Achieving Return on Specialty Investment

Post-Acute Care Collaborative

Enhancing Post-Acute Providers' Core Value Proposition Through Specialization

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Executive Summary ...... 5 Introduction: Sizing the Gap to Goal ...... 7 Chapter 1: Maximize Volume-Driven Specialty Reimbursement...... 13 Chapter 2: Strengthen the Specialty’s Value-Based Appeal...... 23 Chapter 3: Leverage Existing Specialty Expertise to Access New Revenue Streams...... 35

The Post-Acute Care Collaborative has developed numerous resources to assist program leaders in securing Strategic Guidance for Securing Market-Specific long-term growth and market share. Hospital Partnerships Data and Analytics The most relevant resources are outlined here to supplement this Hardwiring Cross-Provider Care Transitions Mapping Tool publication. All of these resources are Collaboration available in unlimited quantities The Care Transitions Mapping Tool provides • Understanding new demands acute insights on patient movement between acute through the Post-Acute Care care providers are placing on and post-acute providers within 30 days of Collaborative membership. post-acute partners discharge from the acute care setting. Providers can use this data to better • Models for post-acute involvement in patient-centered medical homes understand relationships between acute and post-acute care partners, and understand • Integrating with home and opportunities to forge new partnerships that community-based services improve outcomes and reduce cost of care.

Next-Generation Partnership SNF Benchmark Generator Strategy The Skilled Nursing Facility Benchmark • Honing outreach messaging and Generator provides Medicare benchmarks so organizational value proposition you can compare your performance to your peers across an array of financial and • Improving clinical collaboration with acute care hospitals utilization benchmarks. Providers can customize a cohort to compare their own • Serving as the care manager for performance to others in the same market or to at-risk populations SNFs with similar characteristics in other markets.

To Order Publications To Access Data and Analytic Tools To order copies of these and other Post-Acute To access these and other Post-Acute Care Collaborative presentations, please visit Care Collaborative tools, please visit advisory.com or contact your Dedicated Advisor. advisory.com.

Recent market developments—such as growing inter-sector competition, the possibility of site-neutral payments, and increasingly narrowed networks—encourage post-acute care (PAC) providers to better define and promote their value proposition as a means of differentiation. These developments simultaneously offer new and exciting chances for PAC organizations to expand their roles in the care continuum and serve new patient groups. One strategy to both guard against current threats and take advantage of future opportunities created by a marketplace in transition is clinical specialization. Because of the unique nature of their patient populations, many PAC providers already consider themselves specialists. However, there is still significant space for PAC providers to move further into creating well-defined, high-quality clinical service lines. Embracing specialization allows providers to present a clear value proposition that can safeguard volumes by capitalizing on emerging health system needs and preferences. In order to achieve success, a specialty must represent a cohesive business venture, rather than simply a marketing endeavor. It requires significant investment and organizational commitment. Building and sustaining a strong specialty over time means allocating dedicated resources to treating a specific patient population and driving to a high level of clinical quality, ensuring the specialty is different from and clearly, unquestionably better than competitors’ offerings. There are many benefits to a well-run specialty line. A strong clinical specialty can: • Drive volumes to a provider by generating interest in the market among a wide variety of stakeholders—including case managers and patients. • Solidify partnerships with referrers and payers taking on risk by achieving a high level of clinical quality and operational efficiency. • Enable a provider to access new revenue streams by leveraging knowledge gained through practicing the specialty to form new business relationships. This book offers 10 tactics to help providers build and support specialty lines that deliver those benefits—enabling them to achieve full return on specialty investment, and successfully position themselves within the market.

Source: Post-Acute Care Collaborative interviews and analysis.

Sizing the Gap to Goal

The post-acute industry has increasingly turned to specialization as a solution to the commoditization of post-acute services by referrers Specialties Prevalent Across the Post-Acute Care Industry1 and payers.

Specialties are overwhelmingly common with 94% of providers offering 94% 33% 78% Post-acute providers with Post-acute providers with Post-acute providers planning at least one specialty. However, only at least one specialty four or more specialties to add more specialties in the 56% of providers are satisfied with the coming year ROI they have seen from their specialty—a disappointing figure.

One critical reason for that dissatisfaction is a lack of organizational commitment to true Opinions of Specialty ROI Lukewarm… …With Programmatic Investments Lacking specialization. Despite claiming to have Percentage of Organizations Satisfied or Percentage of Organizations That Made No added a new specialty line, over 60% Very Satisfied with Their Specialty’s ROI Organizational Structure Changes in of providers reported no operational n=59 Support of Their Specialty changes to support the program. 100% n=127 Post-Acute Care Collaborative Gap to full interviews confirm this lack of satisfaction investment and highlight the truth that with specialty specialty development is commonly a 56% marketing initiative, rather than a Made No 62% clinical enhancement. Changes

Actual Potential Satisfaction Satisfaction

1) All data on this page is from a survey of Post-Acute Care Collaborative members conducted in the summer of 2014. Source: Post-Acute Care Collaborative interviews and analysis.

Organizations commonly promote specialization not worthy of the term. Krupke House Nursing Center’s1 Homepage The website shown to the right is fictional, but representative of many post-acute and long-term care providers’ home pages. The specialties are commonly offered services, while the accolades are unsubstantiated. The Meaningless, fictional organization shown, like many Sector definition unsubstantiated real providers, believes that marketing misrepresented “Center of materials can sufficiently differentiate as a specialty Excellence” themselves from their competitors. designation

However, as nearly all post-acute organizations claim specialized Listed “specialties” services, such proclamations have are simply the services offered by limited impact in the market. If the facility everyone is special, no one is; when all organizations claim specialization, these offerings become commoditized.

Referrers increasingly recognize the gap between a post-acute providers’ marketing efforts and their clinical capabilities. To achieve competitive

differentiation and increase referrals COMPANY. BOARD ADVISORY CREDIT: THE IMAGE through specialization PAC organizations must ensure their specialties are truly special.

“I’m skeptical of providers who come to us saying they have this great heart failure program or great program XYZ… it seems to me more of a marketing ploy rather than a true clinical model.” Director of Post-Acute Integration Large Acute Care Health System

1) Composite. Source: Post-Acute Care Collaborative interviews and analysis.

To derive value from specialization, it must represent a cohesive, comprehensive clinical strategy with significant support behind it. A What Is Specialization? complete definition of true Specialization is a business philosophy wherein the organization makes conscious, specialization is shown to the right. principled decisions to focus on specific patient groups and creates dedicated, The concept of specialization is based distinct clinical programs to serve those patients. on specialties, or clinical programs. Each of those programs must have all four of the components shown.

A true specialty is a program the Key Components of a Specialty organization supports at all levels with necessary resources committed. It is highly distinct from other offerings in Organizational Dedicated Differentiated Clinical the market, both because it is unique Commitment Resources Offerings Excellence and because it demonstrates excellent clinical care and outcomes.

• Executives, • Distinct staff, • Specialty stands out • Staff and leaders leadership, and leadership, and/or and is sufficiently committed to clinicians visibly equipment dedicated different from delivering excellent support specialty to the specialty competitors’ offerings clinical outcomes

• Specialty program is • Additional investments • Specialty performance • Ongoing staff a key organizational in staffing, training, is demonstrably education and strategic priority and technology made superior to competitors, protocol development as necessary or is unique in the supports quality market

Source: Post-Acute Care Collaborative interviews and analysis.

