By JUDITH VANDEWATER
ST. LOUIS — The health reform law that is reshaping health care finance and delivery in the U.S. is expected to significantly influence how care is delivered to elderly patients inside and outside of hospitals.
Speaking to ministry leaders meeting here for two days in mid-December, Julie Trocchio said that, in writing the law, Congress sought ways to make care more coordinated and patient centered, to weaken the nation's bias toward providing long-term care in institutional settings and to incent providers to do more to keep frail, impoverished seniors in their homes and communities. Trocchio is CHA's senior director of continuing care.
Congress also sought ways to reverse practices that have turned Medicaid into a de facto long-term care financing mechanism for the middle class, she said.
But, particularly in regard to non-acute services for chronically ill and frail seniors, Congress did not mandate change. Instead, it is looking to the states to take up new options for programs and to health care organizations to be creative and point the way forward. It has earmarked money for piloting innovative programming. Quoting CHA President and Chief Executive Officer Sr. Carol Keehan, DC, who kicked off the first day of the conference, Trocchio exhorted the audience: "Leave no demonstration money behind!"
The Catholic Health Strategy Summit: Integrating Services for Seniors brought together about 100 leaders in Catholic health care, including sponsors, chief executives, mission leaders, operations managers and clinical care coordinators from hospitals and long-term care facilities and systems.
Unified goals
The meeting was in response to numerous requests from CHA members who wanted the ministry to collectively examine how Catholic health care can strengthen its services to older people. Many presenters and attendees expressed an interest in an active and ongoing dialogue to shape the evolution of senior care services. In her opening remarks, Sr. Carol said the ministry is providing exceptional care to seniors and is working to ensure that the elderly are treated with dignity and sensitivity.
"It's a watershed time for us within CHA," said Dale Thompson. He is president and chief executive of Cambridge, Minn.-based Benedictine Health System. Thompson said that given the reach of Catholic providers across the country and across all levels of care, and their shared desire to preserve and strengthen Catholic health care, ministry collaborations and brain trusts can help providers survive and prosper in a time of dramatic change.
For its part, Benedictine is preparing for the future by resetting its service mix to reduce the number of beds in its traditional nursing facilities by 25 percent while it increases its focus on providing profitable post-acute care that funds other senior services. The system is working to coordinate its post-acute care closely with referring hospitals and to position its facilities to accept risk-baring contracts from insurers, Thompson said. It is also moving to increase its number of assisted living units by 33 percent.
Thompson challenged audience members to ask fundamental questions to evaluate their service mix. Questions that gave him pause when Benedictine went through that exercise included, "Why is it that we say to people, 'Give up everything you have and move to our real estate and we can help you?' Why is it that every new service involves a $30 million mortgage? Why is it we can't walk across the street, and, in the most fundamental ways, help people stay healthy in the place they call home?"
Reducing readmissions
In advance of the meeting, CHA commissioned Howard Gleckman, a journalist who is a resident fellow at the Urban Institute, to survey the long-term care landscape and identify pressure points and relief valves including cutting-edge approaches to care delivery. Among his discoveries are a program that assigns a registered nurse to provide in-home follow-up for high-risk patients and a program grounded in the emergency department that allows select patients to receive hospital-level care in their homes.
Gleckman said that as Medicare resets its payment schedules in the fiscal year that begins Oct. 1, 2012, and starts to penalize hospitals for excessive readmissions of Medicare patients within 30 days of discharge, hospitals will demand better care management for patients released to long-term care settings. By 2017, hospitals will have as much as 6 percent of their base Medicare payments at risk.
Len Fishman, chief executive of Hebrew SeniorLife, a system of senior housing and health services in greater Boston, said in his presentation that more than one in five Medicare patients discharged from a hospital to a skilled nursing unit is readmitted to a hospital within 30 days. It is estimated that 80 percent of those readmissions are avoidable.
Hebrew SeniorLife, a Harvard University-affiliated academic teaching center, has reduced readmissions by improving hand-off communications in patient transfers from the hospital to the post-acute care setting and by creating a no-blame culture in which staff own up to mistakes, and learn from them, he said.
Shift to subacute care
Dr. Joseph Scarpa cited a 2008 study from Baylor University Medical Center that found being a nursing home patient is the number one risk factor associated with 30-day hospital readmission for patients 65 years and older. The researcher conducting that study said intervention in the long-term care setting "may be effective in reducing readmissions."
As vice president of medical services for Bon Secours New York Health System, Scarpa launched a program in March 2008 that closely links specialty care at Montefiore Medical Center in the Bronx, N.Y., with a cardiopulmonary subacute unit at Bon Secours Schervier Nursing Care Center in nearby Riverdale, a Bronx neighborhood. When the program began, Montefiore had one of the top readmission rates in the country, Scarpa said.
In developing the 39-bed subacute unit, Schervier made investments in its physical plant, installing oxygen and suctioning in the walls. It established protocols for attending physicians and subspecialists to monitor patients on the unit, and it refreshed and upgraded the skills of its nursing staff. Good Samaritan Hospital, a sister institution about 30 miles from Schervier in Suffern, N.Y., put together a program to teach Schervier's nurses assessment skills and update their core competencies in hospital-caliber care. In exchange, Schervier provided Good Samaritan instruction in wound care and in methods that reduce the risk of pressure ulcers.
The subacute unit at Schervier targets patients who expect to recuperate and return to their homes. Most are insured by Medicare and will stay a minimum of four weeks. Scarpa said revenue from the unit is helping Schervier survive in the face of annual cuts in Medicaid reimbursement rates from cash-strapped New York state.
The Urban Institute's Gleckman said Schervier saves Medicare about 75 cents on the dollar compared to what it would cost to care for the same high-acuity patient in a hospital. The comparative lower cost of providing subacute care in a skilled nursing facility may make that an attractive option for care providers who are positioning themselves to participate in accountable care organizations. ACOs will accept bundled payments and distribute those funds to physicians, hospitals and other providers involved in an episode of care for a patient covered by Medicare.
Scarpa said that the Schervier subacute unit has reduced hospital readmissions. Most of its readmissions involved patients with three or more comorbidities.
Fishman of Hebrew SeniorLife said that there will be a "tremendous change pushing patients into whatever care setting makes the most sense from a quality and cost kind of view. I think hospitals will be in the business of trauma, big surgeries and little else," he said.