Download Improving Medicare Post- Acute Care Transformation

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Improving Medicare PostAcute Care Transformation
(IMPACT) Act of 2014
June 24, 2016
Erin Smith, JD
Executive Director, PACCR
Agenda
IMPACT Act Background
Quality reporting
Discharge planning rules
Unified PAC PPS
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IMPACT Act of 2014
Bipartisan bill passed on September 18, 2014 and
signed into law on October 6, 2014
Requires Standardized and Interoperable Patient
Assessment Data that will enable:
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Assessment and QM uniformity
Quality care and improved outcomes
Comparison of quality across PAC settings
Improve discharge planning
Interoperability
Facilitate care coordination
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How did we get here?
1999: MedPAC recommendations (1999, March 2014)
2000: Benefits Improvement & Protection Act
(BIPA)Report on developing standardized assessment
instruments
2005: Deficit Reduction Act (DRA)tested the concept of a
common standardized assessment tool in the form of the
post-acute care reform demonstration (PAC PRD).
Developed the Continuity Assessment Record and
Evaluation (CARE) Item Set
2013: PAC Reform hearing and letter to stakeholders
“The resounding theme across the more than 70 letters
received was the need for standardized post-acute assessment
data across Medicare PAC provider settings.”
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Quality Reporting
IMPACT Act Requires Standardization
IMPACT Act added new section 1899(B) to Title XVIII of the Social
Security Act (SSA)
Post-Acute Care (PAC) providers must
Report standardized assessment data:
• Data on quality measures
• Data on resource use and other measures
The data must be standardized and interoperable to allow for the:
• Exchange of data using common standards and definitions
• Facilitation of care coordination
• Improvement of Medicare beneficiary outcomes
PAC assessment instruments must be modified to:
• Enable the submission of standardized data
• Compare data across all applicable providers
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Why target PAC?
Important Part of the Health Care System
• 42% of Medicare FFS beneficiaries discharged from
hospitals go to at least one PACEscalating costs
associated with PAC
Lack of data standards/interoperability across
PAC settings
Goal of establishing payment rates according to
the individual characteristics of the patient, not
the care setting
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PAC Quality Reporting Programs (QRP)
Nursing Home and Home Health (HH) Compare
2005 – Deficit Reduction Act
• HH QRP
2010 – Patient Protection and Affordable Care Act (ACA)
• Long-Term Care Hospital (LTCH) QRP
• Inpatient Rehabilitation Facility (IRF) QRP
• Hospice QRP
2014 – Protecting Access to Medicare Act (PAMA)
• Skilled Nursing Facility (SNF) VBP
2014 – Improving Medicare Post-Acute Care
Transformation (IMPACT)
• SNF QRP
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Current Tools Differ by Setting
Acute Care Hospitals no standard tool, varies by hospital
Long-Term Care Hospitals LTCH CARE
Inpatient Rehabilitation Facilities IRF PAI
Skilled Nursing Facilities MDS
Home Health Agencies OASIS
Similarities
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Medical complexity
Motor Functional status
Cognitive status
Social support and environmental
factors
Differences
• Individual items that measure each
concept
• Number of functional items
• Rating scales used to measure items
• Look-back or assessment period
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Categories for Standardization
Function
• e.g., self care and mobility
Cognitive Function
• e.g., express & understand ideas; mental status, such as
depression and dementia
Special services, treatments & interventions
• e.g., need for ventilator, dialysis, chemotherapy, and total
parenteral nutrition
Medical conditions and co-morbidities
• e.g., diabetes, heart failure, and pressure ulcers
Impairments
• e.g., incontinence; impaired ability to hear, see, or swallow
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Implementation Timelines
FY/CY Year
IMPACT Act (standardized
measures)
Quality Domain
Functional status and cognitive
functioning
SNF
IRF
LTCH
2017
2019
HHA
October 1, 2016 October 1, 2016 October 1, 2018 January 1, 2019
Skin integrity
October 1, 2016 October 1, 2016 October 1, 2016 January 1, 2017
Major falls
October 1, 2016 October 1, 2016 October 1, 2016 January 1, 2019
Medication reconciliation
Communication of health info
and preferences
October 1, 2018 October 1, 2018 October 1, 2018 January 1, 2017
Resource Use - MSPB-PAC
October 1, 2016 October 1, 2016 October 1, 2016 January 1, 2017
October 1, 2018 October 1, 2018 October 1, 2018 January 1, 2019
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Discharge Planning Requirements