Although the requirements for true Range of Specialization Options specialization are the same across all organizations, not all successful Non- specialties look alike. A wide variety of Diagnostic Suite of high- acuity services specialty types exist—all of which can drive ROI for the organization when properly operated. Impairment-based The most common option for Focus of clinical programs specialization is to focus on one or Specialization more diagnoses, though it’s not the only option. Providers can also choose to specialize in treating select Exclusive focus Traditional View impairments or even patient groups, on one diagnosis DRG-specific such as exceptionally high-acuity DRG-Based service line patients or patients of a narrow age group, depending on the post-acute Generalist Exclusive Specialist provider’s sector and market needs. Intensity of Specialization

The table on the right demonstrates Representative Specialty Programs in Brief how varying specialty types can Organizational Dedicated Differentiated Clinical demonstrate the four key requirements Commitment Resources Offerings Excellence for specialty program development. Craig Hospital (Exclusive Only accepts patients with All resources Nationally 95% of patients with This book will feature a wide variety of Diagnostic) traumatic brain or spinal cord solely known for TBI1 complete paraplegia specialties, all of which meet this injury dedicated to and spinal cord discharged directly specialty injury care home2 benchmark. Sheltering Arms Heavily involved frontline Large Only IRF in 27% greater (Impairment-Based) therapists in specialty care investment in region to focus increase in FIM protocol design, specialty- on impairment, walk scores3 than implementation specific not condition regional average equipment Susquehanna Health Partnered with external 12-bed unit just Only SNF in 0% 30-day all cause Skilled Nursing vendor to operate specialty for ventilated region capable readmission rate and Rehabilitation Center program when in-system patients of handling vent (High-Acuity) resources proved unavailable weaning

1) Traumatic brain injury. 2) National Institute on Disability and Rehabilitation Research, 2009-2013 discharges. 3) As measured at admission and discharge. Source: Post-Acute Care Collaborative interviews and analysis.

Specialization is not an end in itself; it Ten Tactics to Ensure Return on Specialty Investment is a means to enhance patient care and secure a critical place in the market. Program development should enable strong partnerships with referral sources, driving volume growth and inclusion in narrowing referral 1 2 3 networks. Concurrently, a strong specialty enables the organization to Maximize Volume-Driven Strengthen the Specialty’s Leverage Existing Specialty explore new business opportunities Specialty Reimbursement Value-Based Appeal Expertise to Access New amid continuing payment Revenue Streams transformation.

This book provides 10 tactics to ensure 1. Solidify Volumes 4. Address Referrer 7. Recapture Lost successful return on specialty Through Program Cost of Care Priorities Volumes by investment across three vectors. First, Expansion into New Co-Development 5. Implement Staff- Sectors driving volumes and reimbursement in 2. Harness Specialty Driven Care Protocols the current, fee-for-service 8. Fill Downstream Spillover Volumes 6. Support Generalist environment. Second, making the Service Gaps 3. Capitalize on Unique Staff with Specialist organization attractive to referrers who Payment System Experts 9. Productize Specialty are taking on downside risk, improving Opportunities Knowledge the likelihood of network inclusion. Finally, utilizing specialty program 10. Realign Traditional development to access new revenue Competencies into Novel Programs streams—often beyond the traditional payment structures of each post-acute sector.

Source: Post-Acute Care Collaborative interviews and analysis.

Tactic #1. Solidify Volumes Through Program Co-Development Tactic #2. Harness Specialty Spillover Volumes Tactic #3. Capitalize on Unique Payment System Opportunities

Organizations commonly pursue specialization to drive volumes and bolster reimbursement.

As such, specialty lines are often Specialty Development Missing Key Information chosen based on referrer interest. However, choosing a specialty based on referrers’ expressed concerns does not guarantee an influx of volumes. Example A: The referrer’s request for additional Hospital Request PAC Provider Response Overall LVAD volumes are very low, hospital support with a patient type does not SNF that can accept Invests in additional staff, interest stemmed from convey the full scope of the challenge LVAD1 patients training, equipment to build just two cases they are attempting to solve with the LVAD line specialty line.

For example, hospital referrers may request a specialty line for a specific Result: volumes too low to recoup investment costs type of hard-to-place patient not because those patients represent a consistent, long-term priority, but because the hospital has recently seen an unusual concentration of those Example B: Competitor working patients. Hospital Request PAC Provider Response with health system As a result, post-acute providers must LTACH able to handle Hires specialized RNs to psychiatrist to offer conduct their due diligence prior to complex behavioral offer behavioral health behavioral health line health patients services investing in a new clinical specialty.

Result: low referrals; behavioral health nurses assigned to treat general LTACH patients, leading to turnover

1) Left Ventricular Assist Device. Source: Post-Acute Care Collaborative interviews and analysis.

Therefore, referrers’ needs and preferences should be combined with a variety of inputs and considerations Key Considerations for Specialty Selection when analyzing potential investment opportunities. A rigorous and holistic 1 2 3 z process is the precursor to long-term Current State Mission and Values Market Conditions specialty program sustainability. • What services do I • What is my organization’s • What (if any) diagnoses currently offer? mission? are especially prevalent Shown here are select questions post- • What resources do I have • Am I committed to in my market? acute providers should ask themselves available to dedicate to a serving specific patient • What (if any) functional when selecting a specialty for their specialty? groups (e.g., pediatrics, impairments do I see organization. • What is my sector’s geriatrics)? more than others? regulatory environment?

4 5 Referrer Priorities Competition • Who are my primary • What is my competitive referrers? landscape? • What (if any) are my • What (if any) specific referrers’ specialty populations or priorities? comorbidities do my competitors struggle to • Do I need to appeal handle? directly to consumers?

For More Information For additional guidance on weighing these questions in the context of a specific organization, see the Post-Acute Care Collaborative’s “Specialty Decision Aid,” which can be found on advisory.com.

Source: Post-Acute Care Collaborative interviews and analysis.

Lutheran Homes of South Carolina saw Palmetto Health and Lutheran Homes Partner for High-Acuity Patients an opportunity to leverage specialization to strengthen partnership Palmetto Health System Lutheran Homes of South Carolina with and drive referrals from their primary referrer, Palmetto Health. • Struggled to place high-acuity Medicaid • Saw chance to work closely with During conversations with Lutheran patients, creating a bottleneck in the primary referrer and access clinical Homes, the health system expressed inpatient setting training and support for staff that they struggled to place high-acuity • Few SNFs willing or able to care for these • Higher complex-care rate available Medicaid patients. complicated patients for high-acuity Medicaid patients1 Instead of building a specialty to meet • Sought SNF partner to collaborate on • Expanded abilities attractive to their referrer’s need independently, complex care unit other referral sources however, leaders at Lutheran Homes requested support from Palmetto to Provided Training, Referrals Provided Staff, Space High-Acuity collaboratively build a high-acuity SNF Unit specialty line within Lutheran Homes. As part of the partnership, Palmetto provides ongoing training for Lutheran “Most of the SNFs in our market “We have a reputation now of Homes staff, along with a medical don’t want to get pushed out of being able to handle a more director and nurse practitioner to staff their comfort zone…the hunger complex patient…to step up to the the high-acuity unit. just isn’t there.” plate and try something new.”

