AHLA's Speaking of Health Law

Managing Population Health in the Post-Acute Care World

March 31, 2020 AHLA Podcasts
AHLA's Speaking of Health Law
Managing Population Health in the Post-Acute Care World
Show Notes Transcript

Greg Anderson, partner, Horne LLP, speaks with Jeanna Gunville, Shareholder, Polsinelli PC, and Arielle Schmeck, Senior Manager, JTaylor, about their presentation at AHLA’s Long Term Care and the Law conference held March 2-4, 2020 in San Antonio, TX. The podcast covers care coordination between acute and post-acute care providers, discharge planning, and what post-acute care providers can do to prepare for affiliation/collaboration/acquisition. Sponsored by Horne LLP.

To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.

Speaker 1:

Support for A H L A. And the following message comes from Horn, a different kind of accounting and advisory firm whose clients trust for industry focus, insights, street talk and collaboration. Horn's healthcare team is composed of financial professionals, former healthcare executives, and IT experts, 100% dedicated to healthcare. For more information, visit horn l l

Speaker 2:

P.com. Welcome to the HLA podcast. I'm Greg Anderson. I'm a partner in the healthcare practice of Horn, and I'll be the moderator today. I'm here with Gina Gunville. She's a shareholder with Polson, Italy in Chicago. And Ariel Schmeck, a senior manager with Jay Taylor in Fort Worth. Gina, can you tell us a little bit about yourself?

Speaker 3:

Sure. Well, hi everyone. I'm Gina Gunville. I'm a shareholder based in Chicago with Polson Elli. We're a national law firm, and we work frequently with providers along the care continuum that are looking at ways to align with each other and take advantage of opportunities under value-based care models to manage population health. So I'm eager to share some of that experience with you all today.

Speaker 2:

Thanks, Gina. We're glad to have you. Ariel, would you like to tell everyone about yourself as well?

Speaker 4:

Yeah, sure. Thanks for having me. Um, as Greg and Notta, my name is Ariel Schmeck. I'm a senior manager at j Taylor, which is based out of Fort Worth, Texas. Um, our group specifically spends a lot of our time dealing with providers across the healthcare continuum and advising them as part of transactions, as well as integration and strategy work. So looking forward to sharing some insights with you all here all today.

Speaker 2:

Thanks, Ariel. Thank you both. And I know you both have a lot of experience in consulting and providing legal advice in the post-acute space. And I'm really excited of our conversation today. Uh, we're, we're talking today about managing population health as a part of a post-acute network. Uh, Gina and Ariel actually spoke on this subject at the A H L A long-term care and the law conference in San Antonio in March of 2020. And we're excited to have them back to discuss some of the key points that are essential to post-acute care providers and to acute care providers and physicians that work with those providers. So, um, I I think the best way to do this is just to start with a series of questions. We'll, we'll hit on some of these and I'll, I'll probably, uh, ask either Ariel or Gina to, to chime in on, on the question and certainly, uh, the other person can, can add their comments as well. And so to get us started, Ariel, um, I'd, I'd love for you to be able to tell the audience what maybe one or two of the biggest developments are that have encouraged and or mandated, uh, acute and post-acute care providers to collaborate in this world we're in.

Speaker 4:

Yeah, so I'll address that from two points really. I think from the post-acute care provider perspective, and particularly with skilled nursing facilities, one of the biggest changes that we've seen as of late is the shift to the, um, the pdpm or patient driven payment model that Medicare has recently come out with and was effective as of October 1st, 2019. Um, under this model, you know, providers are really required to have a much better holistic sense than of the patient assessment on the front end of when patients are admitted to the skilled nursing facilities, which is really requiring a lot more collaboration with the acute care providers upon discharge. So that's been one of the biggest things. And then I'd say from the acute care provider space as more acute care, um, hospitals are looking to take on some type of risk from a reimbursement standpoint. They're becoming increasingly concerned with what happens to their patients once they leave the hospitals and are discharged to a post-acute care setting. So as pro as acute care providers are looking to get into some type of bundle or some other risk-based arrangement, um, they're really looking to create more partnerships with the post-acute care providers in order to limit readmissions on the backend.

