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What’s the right Rx for lowering hospital readmissions?

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Patients recovering from hip replacements and strokes at St. Pauls House, a short-term rehab center in Chicago’s Irving Park neighborhood on the North Side, are used to seeing doctors and nurses make rounds almost daily. Doctors check that these patients, typically in their 70s or older, are taking the right medications, since prescriptions can get mixed up when they see one physician after another in the hospital. No one is rushed back to the hospital at the first sign of a fever.

This type of care isn’t common at many skilled nursing facilities, where patients recuperate after a hospital stay before heading home. Patients at some facilities don’t see a physician for days, even weeks, experts say.

Driving a change in these facilities’ operations is a big healthcare buzzword: readmission rates. This refers to the percentage of patients who wind up back in the hospital too quickly after being discharged, whether for fever, infection or worse. Hospitals have been on the hook for a few years as the federal government pays closer attention to what happens to patients after they are discharged. Starting next year, skilled nursing facilities will be monitored more closely, too.

Beginning in October 2018, Medicare—the federal health insurance program generally for those 65 and older—will withhold 2% of all payments to skilled nursing facilities, which they can earn back by having a readmission rate likely no more than 20%, experts say. (The average readmission rate was between 5% and 10% in 2015, according to the Medicare Payment Advisory Commission, or MedPAC, a Washington, D.C.-based independent agency that advises Congress on Medicare.)

Worried about losing out, some facilities, like St. Pauls House, are investing in unique approaches. Dr. Dheeraj Mahajan, St. Pauls medical director, who has a practice based in Melrose Park, embeds a team of doctors and nurses there to keep close tabs on patients in what he calls a high-acuity unit. A year ago, St. Pauls’ readmission rate was 23%. The rate had been steadily declining, then dropped to 10% after the unit launched in January.


So far, the facility has spent around $75,000 on its high-acuity unit, including fees to doctors and extra training for St. Pauls nurses and certified nursing assistants. It receives about $4.1 million in Medicare reimbursement a year, about one-third of its total revenue. If the facility was dinged 2% over readmission rates, that would amount to about $82,000, slightly more than its investment in the unit. But that wouldn’t factor in the reputational boost: If you prevent someone from going to the hospital, they spread the word to friends and family that they had a good experience at St. Pauls.

“Recognizing the increasing needs of our patients, mixed with the increasing pressure on us to reduce hospitalizations, we wanted to find a way to handle that,” says Andrew Kazmierczak, St. Pauls executive director. “We’re only expecting it to get more difficult, to get more challenging patients, as hospitals are pushed (by insurers) to discharge people sooner and to get them in our hands quicker.”

The financial hit to skilled nursing facilities could be significant, especially in Illinois, which is chipping away at a $14.6 billion pile of overdue bills (including ones owed to these facilities) that amassed while Gov. Bruce Rauner and Democratic state lawmakers bickered for two years over passing a state budget. In 2015, the federal government spent nearly $30 billion on services in skilled nursing facilities, according to MedPAC.

Born out of the Affordable Care Act, the mandate ratchets up the pressure on skilled nursing facilities. In Illinois, there are more than 700 such facilities, and they’re mainly for-profit, says Pat Comstock, executive director of the Health Care Council of Illinois, a lobbying group. What’s more, their business already is being threatened on another front: Hospitals worried about their own readmission rates are steering patients to facilities where their patients have the best shot at recovering well—and not ending up back in a hospital bed.

Hospitals are amping up pressure, too. At the three-hospital network anchored by Rush University Medical Center on the Near West Side, executives are trimming the number of facilities they refer patients to from more than 30 to potentially up to 10, says Bruce Elegant, who leads the effort and also is CEO of Rush Oak Park Hospital. To help curb its own readmissions, the system embeds nurses at a few skilled nursing facilities. Readmission rates for Rush patients who suffer congestive heart failure, for example, are down, from 50% five years ago to zero within the last six months, Elegant says, declining to name the facilities.