Lutheran Homes now receives more Judy Baskins, VP Clinical Integration Tom Brown, President Palmetto Health System Lutheran Homes of South Carolina patients from Palmetto both within the high-acuity specialty population and the general patient population. Further, other acute care hospitals are now more inclined to trust Lutheran Homes’ Case in Brief: Lutheran Homes of South Carolina staff, given their strong clinical • 5-facility system including skilled nursing and senior living, headquartered in Irmo, South Carolina capabilities. • Specializes in high-acuity Medicaid patients • With Palmetto Health, worked with South Carolina Medicaid authority to expand the definition of complex patients (and the higher reimbursement attached to this definition) to include high-acuity patients • Engaged Palmetto to create a unit for these patients and requested training and staffing support from Palmetto

Source: Lutheran Homes of South Carolina, Irmo, SC; Palmetto Health, 1) Reimbursement is approximately 2.5 times greater than for regular Medicaid patients. Columbia, SC; Post-Acute Care Collaborative interviews and analysis.

A specialty line which is built Estates of Skokie’s Quality-Based Appeal effectively, and well integrated with a hospital partner, has the potential to drive volumes to such extent that the facility or unit simply cannot accommodate all referrals. If the facility is unable to capture those volumes fully, they will not see the full benefit of their investment. 11 day average Less than 1% The quality and reputation length of stay readmission rate1 Alden Estates at Skokie, part of The [the Skokie] facility has, it’s Alden Network, has achieved that level the equivalent of having 10 of success with their specialty: simple hip and knee replacement. marketers on the street. Bob Molitor, COO Training from local Physician-specific The Skokie facility generates Alden Management Services orthopedic surgeons clinical protocols significant interest among physicians and patients, because it is an attractive option clinically with a full range of amenities. Due to limited capacity and strict clinical criteria, however, the facility cannot accept all interested Alden Estates of Skokie, Clinical Criteria patients. Patients must have: To ensure Alden does not lose those volumes, Alden leaders have built a Simple hip Zero or one Minimal or plan to redirect patients unable to go to or knee co-morbid no memory Skokie to other skilled nursing facilities replacement conditions impairment in the Alden system—they have optimized that facility’s volume spillover.

1) All-cause, 30-day readmission rate. Source: Alden Estates of Skokie, Skokie, IL; Post-Acute Care Collaborative interviews and analysis

Alden takes a two-pronged strategy for Methods to Influence and Inform Patient Choice keeping patients in-network while maintaining patient choice. Ongoing Efforts In-the-Moment Reponses to Individual Patients

First, Alden adopts each physicians’ preferred protocols and demonstrates Gain Physician Approval Highlight Facility Similarities Offer Greater Convenience clinical quality at all facilities to further strengthen relationships with referring physicians. When Skokie can not admit a patient, Alden leaders encourage him to go where his physician suggests— Alden leadership reacts to Skokie facility staff react to Skokie facility staff assist and due to the groundwork laid, the patients’ tendency to follow patient desire for a facility families when another physician typically suggests an physician suggestion by: similar to Skokie by: Alden facility is needed by: alternative Alden facility. Developing MD preference for Providing comparisons to Connecting patients with Alden facilities beyond Skokie other Alden facilities; other other Alden facilities by Second, Alden has honed the way they by proving high-quality Alden settings use the same scheduling tours at other interact with patients unable to be outcomes and adopting therapy company, offer high- Alden settings and treated at Skokie in the moment. physicians’ preferred end amenities, etc. connecting patients with Those patients are informed that all protocols throughout the admissions staff Alden facilities use the same therapy Alden network company and offer similar amenities. In addition, if the patient asks, leaders at Skokie will offer to connect the patient directly with administrators at another Case in Brief: The Alden Network Alden facility and schedule a tour for the patient. This approach is patient- • 45-facility system including skilled nursing, senior living, and memory care, headquartered in Chicago, led, but has resulted in keeping an Illinois average of 75% of these referrals • Opened 28-bed Alden Estates of Skokie in 2011; specializing in short-term rehab patients recovering within the Alden network. from simple hip or knee replacement who meet clinical requirements, including having no major memory loss and one or fewer comorbidities; equipped with high-end amenities

• Due to limited capacity and strict clinical criteria, Skokie unable to accept many of the referrals received • Skokie staff draw parallels for patients between Skokie and other Alden facilities, and Skokie staff connect patients with admissions staff at other facilities, setting up tours and visits for the patient

Source: Alden Estates of Skokie, Skokie, IL; Post-Acute Care Collaborative interviews and analysis.

To derive benefit from a specialty line’s spillover, an organization must successfully achieve four goals along two vectors.

First, the organization must obtain sufficient volumes to generate Factors Determining Total Volumes Generated spillover. This requires both the specialty itself to be exceptionally attractive on its own, and the organization’s brand to be strong Attractive Specialty Recognizable Brand enough to maintain patients’ interest Selected specialty creates Clear organizational branding even if their preferred care site is significant interest, draws links other facilities to unavailable. patient and physician attention specialty line Second, the organization must be correctly structured to accept any spillover that occurs. The system must have geographically proximate Factors Affecting Ability to Capture Overflow Volumes facilities; patients will not sacrifice convenience to stay within the system, especially when they have already Geographic Proximity Excess Capacity been turned away from their first choice of care site. Finally, those Alternate facilities as Other facilities able to admit nearby sites must have capacity to convenient for patients as additional patients and take on the additional volumes coming their preferred location accommodate greater volume from the specialty.

Source: Post-Acute Care Collaborative interviews and analysis.

While increased volumes typically Effect of Facility CMI1 on Pennsylvania Medicaid Rates unlock additional revenue, a carefully chosen specialty can also drives increased reimbursement by capitalizing on the idiosyncrasies of a A .01 increase in provider’s payment structures. CMI leads to an Reimbursement additional $1.38 per For example, in Pennsylvania, a .01 Rate patient per day increase in a skilled nursing facility’s case mix index (CMI) correlates with an increase of $1.38 per patient per Facility Case-Mix Index day in reimbursement.

In an effort to leverage that payment Susquehanna Health Skilled Nursing and Rehabilitation opportunity, Susquehanna Health Center’s Vent-Weaning Specialty Line Development Skilled Nursing and Rehabilitation Center, opted to specialize in ventilator weaning. Vent weaning patients are measurably more complex than the Identify Opportunity Choose Patient Type Calculate ROI Create Service Line generally skilled nursing population and an influx of that patient type CMI driven by number Vent-weaning best option Models demonstrate Facility works with of complex patients to raise CMI, due to likely costs are external vendor to offer increased the facility’s CMI from 1.10 prevailing market demand outweighed by potential specialty vent-weaning to 1.18. revenue unit

Case in Brief: Susquehanna Health Skilled Nursing and Rehabilitation Center • 138-bed skilled nursing facility, located on the campus of Muncy Valley Hospital in Muncy, Pennsylvania, part of Susquehanna Health • Specializes in ventilator weaning • Opened 28-bed vent weaning unit in 2011, staffed in part by external respiratory services vendor • After opening vent weaning unit facility CMI increased from 1.10 to 1.18, leading to additional $472,000 per year in Medicaid reimbursement

Source: Susquehanna Health Skilled Nursing and Rehabilitation Center, 1) Case mix index.. Muncy, PA; Post-Acute Care Collaborative interviews and analysis.

