A Solution To Reduce Medicare Spending Per Beneficiary For Hospital Systems, ACO’s, Healthcare Plans and Skilled Nursing Facilities

The Community Integration Model

Post-Acute Non-Medicare Community Options


According to the Centers for Medicare and Medicaid Services, 40.3% of all Medicare spending during a patient’s MSPB Episode occurs after the patient is discharged from the hospital.  The highest Post-Acute cost category is skilled nursing1.


Identifying and eliminating avoidable Post-Acute Skilled Nursing Facility (SNF) admissions is not only a key component of the CIM, but is indispensable in reducing Medicare Spending Per Beneficiary Measures.

 

The problem exists because many physicians “automatically” admit their patients to SNF’s after the hospital discharge even if they only require daily custodial assistance.  This discharge pattern occurs because physicians may be unaware of viable alternative non-Medicare Post-Acute options.


In fact, a 2003-2004 study of Wisconsin hospitals revealed that more than 50 percent of physician-ordered discharges from hospitals to Skilled Nursing Facilities were in fact, deemed “Medically Unnecessary”2. This can severely impact the financial efficiency of a hospital.


The Community Integration Model’s solution involves the use of a sophisticated software platform that “clinically matches” a patient’s diagnosis and care needs to specific individual Assisted Living or Memory Care communities along with the medical oversight of a Medicare Home Health Agency for patients that do not necessarily require an in-patient Skilled Nursing Facility stay.



WHAT YOU MAY NOT KNOW ABOUT TODAY’S POST-ACUTE ALTERNATIVE SNF CARE ENVIRONMENTS.


In the past decade, the Assisted Living industry landscape has changed drastically.  Assisted Living was once thought of as retirement communities with state of the art shuffleboard facilities. That is no longer the case.  


Only 10 years ago, the average Assisted Living Facility resident was 74 years of age and only needed minimal assistance with the Activities of Daily Living (ADLs).  


This profile has dramatically changed.  According to the National Center for Assisted Living2.  Over half of the residents are over 85 years old and the typical resident is an 87-year-old woman who needs assistance with approximately two to three ADLs (sometimes more) including:


Bathing  72%

Dressing  52%

Toileting  36%

Transferring  25%

Eating  22%


ARE ASSISTED LIVING FACILITIES EFFECTIVELY MANAGING PATIENTS WITH MULTIPLE CHRONIC CONDITIONS?


Today’s Assisted Living/Residential Care providers have become increasingly adept at effectively supporting the health and well-being of higher-acuity patients such as elderly residents with multiple chronic conditions.  This experience and skill enables these providers to be highly effective in caring for post-acute patients.


As evidence, 67% of all Medicare beneficiaries and 75% percent of all seniors in assisted living have multiple chronic conditions including:


High Blood Pressure: 57%

Alzheimer's /Dementia: 42%

Heart Disease:  34%

Depression:  28%

Arthritis:   27%

Osteoporosis:  21%

Diabetes:  17%

COPD   15%

Cancer:   11%

Stroke:   11%


Approximately 26% of assisted living residents have been diagnosed with 4 to 10 of the most common chronic conditions, 50% of residents have been diagnosed with 2–3 of the most common chronic conditions and 18% have been diagnosed with one chronic condition.


Noteworthy is the fact that only 6% of assisted living residents have never been diagnosed with any of the top 10 chronic conditions.


HOW ELSE ARE ASSISTED LIVING FACILITIES EFFECTIVELY CARING FOR THEIR RESIDENTS?  


Proper diet and accurate medication management are also extremely important factors in effective post-discharge care and in reducing readmissions.  It worth noting that 87% of assisted living facilities’ residents need and receive professional help with nutritional planning and meal preparation, and 81% receive professional oversight managing their medications.


CAN PROFESSIONAL SKILLED NURSING SERVICES BE PERFORMED BY MEDICARE-CERTIFIED HOME HEALTH AGENCIES IN ASSISTED LIVING ENVIRONMENTS?


Many medical professionals and physicians are not aware that Assisted Living with Medicare-Certified Home Health services is a medically viable, and often, a patient preferred alternative to a rehab SNF for many patients with multiple chronic conditions.  


Medicare-Certified Home Health services are being fully utilized in Assisted Living/Residential Care environments nationwide.


Medicare-Certified Home Health Agencies perform services that are normally performed in SNFs.  Post-Acute patients that are discharged into Assisted Living/Residential Care setting are receiving the following skilled services while in these facilities with a significant savings to Medicare.  Skilled services include;


 Wound Care

 Physical Therapy

 Speech & Language Pathology

 Occupational Therapy

 Registered Nursing Visits

 Social Work Intervention

 Certified Nursing Assistant services


The growing trend towards long-term support of higher acuity patients in assisted living is also being met with higher levels of skilled staffing.  


Silverado Senior Care, a Memory Care Leader headquartered in Irvine, California, for example, recently reported at the National Readmissions Prevention Collaborative Conference in May, 2014, that many of their Assisted Living communities offer more actual nursing hours per day per person than many Skilled Nursing Facilities.  


With the launch of the MSPB Measures, hospitals are already seeking alternatives to skilled nursing facilities that reduce or eliminate Medicare funded services especially using The Community Integration Model.


Essentially, hospitals will be evaluating any post-acute services paid for privately prior to considering those alternatives that are Medicare funded.


Health plans and managed care organizations are likely to be even more aggressive in their pursuit of seeking privately paid services.


Every hospital’s goal is to discharge patients to environments that can effectively manage a patients specific care needs. Assisted Living/Residential Care settings are uniquely positioned to effectively manage many post-acute patients with multiple chronic conditions enabling them to recover in the least restrictive environment that meets their care needs.  


WHY IS IT IMPORTANT TO BE IN THE LEAST RESTRICTIVE ENVIRONMENT?


Many health professionals are unaware of the landmark U.S. Supreme Court decision in 1999, which states that individuals with disabilities must be given the right to receive services in the least restrictive environment possible (Olmstead v. L.C. Olmstead).  


Today’s assisted living and residential care communities have been experiencing ever increasing patient acuity and has effectively repositioned itself to be not only a viable discharge option for seniors with multiple chronic conditions, but in many cases, is the preferred, least restrictive option that meets the care needs of the post acute patient.  


WHAT OTHER FACTS ARE IMPORTANT TO KNOW ABOUT THE CHANGES IN ASSISTED LIVING ENVIRONMENTS?


The National Study on Residential Care Facilities conducted by the Center for Disease Control in 2012 highlighted several important assisted living statistics. Nearly 6 in 10 residential care communities had 4–25 beds, but more than 7 in 10 residents lived in communities with more than 50 beds.


A higher percentage of communities with 26–50 beds and more than 50 beds were chain-affiliated and in operation for 10 years or more compared with communities with 4–25 beds.


A higher percentage of communities with more than 50 beds provided dementia-specific programs for residents with cognitive difficulties when compared with communities with 4–25 beds and 26–50 beds.


The same national study identified that assisted living patient acuity rates have been climbing for the past 5 years.