Speaker 2:

Gina, as we've seen some of these arrangements that Ariel's describing, we, we've seen some of these, uh, facilities and, and there are collaborative efforts embedding practitioners or nursing staff in the skilled nursing facilities to manage some of the care transitions. And that, of course has been one of the big, uh, big complaints about the, uh, siloed, uh, providers and the, the not so clean handoffs that we've seen in the past. And so to better manage those care transitions that we we're seeing some embedded practitioners, um, also, you know, home health professionals as well. Can you speak to just the embedding of, of practitioners and, and even perhaps home health professionals in the, in the post-acute setting?

Speaker 3:

Absolutely. You know, as you're mentioning Greg, as these levers are changing as to how providers are getting paid under value-based care, they're required to collaborate more effectively together and find ways to, to coordinate the care. And so I personally have many clients developing arrangements to support that better care coordination and look at embedding personnel onsite in post-acute care settings to assist with those care coordination goals. So for example, a hospital employed advanced practice professional, like a nurse practitioner or physician assistant, um, on the acute care side, um, as part of their partnership with a post-acute care provider now is being placed within that skilled nursing setting. And, you know, with that, as a legal advisor, we, we have to be very clear under that services arrangement about the role being played by personnel, um, you know, on one side versus the other, the goals of the arrangement and any flow of compensation related to, you know, the benefit of having that resource now on site. Um, you know, and, and any, you know, if there are concerns with regard to taking advantage of resources and increasing referrals between the parties, whether or not, um, you know, that arrangement complies with any applicable waivers under the payment model that they're trying to take advantage of. So, but it is becoming more common that were presented, um, you know, with kind of a strategic idea, what can we do to, to embed those people onsite, just this with these care coordination goals, and then we flush out the terms of the arrangement from there.

Speaker 5:

Thank you, Gina. Ariel, the next question is for you with, uh, with the talk of pdpm, and you mentioned this earlier in our conversation, there've been a lot of across the board, uh, therapy staff reductions. Do you think this might present challenges to skilled nursing facilities in improving quality?

Speaker 4:

Yeah, so that's a great question. I would say at least in our experience in working with our clients, and it hasn't necessarily been across the board consistently, um, historically, I think there's been certain facilities that may have been focusing on the types of care that require a significant amount of more therapy hours as compared to others. Um, specifically those that have focused on some type of orthopedic, uh, care post, um, the acute facilities. But I do think that that is a, you know, a serious concern as it relates to the SNS as they're looking to improve quality. Um, you know, I think all of our providers and clients that we work with in the market would say that there's already such a strain from a staffing perspective to begin with, that in addition to these changes as Smiths are really looking to set themselves apart from a high quality care, is going to become increasingly difficult to continue to recruit some of those providers and maintain their, um, relationships with them and also continue to train them. So in short, yes, I do think this is a challenge that sniffs will continue to need to address, um, and is something that will likely play out for the foreseeable future.

Speaker 5:

Thank you. Uh, we, we tend to focus a lot in value-based care on things like preventable hospital readmissions. And Gina, I'd I'd direct this question to you. To what extent do you think preventable emergency department visits also represent an opportunity for, uh, hospitals, physicians, uh, post-acute care, uh, staff to, to collaborate around, uh, uh, the, the transition of care and the reduction of, of hospital readmissions?

Speaker 3:

Well, there is, as you mentioned, a lot of industry focus on the markers and indicators and certain patient populations that can flag for their providers the likelihood of a future ED visit or the potential for a hospital readmission. So lots of our clients are thinking strategically about how they can deploy resources better to patients in a non-acute setting to to monitor that, those, those potential markers or whether through remote patient monitoring or through at home, uh, visits, you know, maybe from a paramedicine type providers, in order to better manage that population and get ahead of that, the question becomes, you know, which provider has the responsibility to enter into that type of arrangement and bring that as a strength, you know, to the partnership. And so we've seen affiliations between providers where, um, the post-acute care provider has a special arrangement with a vendor for remote contracts, patient contracting, or, um, you know, where the health system requires, you know, in order to participate within its preferred provider network that, you know, the post-acute care provider is willing to deploy this resource as part of the, you know, the care, the collaborative care model. So mm-hmm.<affirmative> there, there's definitely a lot of interest in, um, in focusing on those markers and indicators and getting ahead of that to reduce the emergency department visit.