Medicare has withheld money from hospitals for readmissions since 2013 in an effort to boost quality. This year, medical centers nationwide are estimated to lose a total of nearly $530 million if patients with pneumonia or heart failure, among other illnesses, return within 30 days of going home, according to the Kaiser Family Foundation, a nonprofit based in Menlo Park, Calif.

Since now both hospitals and skilled nursing facilities could lose if patients return too soon, they’re fortifying their relationships. Providers at the hospital and facility might discuss a patient pre-transfer, instead of just handing over a medical chart. While that might seem basic, it actually was not common practice before.

Managers of skilled nursing facilities are closely examining operations, too. Lincolnwood-based Symphony Post Acute Network, which has 28 facilities in Illinois, Indiana and Wisconsin, has invested heavily in an electronic health record system in an effort to lower its readmission rate of about 15%. The beefed-up system allows doctors who send patients off to recuperate to track how they’re doing from afar, says Donna Sroczynski, Symphony president of operations.


At the 19 skilled nursing facilities advised by Extended Care, an Evanston-based consultancy, a telemedicine program is helping bring down rates. Nurses wheel a computer into a patient’s room and use it to help a doctor to remotely look inside the person’s ears, nose and throat, for example. The facilities’ readmission rates range from 9 to 19 percent, and about 25% of patients are on Medicare, says Extended Care CEO Ron Nunziato.

“If you have a hospital getting dinged because of what you’re doing, it’s in your best interest to put a correction plan in place,” Nunziato says. “Otherwise, a hospital is not going to want to play ball.”

At St. Pauls, which also offers assisted living and long-term care services, Kazmierczak hopes a drop in readmission rates will entice more business from doctors who influence where their patients go, and by word of mouth among people in the community.

After all, there’s a hidden cost for a readmission: an empty bed.

Author: Kristen Schorsch


Big Data in Healthcare: How Chief Data Officers Can Help

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With doctors and nurses focused on clinical care and CIOs busy setting up servers and installing software, the emerging role of the chief data officer is becoming more necessary.

These healthcare data scientists help foster innovation, manage compliance with regulations and drive down costs in a value-based care environment. Their job is to make sense of financial, clinical, regulatory and legal data.

In fact, research firm Gartner reports that 90 percent of large companies will hire a CDO by the end of 2019, many of them at healthcare organizations. The responsibilities for healthcare data reporting and analysis that would typically fall to a CIO or CTO are being handed to the CDO, says Nathan Patrick Taylor, a co-chair for the American Health Information Management Association data analytics practice council and director of data science and analytics at Symphony Post Acute Network, a provider of short-term post-hospital rehabilitation, long-term care and assisted living.

By hiring CDOs, companies can prevent CIOs and CTOs from getting overwhelmed, Taylor suggests.

“The CDO role takes that data component away from them and frees them up to do what I think IT should be doing, which is setting the underlying infrastructure to be able to do the analytics component,” Taylor says.

A chief reason CDOs are needed is to govern healthcare data usage and act as a data steward. CDOs manage where employees access data, whether it’s a mobile device, tablet or smartphone. In this role the CDO helps catalog the healthcare data, document business definitions of the data and ensure that the health system improves the quality of the information. The CDO then works with IT to prioritize and fix the data.

Taylor noted that auditing controls in software will be required to meet the requirements of data governance.

CDOs Take the Lead to Protect Healthcare Data Quality

Nick Minale, CDO of Johns Hopkins HealthCare, the health insurance division of Johns Hopkins Medicine, describes his role as a steward of data and a champion of data quality.

“A lot of organizations talk about data quality or those activities, and without a champion, it often doesn’t get prioritized,” Minale says. “I have to put an ROI on the effort and show the value, and so in a typical IT environment, a lot of those things will just fall to the wayside.”

When IT tickets fail to receive attention, it takes a leader to shepherd projects through.

“I’m outside of IT, and I’m a champion for the business to get those data-quality efforts to happen,” Minale says. “I like to call myself the ‘data bridge’ to bridge that gap between what the business needs and what IT could deliver, given the right priorities and direction.”