As a result of a higher CMI, Susquehanna earned an additional $472,000 across a single year. They Additional Medicaid Reimbursement are also eligible for a $35,000 bonus payment if the facility has at least 10 ventilated Medicaid patients on each Additional yearly “This ventilator-weaning program has of Medicaid’s randomly chosen audit $472K reimbursement resulting allowed us to have greater days. from .08 increase in CMI reimbursement for all of our Medicaid residents in the whole building.” Roughly two-thirds of the facility’s One-time incentive ventilator-weaning patients are $35K payment for serving 10 Anne Holladay, Administrator Medicaid beneficiaries, but the MA1 ventilator patients2 Susquehanna Health Skilled ventilator weaning program’s results Nursing and Rehabilitation Center are not limited to Medicaid patients. Susquehanna has successfully negotiated with other payers, including Medicare Advantage and commercial insurers for higher carve-out rates for Additional Non-Medicaid Reimbursement ventilator-weaning patients. Representative Private Insurance per Diem Rates

The opportunity to drive reimbursement $568 by increasing a facility’s acuity level is not limited to Pennsylvania. The majority of states have variations on $300 similar payment structures; each post- acute provider should uncover and understand the reimbursement opportunities available in their local LTC Ventilator market and evaluate their programs to take advantage of these payment rules.

1) Medical Assistance; Pennsylvania Medicaid program. 2) If ventilator patients comprise at least 10% of facility’s total Medicaid Source: Susquehanna Health Skilled Nursing and Rehabilitation Center, occupancy; payment based on one review day per quarter. Muncy, PA; Post-Acute Care Collaborative interviews and analysis.

Strengthen the Specialty’s Value-Based Appeal

Tactic #4. Address Referrer Cost of Care Priorities Tactic #5. Implement Staff-Driven Care Protocols Tactic #6. Support Generalist Staff with Specialist Experts

Driving volumes and census is a primary consideration for a post-acute provider’s financial viability. However, as the health care market transitions away from fee-for-service and toward value-based reimbursement, post-acute providers must ensure their selected specialties are attractive to referrers taking on risk. The ideal specialty In the context of value-based care, Cost of Care will address all three value is generally comprised of three concerns, securing a Tactic #4: Address Referrer place in narrowing elements: cost of care, quality of care, Cost of Care Priorities networks. and cross-continuum patient management. A strong specialty can and should drive all three.

Quality Cross-Continuum of Care Patient Management Tactic #5: Implement Tactic #6: Support Generalist Staff-Driven Care Protocols Staff with Specialist Experts

Source: Post-Acute Care Collaborative interviews and analysis.

A primary consideration for referrers and payers taking on risk is cost. The elements comprising cost in the new market environment go far beyond the traditional costs post-acute providers have managed and monitored.

Traditionally, a low-cost provider was one with low day-to-day operational expenses. While operational expenses Cost Considerations for Providers are still critical, referrers taking on risk Carrying Longitudinal Risk consider cost to be a far broader metric, encompassing the total cost of • Readmissions caring for a patient across an episode. As such, cost includes readmissions, • Avoidable utilization of health care services avoidable downstream utilization, and other challenges associated with • Level of downstream inefficient patient management during Traditional Post-Acute Provider support needed the post-acute stay and beyond. Cost Considerations post-discharge • Acute and post-acute In order to be a valuable partner, • Supply costs care lengths of stay PAC providers must demonstrate to • Nursing HPPD1 referrers that they can deliver cost-efficient care across a patient’s • Therapy costs entire episode. • Operational expenses • In-sector efficiency

1) Hours per patient day. Source: Post-Acute Care Collaborative interviews and analysis.

However, demonstrating their status as Workers’ Compensation Understands Long-Term Cost Management a low-cost provider is challenging for high-acuity, therapy-intensive providers such as LTACHs, IRFs, and select SNFs. Many referrers evaluate a patient episode on a 30-, 60-, or 90-day time frame post-hospital discharge. Long-Term Value of Intensive Viewed narrowly, high-intensity Post-Acute Services providers are quite costly during that Workers’ Compensation in Brief time period. Yet, in many cases, the interventions provided can reduce • Category of payers contracted by costs in the long term, via functional employers to cover health care costs gains and reductions in supportive Functional Benefits and other compensation for care. However, those benefits are not employees injured on the job easily seen within the episodic window, • Generally responsible for all health rendering an uphill battle for those care costs until the patient is fully providers to prove value. Cost recovered and returns to work All providers must position themselves • As a result, workers’ compensation to effectively address their referrers’ carriers may be willing to pay higher cost of care priorities. High-intensity sums initially in exchange for providers may find their ideal strategy improved long-term return to function Workers’ Comp payers is to frame their appeal to referrers 30 Days • Coverage is required in select states whose focus is on a longer episode. see that long-term and optional in others benefits outweigh

Workers’ compensation is one such higher initial cost referrer. Because workers’ compensation carriers are responsible for a patient’s care until the patient returns to work, they are likely to support more expensive care upfront to achieve proven cost reductions in the long term.

Source: Post-Acute Care Collaborative interviews and analysis.

Craig Hospital, an LTACH, has Primary Priorities of Workers’ Ways in Which Craig Hospital Meets successfully built a strong relationship Compensation Carriers Workers’ Compensation Needs with workers’ compensation carriers. Craig’s chosen specialties are 1 Achieve recovery from common Specializes exclusively in traumatic brain traumatic brain injury and spinal cord workplace injuries injury (TBI) and spinal cord injury injury, both injury types common among workers’ compensation cases. Return patients to complete function 2 Proven Ability to Deliver Functional Gains Selecting a specialty that matches the needs of workers’ compensation carriers was the first step in building a 3 Minimize need for long-term 59% relationship with those carriers. The medical support Percentage of patients with TBI who return to second step was to appeal to the work or school one year post-discharge1 carriers’ cost of care priorities: reduce patients’ long-term medical costs and “When someone gets hurt on the work site, 95% return them to work as quickly as that employer or that insurance carrier has the Percentage of patients with complete paraplegia possible. responsibility for a lifetime of care. Like us, discharged directly home1 their primary focus is on long-term Craig Hospital’s outcomes demonstrate functional outcomes, not short-term costs.” to workers’ compensation carriers that 42 points Mike Fordyce they are able to return patients to Average gain in FIM scores at discharge CEO, Craig Hospital 2 function more completely than their for patients with TBI competitors, setting the carriers up for reduced long-term supportive costs despite a higher up-front investment. Case in Brief: Craig Hospital

• 93-bed not-for-profit Magnet-Recognition® rehabilitation and research hospital located in Denver, Colorado, licensed as a general hospital and an LTACH • Exclusively specializes in two diagnoses: spinal cord injury and traumatic brain injury; patients’ ages range from 15 to 65, with the average age being 38 • Strong relationships with workers’ compensation carriers; serves carriers by providing high-quality rehabilitation to their injured workers, education for staff, outcomes reports, collaboration, inclusion in patient team conferences

1) National Institute on Disability and Rehabilitation Research, 2009-2013 discharges. 2) UDS-PRO, 2013. Source: Craig Hospital, Denver, CO; Post-Acute Care Collaborative interviews and analysis.

