DRAFT: This module has unpublished changes.

Proposal for Establishing the Stormont Vail Health

Continuum of Care for Seniors

 

TO: Stormont Vail Health Board of Directors

FROM: Business Development Department (Dion Harris, Hannah Hohendorf, Wael Khreiss, MD, Jesus Rodriguez)

DATE: May 15, 2017

 

Introduction

Stormont Vail Health is a major provider of community health services in Shawnee County Kansas. The elderly population has complex health needs that are expensive to treat. Therefore, the Business Development Department (BDD) proposes that Stormont Vail Health lead an initiative for the creation of a continuum of care for seniors in Shawnee County. By facilitating improvement in their healthcare delivery, Stormont Vail Health will be able to treat these patients more cost-effectively which will contribute the the organization’s financial stability moving forward.

 

Background

2010 census data revealed that 15.5% of the Shawnee County population is ages 65 years and older (Shawnee County Community Health Improvement Plan Planning Group, 2015). This subset of the population is increasing in size, and with it comes the increasing prevalence of chronic physical and mental health issues. Combine these needs with housing and nutrition services and the necessity of partnership with community organizations is apparent. This is why the Stormont Vail Continuum of Care for Seniors was developed.

 

Evashwick & Aaronson (2006) described a continuum of care framework as including providers that covered extended, acute, ambulatory, and home health services as well as overall wellness and housing programs. Then, these organizations were linked by four mechanisms: inter-entity structural mechanisms, care coordination, information technology, and finance integration. This is the framework that the Business Development Department (BDD) used to develop the Stormont Vail Continuum of Care for Seniors to provide a comprehensive, coordinated system of care designed to meet the needs of seniors with complex chronic problems by utilizing community resources appropriately and in a cost-efficient manner.

 

Community Partners

The BDD worked to identify care and community partners that were already established and could be connected to the care continuum with a minimum amount of added resources by the health system. The proposed continuum of care partners are listed in the table below with the rationale for their services and quality metrics.

 

ServiceOrganizationData SetsMeasures of QualityQuality Data Sources
Acute CareStormont Vail Health According to the 2015 Shawnee County Community Health Improvement Plan 15.5% of the Shawnee County population is over 65 years of age (Shawnee County Community Health Improvement Plan Planning Group, 2015). 

-Colonoscopy follow up

-For MI, time to thrombolytics (30 min)

-ED stay time

-Time to thrombolytics after stroke (< 3 hrs)

-Surgical complications

-Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results

-AHRQ

-Hospital Compare

Extended CareKansas Rehabilitation Hospital 

In 2015, 3.7% of the Medicare population in Shawnee County was treated for stroke.

From 2013-2015, the age-adjusted cerebrovascular disease rate mortality rate/100,000 people was 38.9 which is higher than the Kansas average of 38.4 and the national average at 36.5

(Kansas Health Matters, 2017).

-Rate of unplanned readmission after discharge

-Inpatient Rehabilitation Facility (IRF) Compare (Medicare.gov)

Ambulatory CareCotton-O’Neil  Clinics

In 2015, the Medicare population in Shawnee County had the following statistics:

53.9% hypertension diagnosis 48.1% hyperlipidemia diagnosis

25.1% diabetes diagnosis

(Kansas Health Matters, 2017)

-Diabetes

-Nutritional guidelines

-Falls

-AHRQ
Home CareMidland Care Connection Inc.According to the 2015 Shawnee County Community Health Improvement Plan 15.5% of the Shawnee County population is over 65 years of age (Shawnee County Community Health Improvement Plan Planning Group, 2015). 

-30 day readmission

-timely start of patient care

-Functional measures such as grooming, bathing, toilet transfers

-Hospital data (Stormont Vail)

-CMS Home health compare

 
Outreach CareMeals on WheelsAccording to American Fact Finder: 2.9% of males and 7.9% of females over the age of 65 in Shawnee County live alone (U.S. Census Bureau, 2010).

-increased utilization of services

Reported by Agency
WellnessShawnee County Parks and RecreationIn 2015, 32.5% of Kansas seniors 65 years and older performed no leisure time physical activity over the past month (CDC, 2015).