Proposed Rule
The IMPACT Act Created New Requirements
Discharge Planning and Discharge Summary CoPs
Hospital
Discharge
Planning
Process
CAH
Discharge
Planning
HHA
Discharge
Planning
LTCHs and IRFs are subject to the same hospital CoPs
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Hospitals, CAHs, and HHAs Would Have Additional
Discharge Requirements
Provide discharge instructions to patients who are discharged
home
Have a medication reconciliation process, with the goal of
improving patient safety by enhancing medication management
Send specific medical information to the receiving facility (for
patients transferred to another facility)
Establish a post-discharge follow-up process
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Proposed Timelines for Discharge Planning
• Hospitals and CAHs would be required to
Begin discharge planning process within 24 hours of
admission or registration
Complete and document a discharge plan before the patient
is discharged home or transferred to another facility
• HHAs would be required to
Complete an evaluation of the patient’s discharge needs
Complete and document a discharge plan before the patient
is discharged or transferred to another facility
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Discharge Planning Process
Regular reevaluation of
patient
Involve the
responsible
practitioner
Consider caregiver
availability and
patient’s/caregiver’s
capabilities
Involve the patient
and caregiver
Address patient’s
goals and
preferences
Assist in selecting
PAC provider
(for patients who
are transferred)
Timely
documentation to
avoid delays
Ongoing assessment
of discharge plans*
*not specifically required for HHAs in the proposed rule
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Assisting Patients in Selecting PAC Providers
Utilize and share data
on quality and
resource use
measures
Data must be relevant
to the PAC setting for
the patient (HHA,
SNF, IRF, LTCH)
Data must be relevant
to the patient’s goals
and preferences
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Hospital and CAH Criteria for Evaluating Patient Needs
Admitting diagnosis or reason for registration
Relevant co-morbidities and past medical and surgical history
Anticipated ongoing care needs post-discharge
Readmission risk
Relevant psychosocial history
Communication needs, including language barriers, diminished
eyesight and hearing, and self-reported literacy of the patient (and
patient’s representative or caregiver/support person(s), as applicable)
Patient’s access to non-health care services and community-based
care providers
Patient’s goals and treatment preferences
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Discharge Planning for Patients Discharged Home
from a Hospital or CAH
Discharge instructions at
time of discharge
• Patient and/or caregiver
• PAC provider, if referred to
community-based services
Information for follow-up
provider
• Discharge instructions and
summary (48 hours of discharge)
• Pending test results (24 hours of
availability)
• All other medical information
Instructions include
• Post-discharge care instructions for
patient in home
• Warning signs and symptoms, and
what to do if warning signs present
• Prescriptions and medication
information
• Medication reconciliation
• Follow-up appointments and care
instructions
Establish a follow-up
process
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Discharge Planning for Patients Transferred to
Another Health Care Facility
Provider must send necessary medical
information to the receiving facility
Necessary medical information, includes
• Demographic information
• Contact information
• Diagnosis
• Lab tests and other diagnostic testing
• Functional status assessment
• Medication reconciliation
• Patient’s goals and treatment preferences
 Full list can be found in the appendix of this
presentation
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Additional Hospital Requirements for Post-Acute
Care
 For patients who are discharged home with HHA services or transferred
to a SNF, IRF, or LTCH
Provide a list of available
HHAs, SNFs, IRFs, or LTCHs
• In the relevant geographic area
• Participating in Medicare or in
the MCO network
• Document that the list was
given to the patient
Inform patient of right to
choose provider
• Not limit the availability of
qualified providers
• Respect the patient’s preferences
among participating Medicare
providers
Disclose financial interests
• Any financial interest with any
provider to which the patient is
referred
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The Proposed Rule Notes Some Additional
Expectations of Providers
Improve focus on
psychiatric and behavioral
health
Know the availability of
community-based
services and organizations
Take reasonable steps to
provide individuals with
limited English proficiency
or other communication
barriers
Focus on person-centered