To ensure a mutually beneficial partnership, Craig Hospital has established an ongoing process for open communication with workers’ Modes of Communication Relevant Metrics to Share compensation carriers. The carriers are encouraged to attend care Amount of necessary attendant conferences and other ad-hoc care post-discharge meetings with workers’ compensation Patient/Family Facility Tours patients, but Craig also invites Care Conferences Patient satisfaction scores representatives to tour the facility and attend regular education sessions held Percentage of patients who by Craig leaders. They also share return to work or school outcomes data frequently with their Percentage of patients workers’ compensation partners, In-Service Frequent discharged directly to home specifically tailored to the metrics most Education Outcomes Reports relevant to the carriers, such as long- term attendant care costs and return to work percentages.

These efforts have helped Craig to Results of Craig Hospital’s build a national referral base with more Workers’ Compensation Outreach than 50% of Craig Hospital’s patients coming from outside of Colorado, and 16%-18% referred by workers’ compensation carriers. 16%-18% of referrals to Craig Hospital now 16%-18% come from workers’ comp carriers

Source: Craig Hospital, Denver, CO; Post-Acute Care Collaborative interviews and analysis.

Not all providers will find that workers’ Translating Your Impact into Terms Payers, Referrers Understand compensation carriers are the right partners for them; their cost of care priorities may not be well aligned. Regardless of the referral source, post-acute providers should take the Overall Cost of Care broader lesson to heart: incorporate referrers’ specific cost priorities in the specialty selection process, and communicate in the referrer’s preferred Acute Care Post-Acute Outpatient and cost-based terms. Costs Care Costs Home Care Costs A good specialty can be described by the way it impacts costs even beyond the organization’s setting, and How Post-Acute therefore drives value for the referrer. Specialties Reduce Admit Shorten Discharge Improve patient readmissions patients earlier LOS directly to home function The graphic shown here provides a Can Impact Costs thought exercise to help post-acute providers consider the value of their individual specialty lines when thinking beyond in-setting care. The Post-Acute Metrics to Care Collaborative encourages all Demonstrate providers to evaluate their own Impact Readmission Average Average Percentage Functional contributions to lowering total cost of rate onset days1 LOS2 discharged status at care and use those contributions in to home discharge partnership conversations with referrers who are taking on risk.

1) Average acute setting length of stay before post-acute facility can safely admit the patient. 2) Length of stay. Source: Post-Acute Care Collaborative interviews and analysis.

Demonstrating high quality of care is a priority in a value-based care system. In addition to delivering on their commitment to patients, post-acute providers must meet a growing array Three Components to Quality Messaging of outcome and performance measures scrutinized by referral sources. Generate Many post-acute providers, however, 1 Outcomes Essential first Specialization Can Be a Boon to Quality focus more acutely on scorecarding step to generate and communicating outcomes to referrer interest referrers than they do on driving Pressure ulcer improvement in home health agencies with superior outcomes. This is a critical 200% a WOCN1, as compared to strategic error. To attract value-based agencies without referrers, the undeniable first step is to Document 2 elevate clinical standards and Outcomes implement processes that generate Average IRF length of stay stellar outcomes. 6% reduction for each 1% increase in CRRNs2 One of the reasons specialization can Traditional, drive quality is the repetitive nature of a limited focus of Studies demonstrating specialized program, which allows staff post-acute 91% specialist surgeons achieve practice and time to gain expertise with Market providers better clinical outcomes than 3 a specific patient type. Outcomes generalist surgeons Offering one specialty exclusively is obviously one way to achieve that level of repetition. However, exclusive specialization is not necessarily an optimal strategy for all post-acute providers.

Organizations offering more than one specialty must take a more targeted approach to ensure clinical quality. Source: Westra B, et al., “Effectiveness of Wound, Ostomy, and Continence Nurses on Agency-Level Wound and Incontinence Outcomes in Home Care,” Journal of Wound, Ostomy and Continence Nursing, 2013, 40(1): 25-33; Nelson A, et al., “Nurse Staffing and Patient Outcomes in Inpatient Rehabilitation Settings,” Rehabilitation Nursing, Sep.-Oct. 2007, 32(5): 179-202; Chowdhury MM, et al., “A Systematic Review of the 1) Wound, ostomy, and continence nurse. Impact of Volume of Surgery and Specialization on Patient Outcome,” British Journal of Surgery, Feb. 2007, 2) Certified rehabilitation registered nurse. 94(2): 145-61; Post-Acute Care Collaborative interviews and analysis.

Implementing care protocols, or care Evolution of Sheltering Arms’ iWalk and iReach Protocols pathways, is foundational to improving clinical quality. Good protocols reflect Leaders at Sheltering Arms Leaders sought feedback from iWalk, iReach, and evidence-based guidelines for care decided to specialize in therapists and opted to shift to iConnect programs fully delivery, standardizing elements of stroke and brain injury care impairment-based protocols implemented; outcomes care to ensure consistent outcomes. and developed care protocols data informs ongoing revisions They also support staff in delivering excellent specialty care. Therapists challenged by the Clinical leaders developed new Many organizations make one critical clinical protocols; diagnosis-based guidelines with therapists’ input mistake when designing and guidelines were difficult to absorb into therapy practice implementing protocols: they fail to obtain staff buy-in. Seeking staff input not only improves staff use of and compliance with the protocols, but also Achieving Functional Gains can improve the protocols themselves, “Therapists don’t treat a diagnosis. based on staff members’ extensive They treat a functional impairment. on-the-ground knowledge. iWalk and iReach work for a wide Additional FIM improvement for iWalk variety of patients because the 20% patients as compared to regional average1 Leaders at Sheltering Arms, an IRF, disease might be different, but the listened to therapist feedback that their impairment is the same.” Average additional improvement in iWalk protocols were overly focused on 425 patients’ in six minute walking distance, diagnosis. The leaders revised the Jim Sok, CEO in feet, with clinical practice guidelines1 protocols to target physical Sheltering Arms impairments common across their patient population instead, building the iWalk and iReach clinical programs specializing in patients with gait and Case in Brief: Sheltering Arms Physical Rehabilitation Hospital upper limb mobility, respectively. • Rehabilitation system including two IRFs, several outpatient therapy locations, multiple physician clinics, Together, the protocols and associated community-based transitional programs, and a home health agency, headquartered in Richmond, Virginia programs have achieved strong functional gains and driven physician • Specializes in gait and upper arm mobility; programs designated iWalk and iReach, respectively referrals to Sheltering Arms. • Restructured specialties to target functional impairment rather than diagnosis at therapists’ request • Working with a local acute care hospital to expand iWalk and iReach protocols into the acute care setting

1) Controlled for age, length of stay. Source: Sheltering Arms Physical Rehabilitation Hospital, Richmond, VA; Post-Acute Care Collaborative interviews and analysis.

As referrers become increasingly accountable for care delivered beyond their setting, they are identifying post- acute partners who can impact results beyond their setting. Planned Future Uses of Sheltering Arms’ Specialty Care Protocols Comprehensive, cross-setting care is the motivation behind Sheltering Arms’ future evolution of the iWalk and iReach programs. While the protocols are currently used in Sheltering Arms’ Predictive Modeling inpatient and outpatient rehab services, • Protocols as standardized as leaders plan to implement the protocols possible across all settings, in the acute care setting by partnering while maintaining sector with their referral sources to establish a Acute Care Partners specificity single, cohesive cross-continuum care • Protocols developed in • Leaders can predict patient plan for patients with gait and upper IRF but customized for LOS, cost, and ultimate limb mobility impairments. hospital partners with functional outcomes on acute physician and hospital care admission via an algorithm Inpatient and The ultimate goal is to utilize the input based on prior cases Outpatient Rehab protocols consistently across a patient’s full episode so that Sheltering • Protocols developed in IRF • Patients begin to receive • Patient care is customized Arms can capture reliable data on and used to treat specialized gait and upper based on knowing patients’ Sheltering Arms patients limb mobility care likely clinical and functional patients’ assessment at admission and immediately upon injury outcomes functional outcomes at discharge. This comprehensive data set will enable Sheltering Arms to predict a patient’s likely length of stay, cost of care, and Present State Future State functional outcome at the point of acute care admission.

