When building a value-based care strategy, healthcare organizations should focus on improving care delivery across skilled nursing facilities, at-home services, and end-of-life services, Steven Strongwater, MD, President and CEO of Atrius Health, said at Xtelligent Media’s Value-Based Care Summit in Cambridge, MA on November 15, 2016.
At Atrius Health, a Massachusetts-based healthcare system, providers started to achieve value-based care goals, such as improving quality of care and driving down overall healthcare costs, by targeting care delivery at skilled nurse facilities.
Strongwater pointed out that Medicare reimburses providers for a certain amount of days in a skilled nursing facility, but most patients don’t need care for the full 30 days. By better managing skilled nursing facility patients, organizations can save healthcare dollars.
To improve this area of care, Strongwater explained that Atrius Health partnered with high quality skilled nursing facilities:
“This was our approach to the skilled nursing opportunity. What we effectively did was that we vetted skilled nursing facility experts inside those skilled nursing facilities. These are typically nurse practitioners that cared for people in the skilled nursing facility and when you have these providers imbedded in that facility you can see that the length of stay is lower by 14 days typically versus 30 days. So, we cut that metric almost in half and the readmission rate, which was in the 25 percent range, was down to 8 percent.
And for us, a two-day length of stay reduction is worth about $2 million. So, it was a great investment for us. When we went to our skilled nursing facilities partners and said, look, we want you to use these protocols, we want you to work on the same issues we are working on. The length of stay went down to about 15 days. For those that were unmanaged, the stay was 22 days and their total medical expense was $11,000. That’s $4,000 difference in costs when they are managed or unmanaged. Over the course of a lot of cases, that turns out to be a lot of money."
By improving this area of care, Atrius Health saw a 15 percent improvement in length of stay at skilled nursing facilities as well as lower hospitalization and rehospitalization rates.
Atrius Health also focused on improving home healthcare to strengthen their value-based care strategy, Strongwater added. Atrius Health developed its own visiting nurse association, which acted as the organization’s core primary partners.
However, Strongwater noted that patients were admitted to almost sixteen different hospitals that did not always use Atrius Health’s skilled nursing staff because they had their own associations.
Atrius Health focused on getting more of their patients to see their own skilled nursing staff or visit a trusted partner, Strongwater said. The organization ended up getting their patients to see their association about 66 percent of the time, but Atrius Health plans to continue working to keep patients in their system that follows the same value-based care protocols.
Strongwater also pointed out that Atrius Health targeted end-of-life care to improve their value-based care strategy. The organization encouraged their providers to create end-of-life care plans for their patients to improve quality of care when the time comes and reduce wasteful spending.
“End-of-life care is another really important area to focus on," he explained. "We spend a lot of money in the last six months of life and many patients are dying in hospitals as opposed to dying where they prefer, which is in typically their homes with their families.
What we’ve done is being able to move 14 percent to 52 percent of patients having that plan. The best practice is to do this on an annual basis when you’re healthy, so people can think about it and your mind changes over time. It has to be a conversation that takes place over a long period of time.”
Atrius Health started out by developing a communication strategy for social workers and their patients, but the organization went on to establish social workers in the practice to improve end-of-life care and care planning.
“This also helps us with end-of-life care and some of the social determinants that drive 40 percent of healthcare costs,” Strongwater added.
While Atrius Health focused on these three care delivery areas, the organization also implemented value-based practice transformations across their care sites, Strongwater continued. Atrius Health started by reducing use of low-value services, decreasing unjustified practice variation, incentivizing providers, and implementing data analytics tools.
“We started off by targeting these low-value tests and basically, there are recent studies that show 28 low-value tests could save a whole lot of money,” Strongwater remarked.
Targetting unjustified practice variations also helped to improve population health management and value-based care, he continued.
“How do you do that,” Strongwater said, “Practice guidelines, cookbook medicine. We’re talking about highest quality. Talking about what’s referred to as practice reliability where your patients get what they should get all the time. That’s what a practice guideline gives you, safety, security, quality for your patients.”
Providers also need to understand how well they are performing to spur behavior changes, Strongwater added. Atrius Health provides physicians with a monthly report card that explains how well they are going with practice variation guidelines, where they spend the most money, and how well they are using referring providers and skilled nursing facilities.
Using individual performance reports, Atrius Health financially rewards providers for high-quality and affordable care. But the incentives focus more on quality versus cost, he added.
Strongwater also emphasized that healthcare organizations need data analytics tools to implement value-based care.
“The starting point really is investment in your data analytics tools to be able to accurately identify high-risk patients, which gives you the greatest opportunity to intervene and care for those patients,” he continued.
Using the Atrius Health roadmap, Strongwater noted that healthcare organizations can develop and implement value-based care strategies. Based on his organization’s successes, he advised organizations to focus on easy methods for improving quality and reducing costs.
“This is my effort to say where you should start,” he said. “If you simply do a high effort versus low effort, low reward versus high reward grid and you kind of map out the things that Atrius Health has done. And you say what’s low effort but high reward, that’s where we would say to start.”
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