As a data steward, Minale also spearheads the collection of data for population health projects.

“In my role, I’m not creating any of the analytics, but I’m helping to clean it up, get it to the population health analytics team in a better format, shape and quality so that they can then help the [insurance plan] members,” Minale says.

CDOs manage the gathering of information from multiple data sources and oversee the monitoring of data from cloud-based servers and vendor contracts, says Gloria Kupferman, chief data strategy officer at the American Hospital Association.

“Most large enterprises now store data in the cloud and are bringing together information from disparate sources (external and internal) to create deeper insights,” Kupferman explains. “From an IT perspective, this requires a different set of skills to manage and monitor the cloud-based servers and the vendor contracts.”

How Healthcare CDOs Address Data Regulatory Requirements

As part of the effort to maintain data compliance with regulations, Minale convenes a data sharing committee to vet data requests and ensure that data releases comply with state and federal regulations. Minale and the committee also ensure that data use agreements specify who the custodian of the data is. Additionally, Minale must meet the regulatory requirements for privacy regarding military data because he works under DoD contracts.

“[Members] are former military members, and so as you can imagine, there’s an extra layer of scrutiny there,” Minale says.

Data compliance is a key reason why healthcare organizations need CDOs, says Besa H. Bauta, CDO at MercyFirst, a nonprofit child welfare agency that provides healthcare services in the New York area. They are the go-to people for questions about HIPAA compliance and guidelines around protected health information, Bauta says.

“Data and compliance go hand in hand in a lot of ways, just ensuring that we’re providing the data in as timely and accurate a fashion as possible,” Bauta says.

At MercyFirst, Bauta and her team manage child vaccine and EHR data as well as behavioral data and demographic information. MercyFirst also integrates the health data with juvenile justice and educational data.

A Champion for New Data to Foster Innovation in Healthcare

CDOs will bring about innovation in healthcare through the predictive models that are being developed to analyze population health. This data will be critical as healthcare continues to move from a fee-for-visit model to a value-based payment model, says Rajib Ghosh, director of social health information exchange at Alameda County Care Connect and a former chief data and transformation officer at the Community Health Center Network in San Leandro, Calif.

The HIE that Ghosh is building for Alameda County will allow healthcare CDOs to deliver holistic data on patients rather than data from separate medical episodes, he says.

“All those things actually came front and center because the payment model got changed, and that required a transformation in the overall healthcare delivery,” Ghosh says. “Who is the best person to really deliver that is the person who understands the importance and the connectivity of the data elements, which is really the chief data officer.”

By being “plugged into” operations, IT and clinical workflows, CDOs are able to drive innovation, Ghosh says.

The key need will be for someone to help make better decisions on patient care, notes R. “Ray” Wang, principal analyst and founder of Constellation Research. “I think we’ll have chief data officers for some time because we’re inundated with so much data, and what we really want is to make better decisions.”

Author: Brian T. Horowitz


Symphony Shares Secrets of the ‘Super SNF’

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Symphony Post Acute Network has helped redefine the skilled nursing, transitional care business—so much so, some other providers in Symphony’s markets are banding together to stay competitive. But what exactly does Symphony’s model involve?

It’s a mixture of elements that together create a “super SNF,” Symphony President Tim Fields said Tuesday at the Post Acute Link Care Continuum Conference in Chicago. Symphony is based in the Windy City, and the Chicago area is the largest market for the company, which pulls in about $400 million in revenue annually.

The “super SNF” model, also known as a medical resort, combines medically complex care with high-end hospitality. It’s not a brand-new idea; Symphony and one of its development partners, Carmel, Indiana-based Mainstreet, have been among a few organizations to pioneer and go big on this type of facility over the past several years.