Source: Sheltering Arms Physical Rehabilitation Hospital, Richmond, VA; Post-Acute Care Collaborative interviews and analysis.

Care protocols set a foundation for MedStar VNA Restructures Clinical Support System high-quality care delivery but are not a substitute for clinical experience and Nurse A’s expertise. Service Area Specialty expertise can be especially challenging for home health providers, Nurse B’s who are typically generalists out of Service Area necessity. Home health nurses typically manage geographic areas and must be prepared to care for all patient types nearby. This type of assignment Clinical Manager Assignments improves efficiency by minimizing nurse travel time, but reduces nurses’ Nurse C’s ability to deliver specialty care once a Oversees CHF care Service Area patient returns home.

MedStar Visiting Nurse Association, a home health provider associated with Oversees diabetes care the MedStar health system, has solved this challenge by assigning each nurse manager to a clinical specialty area. Oversees IV infusions

At MedStar, home health nurses themselves are still assigned to patients geographically, but they are matched with a different manager based on each patient’s clinical Case in Brief: MedStar Visiting Nurse Association presentation. This allows the nurses • Home Health agency serving parts of Maryland, Virginia, and Washington, DC; part of MedStar Health easy access to a specialist in the • Functions largely as a generalist provider. Services include at-home infusion, diabetes care, and patient’s primary condition, delivering orthopedic rehabilitation; staff nurses are generalists, expected to care for any patient in their assigned specialty care without being specialists geographic area themselves. • In order to ensure true specialty-level care, MedStar leaders shifted reporting structures in 2014 to assign nurse managers by diagnosis rather than geography

Source: MedStar Visiting Nurse Association, Columbia, MD; Post-Acute Care Collaborative interviews and analysis.

Two primary components ensure MedStar’s manager assignment structure results in excellent specialty care.

First, managers must be true specialty experts. They are assigned to Experience-Based Manager Assignment Easy-to-Access Support specialties based on previous experience, certifications, and skills, Manager’s Specialty making certain they can coach home Background Assignment Direct EMR Connection health nurses through the complex • Patients assigned to disease category challenges unique to the patient type. Former inpatient Stroke and associated manager in the EMR neurology RN Second, nurses must have real-time • Manager has real-time visibility into access to their assigned managers. nurse’s documentation At MedStar, the correct manager is Certified WOCN1 Wound care/diabetes • If any trouble spots seen in EMR, assigned by the system’s EMR based manager contacts nurse directly on each patient’s most acute or circumstantially relevant condition. SkilledS at IV care IV team The assigned manager’s contact On-Demand Phone Support information is auto-populated, and the manager can view the nurse’s documentation in real time. All nurses • Nurses can securely send photos of • Patients with comorbidities assigned based wounds to managers as needed carry work-issued secure cell phones on most acute or pertinent condition. to create a direct link to the manager, • Nurses provided email-capable mobile enabling the nurse to call the manager • If patient’s condition changes, manager phone for their workday assignment can be altered at any time. with any questions and even send • Appropriate manager’s phone number auto photos as needed. populates in the EMR for questions

These connections ensure specialty care is seamlessly delivered across the entirety of the health system. Strengthening the relationship between the hospital system and VNA.

1) Wound, ostomy, continence nurse. Source: MedStar Visiting Nurse Association, Columbia, MD; Post-Acute Care Collaborative interviews and analysis.

Tactic #7. Recapture Lost Volumes by Expansion into New Sectors Tactic #8. Fill Downstream Service Gaps Tactic #9. Productize Specialty Knowledge Tactic #10. Realign Traditional Competencies into Novel Programs

The benefits of specialization can extend beyond volume generation and partnerships within the traditional bounds of an acute/post-acute relationship. A strong specialty can Expansion of Revenue Sources, Based on Specialty Care also open the door to new business opportunities. New Specialty-Related Revenue Opportunities These opportunities take a variety of Existing Specialty forms and allow post-acute providers to Revenues New revenues captured by access revenue streams they could not using specialty expertise to Reimbursement for previously. A well operated specialty reach new setting, patients, or traditional setting, patient business line line can transition into a new care type, and business lines setting or adapt to reach new patient types. If providers are sufficiently flexible, they can even establish different-in-kind specialties to access funding beyond the guideposts of their traditional reimbursement structures. Avenues to Reach Untapped Revenues by Elevating a Specialty

New Care Setting New Patient Types New Business Lines

• Extend specialty into novel • Serve new patient population • Offer new product based setting or sector via existing specialty on specialty knowledge • Capture revenue not • Expand patient base, attract • Move beyond traditional available in traditional sector higher-margin groups funding sources

Source: Post-Acute Care Collaborative interviews and analysis.

Once a provider develops a successful Development of Sub-Acute Unit to Serve Specialty Population specialty program, a logical next step is to extend that program to their other locations or care settings. Specialty Expertise Market Pressure

1 Armfeldt Rehabilitation successfully Strategic Response: moved their specialty—rehabilitation Orthopedic Sub-Acute Unit following orthopedic surgery—from an Joint venture between IRF to a sub-acute unit to access their Armfeldt and local hospital traditional patients in a new setting. • Armfeldt Rehabilitation1 • Change in medical Armfeldt had developed significant developed specialty line for necessity definition restricts simple joint replacement specialty expertise in treating volumes for simple patients Treats post-op joint orthopedic patients post-operative orthopedic patients, replacement patients but changes in medical necessity • Invested considerable • Most joint replacement requirements shifted such patients resources in training, patients sent to lower- away from the IRF setting. In an effort protocol development, etc. acuity, non-specialty providers to avoid losing that core patient group, • Generated high-quality Occupies dedicated as well as their institutional knowledge, outcomes, saw strong unit with 35 beds • Armfeldt’s specialty Armfeldt partnered with a local hospital volumes for specialty expertise no longer useful to operate a sub-acute unit specifically in traditional setting for post-operative joint replacement Receives 60% of referrals from patients. The unit represents a joint outside partner hospital’s system venture between Armfeldt and the hospital in which it is located, but accepts patients from all local hospitals. Currently, 60% of the Case in Brief: Armfeldt Rehabilitation referrals to the unit come from other • IRF, headquartered in the Northeast hospitals. • Specializes in pediatrics, spinal cord injury, brain injury, stroke, and orthopedics • Developed strong specialty programming to provide post-operative rehab therapy to single joint replacement patients; however, definition of medical necessity for IRF care changed, limiting number of single joint replacement patients Armfeldt could accept • Collaborated on a joint venture with local hospital to create inpatient sub-acute rehabilitation unit focusing on unilateral joint replacement surgery patients

1) Pseudonym. Source: Post-Acute Care Collaborative interviews and analysis.