Speaker 5:

Thank you. Uh, Ariel, to you with another question. Kind of along the same lines, uh, we've found that patients and caregivers tend to express their preferences when we talk about how patients are discharged, uh, to facilities. So a patient in an acute care facility may, may want to be, uh, discharged to a facility that's closer to home, but it may be a lower quality post-acute care facility. Um, do you see effective for these higher quality post-acute care providers to, to gain market share in this environment and maybe in spite of, uh, or certainly in, in dealing with patient and caregiver preferences?

Speaker 4:

Yeah, I really think, you know, one of the biggest things that the post-acute care providers can do is work to ensure that the acute care team, whether it be the nurse, um, coordinators or some type of discharge personnel, has a good understanding of the level of quality of care that your facility can provide. Um, now obviously from a legal perspective, the acute care providers are required to list out what all of the options are from a discharge perspective for, for post-acute care providers to their patients, however, working to ensure that there's some type of partnership, even if it is, you know, a, a loose, not a contractual relationship, I should say. Um, but just ensuring that they understand exactly what quality metrics you've met, um, particularly citing back to information that may be on CMS compare or your state websites. Um, and really just working to make sure that you have a partner within the acute care facility who can be essentially an advocate for lack of a better term, um, when working with patients and caregivers to ensure that they are, um, that they have a full understanding and a good, um, picture of what it looks like from a quality perspective amongst the different post-acute care providers that they may be referred to.

Speaker 5:

Sure. And, and Gina, have you experienced some best practices for use of care coordinators to, to manage patients through the transition of care, uh, whether it's from hospital to post-acute or maybe from hospital to post-acute all the way to home? Any, any sort of best practices or advice there?

Speaker 3:

Yes, definitely. And really we can, uh, point to, uh, studies that have been done to assess high performing accountable care organizations that have already demonstrated strengths in, you know, reducing cost of care by efficiently working with, you know, skilled nursing facilities and home health agencies on, for example, what, what we call warm handoffs. And we mentioned this a little bit earlier in the podcast, but that concept, again, of having a care coordinator follow, uh, a patient through the transitions of, of care sites, um, has been shown to be very effective at managing care for, for that patient. And that, that strategy involves, um, for example, like if you were working with an accountable care organization, um, you'd assign a, a care manager to establish a relationship with the beneficiary, um, prior to their discharge from an inpatient setting, and then be responsible to follow that patient, um, you know, through to the post-acute care facility site and monitor care provided their, you know, 30 days post-discharge. And that individual too can be essential for, uh, you know, monitoring that there's, um, medication, um, is appropriately reconciled and delivered appropriately, and all the records are transferred and the information is correct from site to site, as well as, um, you know, inquiring about some essential, um, services that are not necessarily delivered by the healthcare provider, but are nonetheless essential like transportation to appointments and, um, that deliveries of necessary me medical equipment are able to be received and, and arrive on time, things like that.

Speaker 5:

Thank you. That's great. And, and I'll start with the next questionnaire, Ariel, with you, but Gina, I'll ask you to chime in as well, and that is what, what is it that post-acute care providers can, can do now to get ready for these provider networks, these partnerships, affiliations, you know, Gina you spoke to, to accountable care, for example, uh, or even acquisitions for that matter. How can, how can post-acute care, uh, providers or facilities better market themselves, uh, and make themselves available to potential partners?