-no leisure time physical activity

-obesity

-CDC Healthy Aging Data

-Department reported statistics

HousingBrewster PlaceAccording to the 2015 Shawnee County Community Health Improvement Plan 15.5% of the Shawnee County population is over 65 years of age (Shawnee County Community Health Improvement Plan Planning Group, 2015).

-Pressure ulcers

-Falls

-Long-term indwelling urinary catheter

-Pain

-Delirium

-Depression

-Physical restraint

-CMS nursing home compare

-Resident Satisfaction Ratings (Kansas Department for Aging and Disabilities Services)

Integrating Mechanisms

Inter-entity management and structure

Stormont Vail Health will need to dedicate care coordinators who will be responsible for facilitating seamless care delivery across the Stormont Vail Hospital, Cotton O’Neil Clinics and the Kansas Rehabilitation Hospital (affiliated). Also, process management guidelines for the most common disease or care processes provided to seniors and the manner through which these patients will transfer among organizations needs to be addressed. All of the medical needs of the Shawnee county geriatric population should be covered within the Stormont Vail Health umbrella of services.

 

Care Coordination

For those who qualify, Midland Care Connection, Inc. has a Program of All-Inclusive Care for the Elderly (PACE). Identifying and connecting patients who would benefit from this program, provides services that will reduce the cost of treating these patients and makes healthcare more manageable for them and their families.

 

Furthermore, this continuum of care not only addresses medical providers, but also housing, wellness, nutrition, and care delivery outside of a clinic/hospital setting. These resources are already available in the community, and the Jayhawk Area Agency on Aging is established as a case management organization connecting seniors with community resources such as Meals on Wheels. By working with them, our patients will be able to get a wide range of services available in Shawnee County, without the need to create a new department to perform this function.

 

Integrated Information Systems

The Kansas Health Information Network (KHIN) is a health information organization that “implements, coordinates and oversees the exchange of electronic health information” (KHIN, 2017). The Stormont Vail Continuum of Care for Seniors will depend on this information network to facilitate information exchange allowing participants in the network to access their patient’s electronic health records enabling continuity of care across organizations and providers.

 

The following community partners are already part of the KHIN: Stormont Vail Hospital, Cotton O’Neill Clinics, Midland Care Connection Inc., and Brewster Place. The Kansas Rehabilitation Hospital is not on the KHIN, however, as a venture partner for this hospital, Stormont Vail Health will need to work with their leaders to join the network. With all of these providers able to exchange health information, patients will be better managed at each stage of their medical care.

 

Integrated Financing

Current financing plans are fragmented and the patient has to carry the burden of dealing with insurance companies and secure payments. With this continuum of care model, we advise transitioning to a bundled payment model where a fixed amount is paid by the third-party provider to cover all services, including acute and post-acute care, per specific disease entity as defined by diagnosis-related group (DRG) on admission. Stormont Vail Health has already experimented with this model of reimbursement in orthopedic and spine surgery to great success and considerable savings. A bundled payment method will also incentivize providers to avoid unnecessary testing and procedures, further increasing savings and net revenue per patient episode.

 

A bundled payment model for reimbursement for senior care will fit well with the continuum of care due to the grouping of services in an organization, making it easier and more resource-efficient method of payment.

 

Quality Metrics

The Stormont Vail Continuum of Care for Seniors has been described above, but it is equally as important that Stormont Vail Health determine whether it is actually reducing cost and improving outcomes.

 

Several benchmarks exist and are readily available. Three sites provided by the Centers for Medicare and Medicaid Services (CMS) are Home Health Compare, Nursing Home Compare, and Hospital Compare. Using an OASIS (Outcome and Assessment Information Set) system since 1999, Home Health Compare gathers information that is used to guide evidence-based best practices for our target population and is readily available on the CMS Home Health Compare website. The Nursing Home Quality Initiative collects metrics regarding pressure ulcers, pain, appropriate vaccinations (like flu and pneumococcal), falls, urinary tract infections, and depression among many others. These metrics are readily available and can be used to compare nursing home quality of care through the CMS Nursing Home Compare website. Hospital Compare gathers a large amount of data regarding hospital performance. Several factors related to quality metrics are measured and monitored and will be used to make sure Stormont Vail Health meets and exceeds all national standards. For example, inpatient surgical unit risk of complications such as iatrogenic pneumothorax, surgical site infections, postoperative deep vein thrombosis, postoperative wound dehiscence rate, and accidental patient injury from surgical instruments. These metrics are readily available and can be used to compare Stormont Vail Health’s quality of care through the CMS Hospital Compare website.