When transitioning a specialty to a new Maintaining a Tried and True Clinical Process care setting it is imperative to ensure the strength of the specialty is not diluted. While care processes must adjust to meet the needs of the new setting, the same dedication to Care at Orthopedic Sub-Acute Unit high-level specialty care must remain consistent. Patients At least 2 ambulate hours of “When you have a To do so, Armfeldt maintained the first day therapy homogeneous patient same level of care for the patients in post-op daily group and staff all trained the sub-acute unit that they had offered in the same way, you’re in their IRF, including delivering No relaxation in really able to be efficient.” Staff trained frequent, intense therapy not Evidence- commitment to Medical Director, commonly offered in a sub-acute based at Armfeldt program quality Sub-Acute Unit setting and following the same clinical clinical main campus pathways they had initially designed for protocols IRF patients. Patients ambulate early and often, resulting in faster and more complete recovery than at similar sub-acute offerings.

The sub-acute unit breaks even Specialty Experience Yields Strong Outcomes in New Setting financially, but provides benefits by generating consumer interest in 8.4 5.6% 96% downstream Armfeldt services, such as Average length of stay, All-cause 30-day Rate of discharge back home health or outpatient rehab. in days readmission rate to the community Simultaneously, the program strengthens referring relationships with orthopedists, while enabling Armfeldt to continue to serve simple orthopedic patients.

Source: Post-Acute Care Collaborative interviews and analysis.

In select cases, the opportunity to TLC1 Responds to Patients’ Needs for Long-Term Support extend a specialty is not limited to a new sector or care setting, but also includes an opportunity to reach new Patient Pathways at TLC Typical Discharge Destination patient types. Neurorehabilitation LTC Facility, Low level of function, no potential to live Transitional Learning Center (TLC) is a Group Home rehabilitation provider specializing independently, ALOS2 of 7 months Opportunity to serve specialty exclusively in traumatic brain injury. population at Upon initial assessment, patients are Functional Independence Community, LTC new acuity level segmented into one of four care Intermediate level of function, potential to live in Facility, Group pathways: two aimed at return to the supervised environment, ALOS of 7 months Home community and the other two intended to help more severely injured patients Return to Work achieve basic physical skills. High level of function, potential to live Community Following discharge, the more severely independently, ALOS of 4 months injured patients frequently sought additional support from TLC, as they Return to School were unable to find specialized High level of function, potential to live Community long-term care. TLC, however, offered independently, ALOS of 4 months only short-term rehabilitation—failing to meet some patient needs and capitalize on an opportunity for programmatic growth. Case in Brief: Transitional Learning Center

• 3-facility system including inpatient rehabilitation and assisted living, headquartered in Lubbock, Texas • Specializes exclusively in Traumatic Brain Injury (TBI) • Realized higher-acuity patients in facilities providing intensive inpatient rehabilitation were either discharged to the community but readmitted for additional care due to lacking community supports, or were discharged directly to LTC facilities • Identified TBI patient population’s need for long-term care, saw this demand as a business opportunity and opted to build a third facility offering long-term assisted living, not short-term rehabilitation

1) Transitional Learning Center. 2) Average Length of Stay. Source: Transitional Learning Center, Lubbock, TX; Post-Acute Care Collaborative interviews and analysis.

Following a due diligence process, Tideway Assisted Living Facility TLC expanded their specialty into a new care type: assisted living. They opened the Tideway facility specifically for the patients who, even after rehabilitation, would never live independently again.

In addition to moving into the long-term care space, Tideway allowed TLC to access patients they previously would not have seen—patients with traumatic brain injuries dependent on support for

ADLs, but who were not in need of IMAGE CREDIT:TRANSITIONAL LEARNING CENTER. intensive rehabilitation. Although many of Tideway’s residents previously Profile of Tideway’s Target Patient Population received rehabilitation services from TLC, Tideway also receives residents from other rehabilitation facilities. Primary resident needs Residents must have Many, but not all, TLC maintained not just their require long-term TBI, require assistance residents previously specialized staffing but also their support, not with ADLs1, IADLs2 received rehab therapy community-focused care model at rehabilitation at main TLC facilities Tideway. While residents at Tideway are expected to live out the remainder of their lives within the facility, TLC provides many opportunities for Case in Brief: Transitional Learning Center’s Tideway Facility residents to participate as fully as • 12-bed Tideway facility, located in Galveston, was constructed in 1998; has now grown to 32 beds possible with activities in the • Requirements for admission to Tideway similar to those for admission at other TLC facilities, but those at community. Tideway have also reached the maximum potential benefits from rehabilitation and are unable to live independently • Tideway facility allows TLC to care for patients within their specialty diagnosis but at a new level of acuity • Texas law allows TLC’s two original facilities, both ALFs, to receive reimbursement for short-term, inpatient TBI rehabilitation despite their licensure

1) Activities of Daily Living. 2) Instrumental Activities of Daily Living. Source: Transitional Learning Center, Lubbock, TX; Post-Acute Care Collaborative interviews and analysis.

Extending a specialty to access new Oncology Care Home Health Brings Internal Training Modules to Market patients or new care settings can effectively achieve program growth. Another less common approach to Oncology Care Training Collateral Operational Support System growth is to think beyond care delivery and productize hard-earned specialty knowledge. Parenteral Opiate Therapy Experienced Clinicians Specialized nurses and Purpose: To ensure safe administration of Leaders at Oncology Care Home physicians with significant parenteral opiates administered in the home Health had developed extensive experience in the field available training materials and clinical General Information: for consultation guidelines for staff over 16 years of 1. Parenteral opiates can be administrated specialized clinical practice. either intravenously or subcutaneously Accessible by Phone 2. A subcutaneous site for opiate delivery Majority of communication is Recognizing the value of their must be changed every 3 to 7 days; a telephonic; one-off calls and intellectual property, they began subcutaneous site is best maintained when standing phone appointments offering training modules, clinical the hourly volume of the opiate infused protocols, operational guidance, and does not exceed 2 mL/hour marketing strategy (along with as- Unlimited Duration needed consulting services) to other Extensive support provided home health providers wishing to during implementation with develop a specialty oncology line. continued resources available on an ongoing basis as needed

Case in Brief: Oncology Care Home Health • Consulting and educational materials provider to home health agencies looking to add an oncology specialty line; headquartered in Wilmington, DE • Originally founded by a home health nurse with an oncology background as a home health agency exclusively specializing in at-home oncology care • Oncology Care Home Health staff are entirely focused on oncology—including the phone receptionists and aides—which better equips them to understand the needs of cancer patients

Source: Oncology Care Home Health, Wilmington, DE; Post-Acute Care Collaborative interviews and analysis.

The product offered by Oncology “Solution” Sales on the Rise for Non-Providers Home Health meets a traditional delivery system need. However, understanding specialty lines in terms of non-traditional collections of services is a newer idea and a strength of companies such as Walgreens, who have been successful assembling sets Case in Brief: Walgreen Co. of otherwise unconnected services into WellTransitions™ Program Components products aimed at meeting a specific • Largest drug retail chain in the United market need. States, with 372 Take Care Clinics and over 700 locations throughout the country Walgreens’ WellTransitionsTM program is a set of services, such as medication Medication Prescription • In 2012, created WellTransitions™ reconciliation and follow-up phone Reconciliation Delivery program to help health systems reduce readmissions by offering transitional calls, bundled together and marketed support for at-risk patients to health systems as a way to manage high-risk patients and reduce • Strong initial results include 5 point lower rehospitalizations and avoidable Appointment Follow-Up readmission rate over 6 months for utilization. Response to the program Reminders Phone Calls patients enrolled in the program versus eligible patients who did not enroll has been strong so far. • Received American Hospital Association Post-acute providers have a similar endorsement for medication adherence opportunity to bundle their existing portion of WellTransitions™ tasks into new service lines, and in doing so access new patients and revenue streams.