Speaker 4:

Yeah, I'd say from, you know, first off is really focusing on quality, um, first and foremost, and not only just ensuring that you're focusing these things on the day-to-day, but what can you be doing from an actual data perspective to prove this out? Um, so working to ensure that you have the IT structure or infrastructure in place, um, so that you can actually track this on a regular basis and working to ensure that this reporting, um, can be interoperable with other acute care and other types of partners that you may be interested in to looking into doing some type of either affiliation or transaction with. Um, and then I would also say, you know, once again, going back to just trying to work with the partners in your area to ensure that they have a good understanding of the type of care that you can actually provide on a high quality basis. So we've seen some of our clients who have really focused on working on some of the more complex cases as it relates to C O P D or congestive heart failure, and really, you know, working to focus on some of those specific areas may be helpful depending on the type of partnership or potential acquisition that you're looking to, to affiliate with.

Speaker 3:

Mm-hmm.

Speaker 5:

<affirmative>, Gina, anything to add?

Speaker 3:

Yeah, likewise, I think like in this process of determining the, the strategy or the types of arrangements that would be a good fit for your organization considering, you know, where you have shared values and alignment with other providers in your community and, uh, shared interest in serving a specific patient population you're talking about with, you know, Ariel saying, knowing your strengths in terms of the types of, um, patients that you're best able to serve. And then taking that and finding alignment with values in a, in a, in a, in another provider along the continuum, how you can partner together to provide the, the best care possible for that patient population.

Speaker 5:

Fantastic. Thank you. And, and Ariel and Gina, this, this has been super insightful and I know our members and, and I certainly do appreciate the time and effort you put into the podcast and, and the great insights that you've shared with us. I've got one more question for each of you as we wrap up today's talk and, and this question, essentially this, and I, I guess, uh, Gina, since you went last, I'll, uh, I'll pose this one to you first and then Ariel, I'll come back to you with the same question. But Gina, what, what sort of creative ideas or strategies maybe that we haven't already talked about? You both brought up some very good ideas already. Uh, what would you recommend to post-acute care facilities who want to take advantage of just this, this environment that we're in right now of moving from volume-based, volume-based, uh, care and payment to, to value-based care and to value-based payment models? Any specific advice or strategies that you might recommend to post-acute care facilities?

Speaker 3:

So I think that in this environment, uh, post-acute care providers are already limited in resources to adapt to changing payment models and really do need to be strategic about, about what efforts they they put in to be able to engage with other providers along the continuum. And I think my advice would be, uh, you might be targeting only one particular type of arrangement now, but think broadly enough about building infrastructure and, um, you know, building out your, your model of care in a way that will help you target, uh, type of relationship for the present, but also, um, give you, um, good access to data about your quality and your ability to serve patients that you can, um, still remain nimble to, to use that for partnerships that are going to emerge in the future. I do think there's going to be continued interest both from government and commercial payers and, uh, bundled payment programs and other, other, uh, you know, reimbursement, uh, models to take advantage of. So, um, try to, try to be forward thinking, um, and not just target just a present relationship, but building that infrastructure and those relationships, um, within your, uh, organization and outside of it that can position you all for the future.

Speaker 5:

Great advice. Gina, Ariel, do you, uh, want to chime in on that question as well?

Speaker 4:

Yeah. I'd say one of the things that we've seen some of our larger independent skilled nursing facility providers who may have, you know, more than a few dozen, um, facilities within their network is actually looking to become a payer themselves. Um, and so by that I mean specifically taking, uh, taking advantage of some of the provider led Medicare advantage or institutional special needs plans, um, some of our clients have had success in getting these plans actually up and running such that they're able to bear some of the risk from a Medicare advantage reimbursement standpoint and really use those dollars to fund their care. Um, now this is something that is, would be, you know, pretty difficult to do for some of the smaller independent providers, but certainly something that I think a number of clients have had success with if they have the scale to do it.

Speaker 5:

Great. Thank you very much. Well, again, this has been tremendously insightful and, and I, for one, appreciate the time and effort you put into this. So, uh, just to wrap things up again, I'd like to thank Ariel Schmeck, who is with Jay Taylor in Fort Worth, and Gina Gunville with Polselli in Chicago for your insights and for the time you spent in the conversation with us today. And this concludes today's podcast. Thank you.