 

Another valuable source of information, regarding assessment of appropriate delivery of care, is the Agency of Healthcare Research and Quality (AHRQ) website. This data source allows organizations to screen for quality metrics that are deemed appropriate for the care of patients. For example, in the acute and ambulatory care setting caregivers can make sure appropriate guidelines are being followed by an organization. Stormont Vail Health identified obesity and poor nutritional habits as a major health issue on the Community Health Improvement Plan (CHIP), and can use the AHRQ website for the latest nutritional guidelines for seniors and evaluate the adherence of ambulatory clinics to these guidelines. Similar information can be found for diabetes, pressure ulcers, falls and other preventable conditions.

 

Finally, monitoring senior hospital readmission rates will indicate whether the continuum of care initiative is successful in improving patient care and Medicare reimbursement.

 

Implementation

In order to implement the Stormont Vail Continuum of Care for Seniors, a team of care coordinators must be formed and trained to coordinate care between Stormont Vail Hospital, the Cotton O’Neil Clinics, the Kansas Rehabilitation Hospital, Midland Care Connection, Inc., the Jayhawk Area Agency for Aging, and Brewster Place. This will require multiple FTEs.

 

Stormont Vail Health leadership must reach out to the Kansas Rehabilitation Hospital leadership about joining the Kansas Health Information Network in order to facilitate continuity of care between the two hospitals and further information exchange across the continuum of care.

 

A partnership agreement must be reached among all of the participating organizations so that all parties know what is expected from the continuum of care and their role within it. This will be particularly important for Midland Care Connection Inc. and the Jayhawk Area Agency for Aging as they will be working across the continuum of care.

 

Lastly, funding for the Shawnee Parks and Recreation Department as well as Meals on Wheels will be important to establishing a relationship with these supporting organizations for wellness among seniors in the area. Also, it is a chance for information distribution to seniors that utilize services at the other organizations in the care continuum.

 

Conclusion

By partnering with community organizations, Stormont Vail Health will be able to improve the health of a large number of seniors, with less expense, and less duplication of services, than if acting alone. Overall, the Stormont Vail Continuum of Care for Seniors plan has been developed to streamline the health, wellness, and housing services available to seniors while increasing coordination among caregivers. Achieving success in this initiative will be seen in reduced hospital readmissions, higher patient satisfaction, and more efficient care management. This improved quality of care is what makes the care continuum a sound investment of resources.

 

References

Centers for Disease Control and Prevention (CDC). (2015). Healthy Aging Data: Kansas. Retrieved from https://www.cdc.gov/aging/agingdata/index.html.

 

Evashwick, C. & Aaronson, W. (2006). The Continuum of Care Today. Health Progress: The Journal of the Catholic Health Association of the United States, 87(5), 46-55.

 

Kansas Health Matters. (2017). Shawnee County Dashboard. Retrieved from http://www.kansashealthmatters.org/.

 

Shawnee County Community Health Improvement Plan Planning Group. (2015). 2015 Shawnee County Community Health Improvement Plan. Retrieved from https://www.stormontvail.org/userfiles/file/Shawnee%20Co%20Comm%20Health%20Imp%20Plan%202015.pdf

 

U.S. Census Bureau. (2010). American Fact Finder: Shawnee County, KS -  Profile of General Population and Housing Characteristics: 2010. Retrieved from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF

 

Kansas Health Information Network. (2017). Participant FAQ. Retrieved from http://www.khinonline.org/Member-Resources/MEMBER-FAQ.aspx

 

Proposal for Establishing a Continuum of Care for Seniors.pdf

DRAFT: This module has unpublished changes.