That is the root of the final tactic of this book: understanding the value of the individual tasks an organization offers, and then realigning them into service lines that not only allow access to new patients, but also new reimbursement opportunities beyond the constraints of the post-acute sectors. Source: “WellTransitions©,” Walgreen Co., http://healthcare.walgreens.com/healthcare/business/ProductOffering.jsp?id=wellTransitions’; Post-Acute Care Collaborative interviews and analysis.

A New Model for Transitional Care

Visiting Nurse Association of Ohio assembled their existing competencies Visiting Nurse Association of Ohio’s Transitional Coaching Program to build a transitional coaching program for all high-risk patients, regardless of their eligibility for Medicare’s home Transition: Hospital Transition: Home Health health benefit, funded through to Home Health to Living Independently partnership with a local ACO. This enables Visiting Nurse Association of Ohio to build new relationships and access an entirely new revenue stream.

The program provides support for patients transitioning from the hospital to home or from home health to routine Designed for High- Based on Intensive Reimbursed care. It offers two in-person visits and Risk Patients Patient Interaction Directly by ACO six phone calls over the 60-day period following discharge. • Serves 10% most costly • Nurses visit within 24 • ACO pays case rate of Medicare patients hours of discharge $250 for these services Many patients enrolled in the program • Program created to reduce • Nurses make two visits • Many patients not eligible do not qualify for home health expensive hospital and six phone calls during for Medicare coverage of coverage under Medicare because readmissions first 60 days post- home health services they are not homebound. However, discharge they are high-risk, and without dedicated support at home, they are at risk for a readmission. As such, when presented with the planned transitional Case in Brief: Visiting Nurse Association of Ohio coaching program, an ACO agreed to • Home health provider, headquartered in Cleveland, Ohio pay a $250 case rate for these services • Specializes in readmission reduction and behavioral health for the top 10% of their most expensive • Saw demand in the market for a readmissions reduction solution and recognized that many of their core Medicare beneficiaries. competencies could directly impact a patient’s likelihood of readmission • Combined relevant tasks into a new transitional care service line, overlaying additional protocols and providing additional training for staff; resulting service line does not include many aspects of traditional home health care such as medical support or nursing care

Source: Visiting Nurse Association of Ohio, Cleveland, OH; Post-Acute Care Collaborative interviews and analysis.

The opportunity to assemble existing FirstLight Develops “Readmissions Rescue” Program tasks into a new service line and use the resulting program to access new revenue streams is not limited to home Potential of Non-Medical Home Care health. FirstLight Home Care, a non- medical home care provider, took a Factor Self-Care Follow-Up Home similar path when developing their Affecting Capability Appointment Environment Readmissions Rescue program. The Readmission services FirstLight brought together, while not medical in nature, have a Offer patient education, Schedule follow-up Monitor vital signs Non-Medical significant and proven impact on assist with medication appointments with remotely and offer Home Care readmissions. administration and lead physician and provide personal emergency Interventions exercise regimen safe, timely transportation response system Understanding the impact of social determinants on health outcomes, local ACOs have funded the Readmission Additional Investments to Create Separate Service Line Rescue program for their Medicare patient populations—expanding Targeted Dedicated Technology FirstLight’s client base. Previously, Protocols Staffing Acquisition FirstLight, as a non-medical provider, only served private pay clients. Developed internally, RN leads program Upgraded data systems guided by on-staff RN, nationwide with for greater compatibility Both Visiting Nurse Association of Ohio to reduce readmissions specialty care with hospitals and and FirstLight successfully leveraged a managers present at easier access for MDs different-in-kind specialty type to each branch access entirely new patient pools and revenue streams. Case in Brief: FirstLight Home Care The flexibility demonstrated by these • Non-medical home care provider, headquartered in Cincinnati, Ohio programs is increasingly important as referrers and payers experiment with • Specializes in readmission reduction care management program design and • Realized that although many of their traditional services reduce risk for readmissions, health systems funding. did not consider non-medical home care a viable option in readmission reduction strategies • Decided to highlight existing competencies via targeted service line with sole aim of preventing readmission for high-risk patients; created Readmission Rescue program in 2013

Source: FirstLight Home Care, Cincinnati, OH; Post-Acute Care Collaborative interviews and analysis.

Both Visiting Nurse Association of Ohio and FirstLight have seen positive clinical results from their unique programs and focused their impact on VNA Ohio Transitional Coaching FirstLight Readmission Rescue readmission rates. Readmission Rate ED1 Visits Readmission Rate In order to be successful with a new 30-Day, All-Cause 30-Day, All-Cause service line built from traditional competencies, it is critical that the new line maintains the same level of 55% 58% dedication and focus as any other Reduction Reduction specialty, and continues to meet the 2% hallmarks of a specialty seen on page 9 of this book.

Appeal to Physicians Building Volumes “Physicians are making referrals like crazy because they didn’t know these 1,000 services were an option before.” Patients currently enrolled Dana Traxler, Regional Executive Director in Readmission Rescue Visiting Nurse Association of Ohio

For More Information To learn more about how to access new revenue streams by building a specialty service line from an organization's existing skills, access the Post-Acute Care Collaborative’s workbook, “Leveraging Traditional Competencies to Meet New Market Needs,” available on advisory.com.

Source: Visiting Nurse Association of Ohio, Cleveland, OH; FirstLight Home 1) Emergency Department. Care, Cincinnati, OH; Post-Acute Care Collaborative interviews and analysis.

As the industry evolves to incentivize long-term population health, newer specialties focused on patient Shared Goals for Patient Management Across All Sites of Care management continue to emerge. In addition, patients are becoming more complex, and specialties must maintain the clinical strength of a Those with Integrate Improve High-Risk complex narrow focus, while providing care Care Plan Outcomes for a whole person, rather than just Patients disease(s), a specific diagnosis or impairment. Top 5% comorbidities

Post-acute providers who do not Those whose recognize this change will fail to Rising-Risk conditions may achieve the initial partnership and Patients not be under Teach Patients Improve Self- growth goals that drove their desire for 15%-35% control New Skills Management specialty program development.

Concurrently, new incentives provide opportunities for post-acute providers Low-Risk Those with minor, to offer services they would not have Patients easily managed Coordinate Optimize previously offered for financial reasons. 60%-80% conditions Across Team Utilization While the specific types of specialty Members Patterns offerings evolve, the importance of strong clinical programs remains critical for future growth amid industry Sample Next-Generation Specialty Areas change. Organizations must recognize these shifts, and ensure their specialties keep pace. Preventing Deterioration Maintaining Wellness Following an Episode of Care Among Healthy Seniors

Improving Patient Self- Caring for Exceedingly Management of Chronic Conditions Costly, High-Need Patients

Source: Post-Acute Care Collaborative interviews and analysis.