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Leading Age Magazine

Quality and Innovation: Providers Learn to Work With ACOs

by Gene Mitchell
As “population health management” becomes a growing focus of long-term services and supports for U.S. seniors, providers in our field will be called upon to understand and work in a changing environment. As outlined in our November/December 2014 article, “Population Health Management Comes to Aging Services,” this means a variety of new strategies are being created to manage populations, improve quality and hold down costs.

One of the most well-known approaches is the creation of accountable care organizations (ACOs), which the Centers for Medicare & Medicaid Services define as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.”

The Medicare ACO model created under the Affordable Care Act includes both Pioneer ACOs and Medicare Shared Savings Program ACOs. CMS describes the Pioneer ACO model as one “designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. It will allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program.” There were initially 32 Pioneer ACOs, but attrition has reduced that number to 19.

According to Leavitt Partners Center for Accountable Care Intelligence, states have also created ACO contracts with commercial payers. Leavitt put the total number of ACOs of all types in the U.S. at more than 600 by mid-2014.

A few LeadingAge members, seeing the potential in joining forces with ACOs, have proactively reached out to the latter in their areas. Here is a look at three provider organizations that have taken the plunge, and the lessons they’ve learned.

Services: Helping ACOs Meet Quality Metrics

Hebrew SeniorLife, a Boston-based provider offering a full continuum of care, received a Center for Medicare & Medicaid Innovation (CMMI) grant in 2012 to study ways to lower readmission rates from the post-acute setting, according to Mary Moscato, president of Hebrew SeniorLife Health Care Services and Hebrew Rehabilitation Center.

The grant fueled the organization’s desire to partner with ACOs, and because of its location, it had no shortage of ACOs to talk to.

“The Boston market, which is unique in the health care/academic world, has five Pioneer ACOs,” Moscato says. “That alone gives you a message that this is a market that’s leading the crusade on health care reform.”

Moscato says HSL works with three of them: Beth-Israel Deaconess Care Organization, Partners HealthCare and Atrius Health. The relationships began soon after the ACOs received their “Pioneer” classifications. HSL provides short-term rehab and post-acute care in a variety of settings, and served more than 400 ACO-aligned patients during 2014. Of that group more than 50 Medicare beneficiaries were able to receive services from HSL directly from emergency rooms, hospital observation stays or home, because these Pioneer ACOs received waivers for the three-night hospital stay requirement.

HSL representatives meet quarterly with the ACOs’ representatives to share data on quality, financial issues, readmissions, transitions of care and more. Weekly video conferences enable clinicians to discuss patient care. “With each of the three ACOs we share different information,” says Moscato. “In an ideal world it would be great if we could get together and share similar quality data and metrics information in the same format; the downside is that it’s almost like working with three different organizations; it’s more work for us, but we believe over time there will be consistency.”

LeadingAge e-mag Jan-Feb15 ACO OPRS 2atTable 712w

An OPRS resident meets with a Senior Independence nurse. Senior Independence offers a “Home to Stay” service, a transitional care program for Medicare beneficiaries who leave any of the hospitals served by the ACOs it works with.

Senior Independence, the home health, hospice, home care and adult day division of Ohio Presbyterian Retirement Services (OPRS), has relationships with two ACOs. Senior Independence began working with Northwest Ohio ACO in August 2013. It began its relationship with the other ACO, Mercy Health Select, in September 2014.

Physician-based Northwest Ohio ACO serves about 12,000 Medicare beneficiaries in the Toledo area. When Senior Independence approached it, says Laurence Gumina, president/CEO of OPRS, it made an offer the ACO didn’t expect.

“We told the group, as you’re managing and coordinating care and assuming risk for about 12,000 Medicare beneficiaries in your market, we’d love to provide support staff, regardless of their ability to pay,” says Gumina.

Senior Independence offers a “Home to Stay” service, a transitional care program for Medicare patients who leave any of the eight hospitals served by the ACO but do not qualify for Medicare billable home health episodes.

Senior Independence employees introduce themselves to ACO clients in the hospital and, for those who elect to join the program, provide five interventions in a 30-day period, Gumina says. “The focus is whatever we can do to transition them back home safely, securely, and without coming back to the hospital,” he adds. “We introduce ourselves at bedside, send a nurse back to their home in week one and do a series of checks: medication variance analysis, a fall risk assessment, and we make sure they follow up with their physician.”

