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Medical Directors' Presence Key to SNF Performance Improvements

 |  By jfellows@healthleadersmedia.com  
   December 03, 2015

Physician leadership at nursing homes can substantially reduce costs and improve quality measures, but is a woefully underutilized resource.

A unique ACO partnership has reduced length of stay, readmissions, and costs for Medicare beneficiaries receiving post-acute care at skilled nursing facilities in New Jersey.  

How it achieved such improvements relies largely on the influence of physician leadership.

When Poonam Alaigh, MD, was New Jersey's Health and Senior Services Commissioner in 2010, her mother-in-law was diagnosed with a serious illness. Alaigh was able to navigate the fractured healthcare system because of her unique experience as a physician and healthcare executive. But she says she knew other patients and families were unlikely to have someone like her that could steer medical care appropriately.


Poonam Alaigh, MD

That experience led to a sort of personal mission for Alaigh after she left her appointed post in 2011 and says that "taking care of elderly and making sure they have the autonomy and respect they want is my personal and professional mission."

Alaigh drew on her personal connection to her in-laws to help develop the Atlantic Accountable Care Organization, a joint venture developed in 2010 between Atlantic Valley Health System, a Morristown, NJ-based nonprofit health system, and Valley Health System, a 451-bed acute care, nonprofit hospital, based in Ridgewood NJ.

"I work in the nursing home at the VA on the weekends," Alaigh says. "My patients tell me, 'If only we had all those resources.' Those things have inspired me when looking at the post-acute care world."

Focusing on Post-acute Care
Atlantic ACO decided to focus on post-acute care last year with Optimus Healthcare Partners, a clinically integrated network with 500 primary care and specialty physicians.


Thomas Kloos, MD

"Our analysis of data showed a significant regional difference in the post-acute care costs for both our ACO's as compared to national averages," says Thomas Kloos, MD, executive director for Atlantic Management Services Organization, which provides management services to both the Atlantic ACO and Optimus Healthcare Partners.

Two approaches helped Atlantic ACO understand why its metrics were an outlier. The ACO formed a multidisciplinary group of physicians, social workers, nurses, and others to analyze the data. The ACO also worked with the American Health Care Association (AHCA), the organization that represents more than 11,000 nursing facilities, assisted living facilities, and sub-acute care providers in the United States. ACHA shared data on length of stay, readmission rates, and the percentage of patients discharged back to community.

The collaboration helped Atlantic ACO develop a program that was meaningful to the 89 nursing home providers that are now part of the Atlantic and Optimus post-acute care initiative. "The nursing home partners raised the bar," Alaigh says. "It wasn't top down; it was organic. It met the needs of what they expected and at the same time, [it helped] the changes become sustainable."

New Jersey-area nursing home providers were also invited to the table. It gave them a voice, says Denise Ratcliffe, LNHA, strategic advisor at Christian Health Care Center (CHCC), a nonprofit, full continuum of care facility for seniors that includes short-term and long-term care.

"It's been great to let some guards down and share what's working and what's not," she says.
               
The Medical Director's Pivotal Role
The improvements that Atlantic ACO has seen are significant. Alaigh says for the first time, there have been two consecutive quarters of cost reduction in post-acute care among Medicare beneficiaries. In the first quarter, cost-per-member decreased by 1.8%, and by the second quarter, costs fell by 3.4%.

"That's huge," says Alaigh.

Ratcliffe says CHCC has seen improvements in some of its measures, too, since becoming part of the ACO. "Our readmission rate was 25%, we are down now, year-to-date, to around 16.6% and have gotten as low as 13%."

Ratcliffe also says that length of stay, previously 28 to 29 days, is now down to 25 days and CHCC is looking for efficiencies to reduce LOS even more. The facility's performance is on par with others in the high performing network.

It's an accolade that the nursing homes try to earn quarterly instead of yearly. Alaigh says the rapid cycle improvement keeps everyone engaged and energized. "This is not, 'my way or the highway,' " she says. Rather, "it's 'all boats rise together.' There are four pillars: evidence-based medicine, clinical operations, physician leadership, and outcome data. The top three quartiles are automatically in the high-performing network."

For facilities that don't make the cut, there is always next quarter, but they can also earn entry by improving significantly, says Alaigh. "We added an improvement score. Out of 89, only 12 haven't made it."

The pillar of physician leadership was added because early on in the development of the post-acute care program, it became clear to Alaigh that medical directors of nursing homes were key to improving metrics, but they weren't as active as they needed to be. "We believe if you're going to be involved in meaningful change, physicians have to take the lead," Alaigh says. "That's why 25% of the (high performance) score is based on how active the physician is in the nursing home."

At CHCC, the medical director is on site five to six days a week, but Ratcliffe says that isn't typically the case. "Many facilities have a medical director who is in once or twice a week. I think that's the biggest challenge as well where we're seeing the biggest improvements."

One of the most unique aspects of the program is that it is open to any nursing facility. Instead of approaching only those that were deemed high performing by the ACOs, Alaigh says she wanted it to be inclusive.

"We went from 61 to 89 facilities who want to participate," says Alaigh. "We wanted to engage with like-minded facilities, who wanted to experiment with change and knew the status quo was not sustainable."

And even though the nursing facilities are competitors, Ratcliffe believes there is more focus on working together because of population health goals. Such a broad approach also helps clinical staff who are doing the day-to-day work to better understand their roles in healthcare transformation.

"This program was inclusive to allow our post-acute facilities to develop the quality measures to report on and develop the transformational change processes to improve outcomes and reduce LOS and readmissions," says Kloos.

Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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