible, because we know they are going to stand side-by-side with us and our patients to ensure they receive the appropriate level of care.”
Patients are carefully screened to determine if they should go directly home or to a SNF/rehab facility following discharge, says Renee Coughlin, PT, DPT, MHS, Director, Rehabilitation Services, Cleveland Clinic Home Care, part of the Center for Connected Care.
“We need to determine who will be most successful going directly home,” she says. “We take into consideration their age, who is home with them to help, what their home environment looks like — is it a ranch or Colonial, is the bathroom upstairs or downstairs — and other factors.”
In the past, patients who are now able to go directly home and receive PT and home care might have gone to a SNF and experienced varying lengths of stay, and then they would have been discharged with home care.
“Connected Care is focused on making sure patients are safe and that they go home once they are strong enough and ready,” Coughlin says. “Sometimes that is when they are discharged from the hospital, or it may be after 6 or 7 days in a SNF or rehabilitation facility. The SNF and rehabilitation facility stays are more costly to the healthcare system than care that is provided in the home.”
She adds: “In order to appropriately allocate our healthcare resources, the Orthopedic & Rheumatologic Institute has developed a total knee and total hip replacement care path that incorporates best evidence care with the right care, right amount of care, provided in the best setting for the patients.”
Getting home sooner
Coughlin notes that going home as soon as the patient is ready offers a number of benefits while also containing costs. “Patients tend to be more active at home,” she says. Recovery following joint replacement surgery is enhanced when patients are more active, walking and doing their exercises frequently. Inactivity may increase the risk for rehospitalization, and in a congregate environment such as a SNF, patients may be at a higher risk for exposure to infection.
In addition to its two Cleveland Clinic-run, hospital-based SNFs, the Center for Connected Care partners with eight community-based SNFs. Cleveland Clinic physicians and nurse practitioners are embedded at these SNFs and see patients regularly to monitor their status and recommend discharge as soon as appropriate and safe. “If we can keep the recovery process moving in the right direction and return them to their home environment sooner, they are better off in the long run,” Coughlin says.
Home care led by physical therapists
PTs lead the home care teams for joint replacement patients, while also keeping surgical teams and medical providers updated on the patient’s condition via email through Cleveland Clinic’s electronic medical record (EMR) system. All patients are seen in the home within 24 hours of discharge. The average number of home visits is eight, with “proactive transitioning to outpatient status as soon as the patient is able,” Coughlin says. “Connected Care providers transition patients to the Cleveland Clinic outpatient rehabilitation therapy team in a timely manner, ensuring that they are able to do so without going on a waiting list.”
Connected Care’s home health team serves 14 counties in Ohio, and Cleveland Clinic has more than 100 PTs and PT assistants on staff.
Shared cost savings
Medicare’s bundled payment program approach is based on the premise that if healthcare providers can decrease the cost of care for specific procedures while maintaining or improving quality, providers share the financial benefits.
“Medicare looks at a specific type of problem or procedure and uses their data to calculate how many resources were used and how much they paid for it historically,” Dr. Froimson says. The allowable expense for the bundled care is 97% of that total, giving Medicare an automatic 3% cost savings. If the provider can deliver the care for less through better resource utilization, the cost savings are passed on to the provider.
“At the same time, it works the other way,” he says. “If we participate in the next phase of the pilot and we deliver care at exactly the same price as before, we lose 3% of our previous revenue.”
Cleveland Clinic is still in phase 1 of the pilot, which is a data collection and reporting phase with no financial implications. A decision will be made in January 2015 about whether the health system will move on to the “at-risk” phase, in which financial savings could be realized.
The bundled payment approach has the potential for broad applicability. “There are 47 additional episodes where we feel this can be effective, including cardiac, pulmonary and medical care and procedures,” Dr. Froimson says.
“The pilot requires submitting a plan of care to Medicare outlining what the care redesign is going to look like,” he says. “This is a quality improvement initiative and not just a cost savings one.” Visit Center for Connected Care website for more information or to refer a patient. Renee Coughlin can be reached at firstname.lastname@example.org or 216.636.8618.
Palliative, Hospice Services Provide Continuity of Care, Put 'Patients First'
The Center for Connected Care’s mission is to keep patients connected to the highest quality of care and to be by their side “the whole way” — including end-of-life care, says Terence Gutgsell, MD, Medical Director of Connected Care’s Hospice and Palliative Medicine programs.
The Center for Connected Care offers a variety of services that put “Patients First” based on their evolving needs on the post-acute care (PAC) continuum, while offering continuity of care. Patients are carefully assessed to determine if they are candidates for:
- the Palliative Medicine at Home program
- the Hospice at Home program, or
- the newly launched Inpatient Hospice Service at Cleveland Clinic’s main campus.