A nurse is sent back during the second week and in weeks three through five Senior Independence does telephone check-ins.

Gumina says the costs generated by those participants who can’t pay for the Home to Stay service is offset by increased referrals from hospitalists who now understand what the organization can provide. Gumina cautions that Senior Independence can offer a free care element only because it has a contracted relationship with the ACO, whose waiver guidelines permit it. “You need a contract in place before you offer a free care element,” he says.

He also says the transitional care program shows dramatic results: Northwest Ohio ACO clients (524 people) who participate in Home to Stay had a 30-day re-hospitalization rate of 3.4% during a 15-month period ending in November 2014. Gumina compares that to the regional rate of 14.5% and a national norm of about 20%. He also adds that, according to the ACO, people who refused Home to Stay had a re-hospitalization rate exceeding 50% during that period.

Senior Independence employees introduce themselves to ACO clients in the hospital and, for those who elect to join the program, provide five interventions in a 30-day period. “The focus is whatever we can do to transition them back home safely, securely, and without coming back to the hospital.”

The Senior Independence Toledo office realized a 34% growth in revenue over a 12-month period. The additional volume required an increase in FTEs from the mid-70s to 102, Gumina says.

Senior Independence’s agreement with Mercy Health Select is still in its early stages but the organization expects to provide similar services to an as-yet-undetermined number of people. Gumina credits the Northwest Ohio ACO relationship for helping get the Mercy Health relationship off the ground; three of the eight hospitals involved with the Northwest Ohio ACO are in the Mercy system. He also notes that those three Mercy hospitals all had their own home care agencies, which have now been transitioned over to Senior Independence, the staff becoming Senior Independence employees and working out of the Toledo office.

Western Home Communities, based in Cedar Falls, IA, works with UnityPoint Health Partners, an ACO formed by a group of hospitals, physicians and other providers.

Western Home works with UnityPoint’s Waterloo region, and provides the caregivers for UnityPoint at Home and UnityPoint Hospice. All of the direct caregivers and some of the nurses are Western Home employees.

“The Medicare and Medicaid licensure belongs to UnityPoint at Home and we’re contracted caregivers underneath that,” says Kris Hansen, CEO of Western Home Communities. He says the organization has provided up to 2,200 hours per week of services.

“We knew we needed to be in a relationship,” says Hansen about how Western Home approached UnityPoint. “They wanted a quality partner on the private-duty side. As we started talking about that, it came out that they wanted to be responsible for the nurse side of things and not so much the direct care staff. So instead of outsourcing or insourcing, we co-sourced.’”

What Is the Value Proposition?

For a typically medically oriented accountable care organization, the promise of working with an aging-services provider is the latter’s vast experience in coordinating the needs of the demographics requiring the highest-cost services. In the future, providers hope, that could mean full participation in shared savings or bundled payment plans for long-term services and supports (LTSS) providers.

In the shorter term, relationships between ACOs and LTSS providers can begin with services that help ACOs achieve their quality goals, even if limited to a few.

Hebrew SeniorLife sees its value to ACOs as a matter of improving transitions and managing costs and utilization.

“The transition of care can be one of the most critical components of a patient’s move through the health care system,” says Moscato. HSL works with ACOs to streamline communication, especially in the crucial hand-offs between hospitals and post-acute care. The processes have been checklisted and rely on “nurse-to-nurse and doctor-to-doctor” communication, she says. HSL continues to monitor patients 60 or 90 days after discharge.

Hebrew SeniorLife sees its value to ACOs as a matter of improving transitions and managing costs and utilization. “The transition of care can be one of the most critical components of a patient’s move through the health care system.”

In a presentation at the LeadingAge Annual Meeting and Expo in 2014, Moscato outlined the ACOs’ expectations as including communication upon hospital discharges, early care planning for discharge from post-acute care, a “soft landing” for patients, preventing re-admissions and reducing primary admissions.

Gumina made a point of selling his organization’s experience in home health services: “We introduced ourselves and said, ‘We know you’re assuming risk, and we have 30 years’ experience in providing home health in your market, and we’d love to work with you on making a difference to the community.”

“The key deliverable here is … an innovative care delivery model that we’ve demonstrated significant results with,” says Gumina. As a not-for-profit, he adds, Senior Independence was also willing and able to incorporate the element of free care into its Home to Stay services, something that for-profit providers might shy away from.