care to increase patient
participation in postdischarge care decision
making
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Hospitals and PACs Would Face Significant Financial
Implications
• In the first year, compliance would cost providers $454M, and
$396M annually in the following years
• HHAs would bear a majority of the costs
Provider Type
# of Entities
Frequency
Est. Cost (Millions)
Hospitals
4,900
1st Year
Annually
$17
$107
CAHs
1,328
1st Year
Annually
$7
$6
HHAs
11,930
1st Year
Annually
$34
$283
Total for first implementation year $454
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Unified PAC PPS
Timeline for Creating a Unified PPS
The IMPACT Act requires research and reporting on a
Prospective Payment System for all PAC providers
Would replace the four payment systems that are in use
today
Timeline
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June 2016: MedPAC report – concludes feasibility of PAC PPS
2022: HHS report in response
2023: MedPAC report with prototype of PAC PPS
2025(?): Possible implementation of PAC PPS
MedPAC encourages quicker implementation of a unified
payment system
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MedPAC Goals for a Unified PAC PPS
June 2016 Report: Conclusion that PAC PPS is
both feasible and within reach
General structure: Episode-based payments
focusing on the care needs & outcomes for
Discouraging provision of unnecessary services
Common payment framework across SNFs,
HHAs, IRFs, & LTCHs
Minimize financial incentives for providers to
admit certain types of patients over others
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Transitioning to a PAC PPS
Working towards uniformity
Need time for providers to adjust their costs
• Particularly for high-cost providers to lower their
costs to match the PAC PPS payments
MedPAC foresees a transition period where:
• Payments remain based on patient characteristics to
focus on care needs
• Unnecessary spending is financially discouraged
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Key Elements of a PAC PPS Presented by MedPAC
Uniform unit of service
Base rate for defined unit of service
Case mix adjustments to base rate. Must reflect:
• Differences in patient severity
• Differences in cost of labor, space, etc.
• Other differences in cost beyond provider’s control
Policies to adjust for both unusually low-cost
and high-cost stays
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Need for Companion Policies Alongside PAC PPS
Supporting the adoption of the PAC PPS at start
Dampening incentives that encourage fee-forservice (FFS)
MedPAC proposes:
• Readmission policy to prevent unnecessary hospital
readmissions
• Value-based purchasing policy to tie payments to
outcomes & resource use
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Connect with PACCR!
Post-Acute Care Center for Research
www.paccr.org
@PAC_CR
[email protected]
Post-Acute Care Center for
Research (PACCR)
[email protected]
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Appendix: Acronym Library
CAH
CMS
CoPs
EHR
HHA
IMPACT
IRF
LTCH
MCO
PAC
PDMP
SNF
Critical Access Hospital
Centers for Medicare and Medicaid Services
Conditions of Participation
Electronic Health Records
Home Health Agency
Improving Medicare Post-Acute Care Transformation Act of 2014
Inpatient Rehab Facility
Long-Term Care Hospital
Managed Care Organization
Post-Acute Care
Prescription Drug Monitoring Program
Skilled Nursing Facility
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Appendix: Information for Transfer to Another
Health Care Facility
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Demographic information, including but not limited to name, sex, date of birth, race, ethnicity, preferred language
Contact information for the practitioner responsible for the care of the patient, as described at paragraph (b)(4) of this se ction, and
the patient’s caregiver/support person(s), if applicable;
Advance directive, if applicable
Course of illness/treatment
Procedures
Diagnoses
Laboratory tests and the results of pertinent laboratory and other diagnostic testing
Consultation results
Functional status assessment
Psychosocial assessment, including cognitive status
Social supports
Behavioral health issues
Reconciliation of all discharge medications with the patient’s pre-CAH admission/registration medications (both prescribed and overthe-counter)
All known allergies, including medication allergies
Immunizations
Smoking status
Vital signs
Unique device identifier(s) for a patient’s implantable device(s), if any
All special instructions or precautions for ongoing care, as appropriate
Patient’s goals and treatment preferences
Any other necessary information including a copy of the patient’s discharge instructions, the discharge summary, and any othe r
documentation as applicable instructions or precautions for ongoing care, as appropriate
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