Cleveland Clinic’s commitment in this area dates back to the creation of its Palliative Medicine Program in 1986 by Dr. T. Declan Walsh, the launch of Hospice of Cleveland Clinic in 1990, and the opening of the Harry R. Horvitz Center for Palliative Care in 1994. While the Palliative Medicine Program remains a separate entity, the Palliative Medicine at Home and hospice services were a natural fit to include within with the Center for Connected Care when it was formed last year, Dr. Gutgsell says.
Bridging patient needs
“These programs serve as a bridge between the hospital and the home setting based on the patient’s evolving needs,” he explains. “A patient who is discharged from the hospital who needs Palliative Care at Home may not be hospice-eligible but may be moving in that direction or may have a condition such as congestive heart failure, severe stroke or dementia that need to be actively managed.”
Connected Care’s four hospice and palliative medicine physicians and two certified nurse practitioners manage the care for these patients, keeping their medical information updated in the electronic medical record (EMR) system and ensuring that the patients’ entire care team is kept current. If the patient’s status changes, so can the level of care.
“If the patient stabilizes and no longer requires palliative care but is homebound, they are referred to Connected Care’s Medical Care at Home visiting physician service,” Dr. Gutgsell says. “On the other hand, if the patient’s condition worsens, the physician can make the referral for Hospice at Home, and the same physician can continue to follow the patient under the hospice benefit.”
He adds: “This provides excellent continuity of care. The EMR is the cement that holds everything in place, making communication among the patients’ physicians and caregivers very easy.”
Active physician care
Active physician involvement is a key to the success of the Palliative Medicine and Hospice at Home programs. “We ensure that our doctors see a new patient to whom they are assigned within 7 to 10 days of admission into the program,” Dr. Gutgsell says. “Physician visits are part of the standard of care early on.”
The physicians also make home visits for symptoms that are not well controlled, at the request of the patient, family or hospice nurse, or due to issues raised at an interdisciplinary team meeting. “Our doctors are not just in team meetings and fielding phone calls — they are very active in the care of the patients,” Dr. Gutgsell says.
‘At Home’ programs
The Palliative Medicine at Home and Hospice at Home programs focus not only on continuity of care and care coordination, but also system integration and delivery. These “at home” services can be provided in the patient’s home, or anywhere the patient is — hospital, clinic, long-term care/skilled nursing facilities, and long-term acute care (LTAC).
Patients are typically referred to these programs following a palliative medicine consultation at one of Cleveland Clinic’s hospitals, or through the Medical Care at Home’s physician group. In addition, a computerized algorithm analyzes patient records, and when patients are identified in the EMR system who could benefit from these services, a letter is sent to the their PCP. Additionally, any physician in the area can refer patients to these programs at any time.
Coordination of care
Every two weeks, the hospice teams participate in an interdisciplinary team meeting at which the entire patient population is discussed. “Typically the team included two nurses who are managing 10-12 patients at any one time, a social worker, a nurse manager, a chaplain, the director for volunteer services, and if possible, a nurse assistant,” Dr. Gutgsell says. “They discuss how each patient is doing, if their medications are appropriate, if they have all of the equipment that is needed, and if their psychosocial and spiritual needs are being met.”
The team also periodically recertifies patients as being hospice eligible, as appropriate. With a number of diagnoses — such as adult failure to thrive and general disability — now removed from hospice eligibility by government insurers, the team must carefully monitor patients’ conditions.
“If the patient stabilizes, there can be some pressure to disenroll them from hospice,” Dr. Gutgsell says. “They could then potentially be eligible for the Palliative Medicine at Home Program. Their condition is then closely monitored, and if there is evidence of functional decline or decline with illness, they can be re-enrolled in hospice, all with ongoing continuity of care.”
New launch: Inpatient hospice service
Death is part of patient care at any major medical institution, and at Cleveland Clinic, more than 1,400 patient deaths occur at the health system’s main campus each year — an average of more than 4 deaths per day. To better serve these patients and their families, Connected Care recently launched an inpatient hospice service.
“We will now have a hospice physician on main campus seven days a week who will be working with patients that are being transitioned while in the hospital onto the hospice benefit and who will likely be dying in the hospital,” Dr. Gutgsell says. A full-time hospice and palliative care physician has been hired for the Inpatient Hospice Service. Patients will be cared for “where they are” in the hospital, with the exception of patients removed from life support while in the ICU, who would likely be moved to the Palliative Care Unit.
“The physician will visit the inpatient hospice patients every day while they are in the hospital to ensure excellent symptom management,” Dr. Gutgsell says. Patients who survive their hospital stay would be transitioned to Hospice at Home with a coordinated care plan.
As with the Hospice at Home patients, patients who are receiving inpatient hospice services will benefit from oversight by an interdisciplinary care team — physicians, nurses, and social workers, with a chaplain available to the patient and family.
Dr. Gutgsell says: “We established this program to add value to our program and to support patients and their families no matter their location.”
Dr. Gutgsell can be reached at email@example.com or 216.444.4452. To refer a patient to Hospice at Home or Palliative Medicine at Home, please call 216.444.HOME (4663) or 800.263.0403.