Partnership Has Its Privileges

“In my opinion what we’ve done is expand our continuum to branch out throughout the health system,” says Western Home’s Hansen. “Instead of our caregivers only working with seniors, they are taking care of two-week-old preemies, or anyone that is using UnityPoint at Home; it’s our caregivers who are in there. We’re not going away from our senior focus, but at the same time branching out to be part of that total continuum instead of the narrower scope of it.”

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Western Home Communities

atHome with Western Home client Betty McCoy visits with in-home caregiver Laci Tambornino. atHome with Western Home is Western Home Communities’ first partnership with Unity Point Health Partners, an ACO. Western Home provides all of the CNAs for their Medicare home health visits.

Hansen also points to the benefits of continuity of care. “If UnityPoint is there for a Medicare episode and using our caregivers, when that episode is over, if there is still need in that home, our folks can take over on a private-duty basis,” he says. “We can also measure safety and security, and we can deploy different technologies—medication minders or personal emergency responders.”

Moscato says HSL has increased its market share but also adds that working with ACOs keeps the organization forward-thinking. “It is absolutely true that we’ve increased our number of patients served, and we have improved our quality metrics management system. We are proud of our annual surveys and we feel stronger in terms of understanding our patient data, and delivering high-quality care. It’s enhanced our ability to identify research data which allows us the opportunity to take clinical translation to the next level.” (Hebrew SeniorLife does research through The Institute for Aging Research.)

Because many of the people who join Senior Independence’s Home to Stay program upon leaving the hospital remain with the organization, Gumina says, “We have an ability to create a relationship with those we’re serving—and who we’ll eventually serve again. That’s one of the key takeaways: I believe that a successful senior living organization will create opportunities to get to know its residents sooner rather than later. And it’s not only the patient but the family too, so that when, down the road, they need additional care and support in the home they know who to call.”

Preparing to Collaborate

Getting a provider organization ready to work with an ACO is a matter of training, technology and ramping up staff.

“Quality is not negotiable,” says Gumina. “We had to demonstrate quality outcomes to enable to us to get to these tables. Second, we are blessed with a board that allows us to move forward to investigate innovative models of care delivery. It had to be a good cultural fit and our partnership with both parties is. Although this deal was inked in June of 2013, we needed time to ramp up in terms of resources and qualified personnel, because we didn’t want to commit to something we couldn’t deliver on.”

Before the agreement with Northwest Ohio ACO was firmed up, Senior Independence implemented a new EHR from Homecare Homebase, which allows interfacing with hospitals’ databases, and worked with Atlanta-based Premedex, which offers a cloud-based patient engagement platform to interface between different entities’ systems.

In the Toledo region, Senior Independence added more than 30 new staff to facilitate working with the additional clients.

Western Home Communities uses PointClickCare while UnityPoint is using McKesson Homecare Telephony and the health systems are using Epic. One of Hansen’s top priorities now is connecting those to allow real-time information exchange, to end the current need for some information to be transferred by paper.

On the staffing side, Western Home has brought in about 100 new people.

“For us, the ‘eye of the storm’ is our admissions office,” says Moscato. “We really strengthened our admissions team, and added a nurse in the admissions office. That was important, to be able to talk the talk and understand any type of clinical information, clinical equipment needs, secondary co-morbidities, and more.”

Hebrew SeniorLife’s IT staff worked to prepare its electronic health information for sharing (HSL uses the Meditech system), and nurses and physicians needed training in the metrics to be tracked. A new position, care transition coordinator/ACO administrator, was also added.

Hebrew SeniorLife took its ACO relationship a step further by having 16 of its physicians join one of the pioneer ACOs. “We have three primary care practices for our housing sites and they joined the Beth Israel Deaconess Care Organization (BIDCO). We attributed a few hundred residents in our housing sites to BIDCO. Our chief medical officer attends BIDCO’s monthly meetings and serves as one of the practice leaders.”

Those physicians are part of a shared savings plan, but it may be another 10 months before the savings are recognized. HSL paid a one-time fee to BIDCO to have the doctors credentialed. (Because HSL is affiliated with Harvard Medical School its physicians have admission privileges at the Beth Israel Deaconess hospitals.)