However, the super SNF is still a relatively novel concept, and those interested in the model might want to take some cues from what Symphony has done in a few key areas:

1. Staffing: The super SNF is something between a traditional skilled nursing facility and an inpatient rehabilitation facility or long-term acute care hospital. Non-invasive vents, low-dose inotropic drips, wound vacs, IV antibiotics/Lasix, and dialysis are among the services that might be offered. In addition, the business model rests on a high velocity of 100-plus admissions a month from a variety of settings, with a premium on short length of stay and high-quality outcomes to hit expectations of managed care organizations and similar referral partners.

It’s critical to hire staff that can handle and even relish this level of acuity and intensity, Fields said. Symphony gets the wage grids from area hospitals and matches registered nurse compensation dollar-for-dollar. Fields’ ambition was to hire RNs exclusively, but this turned out to be unrealistic in some markets where the labor pool is not so deep. Still, hiring more RNs than licensed practical nurses (LPNs) is important, with a 10:1 to 12:1 nurse/guest ratio.

Physician oversight also is crucial, with the leaders involved in weekly admission reviews, fall/wound/infection control, and quality assurance performance and improvement (QAPI). Symphony has negotiated with some of its hospital partners to designate a hospitalist to act as a SNFist, Fields said.

2. Clinical Programming: “Heart for Life Cardiac Program.” “Breathe Easy, Live Well Pulmonary Program.” “WoundRounds.”

These are just a few of the clinical programs Symphony has branded, to stand out in the marketplace.

“I think [branding] matters when we talk about doing something different,” Fields said.

Of course, clinical care is about more than creating a recognizable brand name, so these programs must be rooted in evidence-based protocols, Fields emphasized. Partner with local cardiologists, pulmonologists, nephrologists, and other specialists, he advised, and utilize tools like INTERACT to create a culture of clinical excellence.

3. Data Analytics: Being able to track data such as hospitalization rates is becoming table stakes for skilled nursing providers in an increasingly integrated health care marketplace, in which they’re being asked to demonstrate their value to hospitals and other referral partners.

Symphony also is implementing analytics tools such as Real Time Medical Solutions, which integrates with and scours the PointClickCare electronic medical record for information in order to flag particular patients for attention.

Another initiative is EMMI, an engagement tool for CHF and pulmonary patients, who are now getting a call every day for 45 days after discharge, in an effort to prevent hospitalizations during this timeframe. The data on this effort still is forthcoming, Fields said.

4. Guest Experience: Providing a top-flight guest experience is one of the hallmarks of a super SNF, Fields emphasized. Just as Symphony tries to lure its clinical staff away from hospitals and IRFs, it hires its hospitality staff from hotels and other customer-first industries. About 60% to 70% of Symphony buildings now employ an executive chef.

“We hired a lot from Chicago hotels, hotel concierges, and we’ve found Starbucks does a really good job training people,” Fields said.

The hospitality model is achieved through the physical plant, with a focus on private rooms and amenities like Starbucks cafes. But service with a personalized focus also is critical. Prior to admission, Symphony asks each guest to share their favorite food and drink, and one thing they miss from home, then has these things waiting in the person’s room at arrival.

“Something as simple as, ‘I miss Diet Coke and sudoku puzzles,’” Fields said. “When they admit to the building, that’s sitting on the bedside table. It’s a good first impression.”

The approach helps Symphony achieve high net promoter scores (NPS), which measures how likely a guest is to recommend Symphony to a family member or friend. Ritz-Carlton, one of the gold-standard hotel chains on this measure, has a 68.2 average NPS. A new Symphony building in Indiana has achieved a 69, Fields said.

As these best practices show, the Symphony model is demanding on an operator, but the payoff also can be substantial.

On the clinical side, for example, Symphony super SNF communities average a four- to five-star rating from the Centers for Medicare & Medicaid Services (CMS), Fields shared. In terms of financials, it’s possible to run EBITDARM margins of 20% or higher on super SNFs, he said.

Symphony is not immune to challenges felt across the sector, such as tight labor markets, Fields acknowledged to Skilled Nursing News. Still, he is firm in his belief that the super SNF is a strong operational model for the evolving health care system.

“I think it’s a great place to be,” he said.