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Care Management as the Essence of Long-Term Services and Supports

by Published On: Jul 27, 2012

KathleenGriffinOne of the most interesting and timely sessions at this April’s PEAK Leadership Summit was a “Learning Circle” presented by Kathleen Griffin, national director, post-acute & senior services for Health Dimensions Group (HDG). HDG is a Minneapolis-based consulting and management services firm that serves hospitals, health systems, and aging-services providers.

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Griffin’s presentation, “Adapting to a Post-Reform Landscape” addressed a variety of topics relating to how aging-services providers can and should position themselves to thrive in the new world created by the Affordable Care Act:

  • Why aging-services providers need to embrace partnerships, networks, technology and risk to thrive in a reformed health system
  • How providers can offer valuable services to accountable care organizations (ACOs)
  • How bundling of payments for hospitalization episodes will affect post-acute and long-term care providers
  • How Medicaid managed care will redefine long-term care

LeadingAge recently interviewed Griffin to learn more about how the changing landscape of health care provision will affect its members.


LeadingAge: Now that the Supreme Court ruling is in, how will it, in broad terms, affect the implementation of the Affordable Care Act? How does it change the landscape?

Kathleen Griffin: The major impact is not on the Medicare side, it’s on the Medicaid side. There are two issues: whether states will proceed with expanding coverage for Medicaid recipients aged 18 to 64, and how successful the employer exchanges will be, considering that many states are upset about how to implement [coverage] without the federal exchanges. There might be fewer Medicaid people aged 18 to 64 covered, and a continued plethora of uninsured.

From the aging-services perspective, neither will have a major impact except [that] individuals in the chronic care categories—who may be using our post-acute services where previously they might have had Medicaid—now will continue to be uninsured. There will be a small impact on [long-term care providers]. There will be a bigger impact on hospitals.

LeadingAge: The paper, “Health Care Trend: Developing ACOs” from the Health Dimensions Group discusses how hospital executives see their roles in creating ACOs, and presents survey data showing that management’s priorities are shifting toward clinical quality and outcomes and preventable readmissions. This brings the role of post-acute providers into the picture. For our members, can you give us a look at ourselves from the perspective of hospital/health system managers? How do they regard post-acute care providers and what do they see as our strengths and weaknesses?

Kathleen Griffin: It varies in various markets. In Oregon, Washington, Arizona, and even in some parts of California, skilled nursing subacute providers are used extensively and lengths of stay are relatively short. Long-term care providers are being used as post-acute venues and most patients end up going home. Some of the more traditional states have not moved to effective use of skilled nursing providers as substitutes for long hospital stays. As a result, in these states, many skilled nursing facilities don’t have 24/7 RNs, just eight-hour RNs, and are relying on LPNs or LVNs [for much of the day], not RNs trained in assessment.

In markets with less sophisticated skilled nursing competencies there is real angst among hospitals to find skilled nursing providers that can take high-acuity patients sooner and handle them effectively.

Most hospitals aren’t in the skilled nursing business and don’t want to be. They have enough on their plates getting ready for new payment issues. The Medicare margins on hospitals continue to erode. Now that insurance companies are creating physician group-driven ACOs, the pressure on hospitals’ pricing and payment will be exacerbated. They are looking for partnerships going beyond hospitalization.

Most hospitals I have worked with do have home health agencies at least, and many have a hospice. Even though the vast majority of home health agencies are owned by proprietary entities, many of the hospital-based home health agencies serve multiple hospitals. Hospitals are pretty comfortable with home health overall. They are comfortable with inpatient rehabilitation facilities, because most are in hospitals. Hospitals also have a level of comfort with long-term acute-care hospitals [LTACHs], even though individual hospitals cannot own an LTACH located within them. But when you get to skilled nursing, that is a totally different business for them; they don’t understand [it]. Most hospitals that have tried to run skilled nursing facilities or units [internally] don’t do well financially.

That’s why when you take a look at the direction hospitals are going in the skilled realm, we see two major thrusts: The most frequently seen initiative is a preferred provider network or continuing care network of skilled nursing [providers] that are geographically compatible with the hospital’s market, have competencies to effectively manage high-acuity patients and are willing to sign affiliation agreements to work with hospitals. We are seeing hospitals sending out RFPs to area skilled nursing facilities.

Hospitals developing continuing care networks of skilled nursing providers are looking for those that can admit and effectively manage difficult-to-place patients and … that allow the hospital to integrate [its] physicians into the facilities for primary care management. Hospitals also are seeking skilled nursing providers that have successful care transitions programs, and acute through post-acute care pathways—processes that create a seamless transition of care for patients.