So far, HSL has been billing Medicare for their components of care, but in January 2015 the organization was preparing to move into a bundled payment methodology for certain episodes of care. “We’re working with a convener, Remedy Partners, and by the end of January we need to choose our episodes of care,” says Moscato. “This bundled payment plan will test us on our costs and clinical outcomes. We have state data and federal data that demonstrate we’re a lower-cost provider right now in many diagnostic areas.”

Moscato anticipated HSL would choose at least five and as many as 20 different types of care episodes for which it could receive bundled payments.

New Accountable Care Organizations Proposed Rule Includes Possible 3-Day Stay Waiver

On December 8, the Centers for Medicare & Medicaid Services (CMS) released its much anticipated accountable care organizations (ACOs) proposed rule titled “Medicare Program; Medicare Shared Savings Program, Accountable Care Organizations.” Included in this rule are several proposals that could impact the long-term care community. They include: the skilled nursing facility (SNF) three-day stay requirement, waivers for referrals to post-acute care settings, and transitional care management codes (TCM).

The SNF three-day stay rule: CMS believes that under a two-sided performance-based risk ACO model it may be medically appropriate and more efficient for some patients who are in need of skilled nursing or rehabilitation care to have it provided at SNFs without a prior inpatient hospitalization or an inpatient stay that was under three days. They believe a waiver of this requirement could allow ACOs to achieve cost savings and improve care coordination that would incentivize them to participate in the two-sided risk model.

CMS also notes that they believe the greatest savings could be achieved by permitting the elimination, where appropriate, of the entire prior hospital stay and improving quality of care for patients who can receive appropriate care through a direct SNF admission.

Waivers for referrals to post-acute care settings: CMS indicates that some ACOs have informed them that they would like to have the ability to recommend high-quality SNF and home health agency (HHA) providers with whom they have established relationships, rather than presenting all options equally.

Based on this feedback, CMS has proposed allowing ACOs participating in the two-sided risk models under the Shared Savings Program to waive the requirement that a hospital “not specify or otherwise limit the qualified provider which may provide post-hospital home services.” And the portions of the hospital discharge planning conditions of participation that implements this requirement. CMS also acknowledges that if they were to implement this waiver that it would be a very narrow waiver.

Waiver to the homebound requirement under the home health benefit: Under the waiver, CMS would permit an ACO beneficiary to have home health care visits from approved home health agencies, even if the beneficiary is not considered home-bound, providing it is determined that the home health services will minimize unnecessary hospital admissions and readmissions. CMS is also requesting comments on whether or not the home health agency should be required to be an ACO provider/supplier.

See a much more detailed description of the proposed rule here. CMS invites comments on all three issues, due to CMS by close of business on February 6, 2015.

LeadingAge is reviewing the proposed rule for comments and will update members as new information becomes available.


Preparing for the Future

What lessons have these providers learned after putting their toes into the ACO waters?

For HSL’s Moscato, before entering a relationship an organization must ask itself hard questions.

“Do you want to be an innovator? Do you have that in your blood?” says Moscato. “Second, if you do want to be an innovator, what’s your infrastructure? Can you support innovation, will your board, your medical staff, your affiliates support that, from quality metrics to data collection to clinician training?”

“We need to start the relationships early on with those we’re serving, and be proactive in terms of reaching out to partners, either from a provider perspective or from a payer perspective,” says Gumina. “From a hospital perspective, there’s significant value in partnering with a LeadingAge member who has that demonstrated commitment to home and community-based services. We’ve done a good job in our field in caring for older adults, and it’s a very exciting opportunity to see all the silos crumbling.”

“They [providers] really need to develop their resumes,” says Hansen, “and help [ACOs] understand what we can do. They don’t understand our world; they are starting to but are measuring it from metrics that are pretty defined: our quality measures, our Five-Star, our readmissions [rates]. They don’t really know who we are and that we’ve been in the continuum of care for a long time, and that we can fill quite a bit of that continuum they’re trying to create.”

Hansen describes the ACO model as transitional. “There’s only so much savings to milk out of this and then we’re down to costs,” he says. “We’ve got to be left standing at the end of this, and what is that margin we need to be sustainable and stable so we can reinvest in ourselves? As not-for-profits we’ve been the ones that have proven that for a long time. We haven’t amassed great big balance sheets because we’ve been very cost-effective and good stewards. Some providers don’t have the resources to reposition themselves and we’ve got to put together some ways to [do that].”

“We have to be around to help create that sustainable model at the end of the day.”