The second direction for hospital relationships with skilled nursing involves a joint-venture relationship for a purpose-built subacute facility. These are typically 80-ish beds, have private rooms, very high-tech, and really focused on taking short-term post-acute or Medicare managed care patients.

Of those hospitals that do not have skilled nursing facilities and that are actively developing skilled relationships, about 80% are developing continuing care networks, [and] 20% are looking at joint ventures or other options.

How do they view aging-services providers? We are finding that now that we have 153 Medicare ACOs, a shift has begun and hospitals and health systems are becoming very interested in working with post-acute and non-acute providers. I just started working with a health system of four hospitals developing their [ACO] application. In the initial meeting I pointed out that having an effective skilled nursing continuing care network is important when your attributed Medicare lives have an acute care episode. However, to successfully bend the cost curve, ACOs must think beyond episodic care. How do you manage a typical dual-eligible living in the community or in a long-term care facility? How do you manage to avoid the high-cost incidents? It was a shift in thinking for them. They realized the secret to success is not just having a network for post-acute care, but to have a continuing care network for chronic needs of older adults.

This is a great opportunity for a multi-level senior housing provider to create an agreement with an ACO to provide a high-intensity care management program for that stratified group of older adults, and a lower-intensity program for those not so much at risk. Many CCRCs are already doing this: They have a nurse on campus, physicians providing weekly clinics, and, they are providing preventative care management for their residents with chronic care conditions, such as blood sugar checks for diabetics. In other words, many CCRCs already are performing care management for their residents in independent and assisted living.

However, the next step is for the multi-level senior living provider to consider value-based payment strategies to be a preferred provider for ACOs and managed care organizations. Are you willing to take the risk and say “Pay us x dollars per month for this level-of-risk person, we’ll make sure of the following things and take some financial risk for avoidable rehospitalizations”? It’s a pretty exciting opportunity for those CCRCs, especially those already involved in home and community-based services, to be the front-line care manager for older adults. That’s what aging-services providers are all about—care management.

Hospitals haven’t thought about how to manage that population unless they have a Medicare Advantage plan. Now they know they have to be out there managing blood sugar tests on thousands of older adults. Hospitals don’t realize the amount of care management that occurs in our skilled nursing units, in low-income housing, in home and community-based services offerings by aging-services providers. It’s a wonderful opportunity to take on the care management program that aging-services providers are already doing. They are not reinventing the wheel. But for ACOs and health plans it’s a brand-new thing.

Our job is repositioning the whole concept of long-term care from institutional [care] to the full range of long-term care services, both institutional and home and community-based. “Long-term care” isn’t the right term anymore; it’s really care management, particularly chronic care management. Instead of being responsible for 500 people on my campus, now I can do care management for 2,000 people in my community.

LeadingAge: In your presentation at the LeadingAge PEAK Conference you mentioned that insurers are purchasing physician groups and hospitals to form ACOs. Do you see insurers purchasing long-term care assets as well, or are long-term care providers likely to remain independent?

Kathleen Griffin: I haven’t’ seen that kind of activity. It could happen but I see very strong interest among physicians, especially primary care doctors, in being able to have some ownership in a purpose-built subacute facility. Previously they got into the ambulatory surgery area, but that’s built up now. Post-acute care is a new opportunity for them. If you look at how insurance companies are creating their ACOs, [they are] buying physician group practices. Of the 153 Medicare ACOs, half are physician practices. These doctors want to take risk, they are very entrepreneurial, and they want to have control of their destiny and are willing to take risks to get there. We see opportunities for ownership in post-acute arenas, and an interest in insurers [in acquiring] group practices, so it could end up that insurers could want to own post-acute venues because doctor groups are strongly interested.

LeadingAge: In your presentation you also discussed Medicaid managed care and the states that have Medicaid managed care already, or plan to develop it. How did the Supreme Court ruling regarding states’ options in Medicaid expansion change this situation?

Kathleen Griffin: The Supreme Court decision didn't have as big an impact on long-term Medicaid recipients as will the dual-eligible demonstration programs underway in more than 20 states. The dual-eligible state plans I’ve read have a clear direction: Reduce the volume of individuals receiving care in institutional settings.

LeadingAge: You offered some cautions to rural providers, and noted that rural hospitals are aligning themselves with metro systems. What should rural providers be doing?

Kathleen Griffin: Rural providers will be impacted but not immediately. What we see in rural areas is that hospitals are joining in one way or another with metropolitan health systems. It’s hard to run a rural hospital and make money. Joining up to get itinerant physicians, to get IT programs going, even critical-access hospitals are moving into relationships with metropolitan health systems. Rural skilled-nursing providers are somewhat protected from the immediate impact of health care reform, but eventually, even in rural markets, there will be movement to look toward home and community-based services, and continued development of assisted living instead of nursing homes alone.


 

 



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