By: William Stephan., MD

Medical Staff Newsletter Fall 2015

Page 1

MEDICAL STAFF

Newsletter 172 Kinsley Street

Nashua NH 03060

A Quarterly Newsletter published by the St. Joseph Hospital Medical Staff Fall 2015

Bundled Payment for Clinical Improvement A Medical Experiment in Coordination of Patient Care Around an Acute

Episode Defined by Discharge DRG

Background

The total cost to Medicare (Part A + Part B) for episodes of care has been steadily

increasing. With a greater proportion of the cost shifting to post acute care and acute

hospital reimbursement, fixed with DRG's, the result has been reduced LOS and "kicking

the cost of care down the road". The reality, now, is the cost of post-acute care now

EXCEEDS the cost of acute care for St. Joseph Hospital discharges.

Ground Rules to Consider ………………………………………………………………...

Patients are grouped in bundles based on the discharge DRG. Medicare Advantage and

other patients are excluded from these bundles. Medicare will take 3% off the top of

baseline bundle costs and will offer to share the surplus against the remaining 97% of

historic cost. Meanwhile cash flow continues as per traditional FFS Medicare. Delayed

reconciliation occurs with the "convening body", which in our case is Covenant Health.

Physician based bundle membership (Part B) takes precedence over institutional bundle

membership (Part A). We are currently involved in Simple Pneumonia and will start

COPD in October 2015. …………………………………………………………………..

Medical vs. Surgical Bundle

Medical bundles can be "messy" with complex patients, containing multiple comorbidities

and non-elective admissions. Whereas appropriate treatment plans are more variable for

surgical cases. Patients are identified by concurrent coding on admission but less than

50% may remain in the bundle based on the final discharge DRG. Patients may also be

identified as high risk for readmission and post-acute care costs to qualify for intensive

discharge interventions and follow-up. Low risk patients receive routine care. We use a

modified Geisinger tool for risk stratification. With these factors considered there is less

money on the table for potential cost reduction in medical bundles.

Re-engineer Inpatient Care & Achieving Mobility Protocol

Adjusting the mindset of how we handle inpatient care will not only benefit the patient,

which is paramount, but also St. Joseph Hospital. With a focus on the following items we

could begin to see a shift in inpatient care necessary for today’s changing payment and

reimbursement structure.

Reduce the need for post-acute care services, eg. Sepsis Screening, Dementia Screening and Early Mobility Protocol.

Identify opportunities for palliative care/hospice APRN intervention in patients with advanced disease.

Implement care pathways and reduce internal cost structure, eg. prompt conversion of IV to PO antibiotic. ……………………………………………………………….. Continued on page 2

Our Lean Journey

Over the course of the

last 3 years, St. Joseph

Hospital has embarked

on a journey to

incorporate Toyota

Production System

techniques in our performance improvement

efforts. We've created a lean academy to train

leadership and frontline staff in this approach,

and awarded 32 green belts after completion of

training and a project that is sustained in the

organization. The hallmark of lean is waste

reduction and we have already begun to see the

benefits of it’s implementation. A dramatic

improvement in our registration process in the

atrium, with corresponding spikes in patient

satisfaction, and outstanding achievement in

patient accuracy are just a couple of the more

than 60 success stories over the last couple of

years.

We are ready to embark on the next steps in

adopting lean as our management philosophy

throughout Covenant Health. As a system,

we've contracted with Virginia Mason Institute

(VMI) in Seattle, recognized as a world leader in

healthcare lean processes, to help take us to the

next level. They've had extraordinary results in

patient safety, patient satisfaction, employee

engagement and even operating performance

through their approach. On a recent visit to

VMI, among the things that impressed me most

was that through re-engineering and reduction of

waste nurses spend 90% of their time with

patients compared to norms of 35% around the

country. That's worth pursuing.

I'll provide you with periodic updates as to how

this process is unfolding, and I'm eager to

include you in many ways as we proceed. I'm

optimistic about what this will mean for our

patients, our staff, and the broader community.

Regards,

Rich Boehler, MD, MBA, FACPE

If you can't feed a hundred people then feed just one--

Mother Teresa

Rich Boehler, MD, Pres-

ident/CEO of

St. Joseph Hospital

Bundled Payment for Clinical Improvement continued

Medical Staff Newsletter Fall 2015 Page 2

Patient Centered Discharge

Start the conversation and ask the question, "how can we get this patient home?" If home with services is not an option due to patient care needs or other circumstances, what is the most appropriate level of care to get the patient back to a residential setting? The discharge team care plan will be distilled in the Green Card - "Returning Home". This will travel with the patient through their journey back to the primary care team. It will be filled out at the time of discharge from the hospital or SNF to home.

The next key step is to ensure essential medication and support at home is in place prior to departure from the hospital. Lastly, follow-up with the patient in order to manage their care after discharge until the primary care "handoff" takes place.

Post Acute Care Partners

• Preferred provider relationships with St. Joseph Acute Inpatient Rehabilitation are Greenbriar, Courville, Crestwood and HHHC.

• TeamHealth physician/ALP can admit patients from SJH (via EMR/Fax) to SNF and will follow up to reduce readmissions and optimize LOS.

• The transition nurse will follow patients into SNF and handoff at SNF discharge to the APRN and the primary care team. This allows for a true coordination of care and will keep everyone in close communication.

Arrival Home

The APRN will visit in home on day two to review, reinforce or alter the care plan after either the hospital or SNF discharge. The ultimate goal is to prevent unnecessary re-admission or ED visits. Home Health Care will deal directly with the APRN until the hand off to the primary care team is complete.

The next step is to coordinate the care plan with the primary care team in order to handoff the patient as soon as appropriate or by 30 days post hospital discharge. The primary care team will continue aggressive management for this group of high risk, chronically ill patients.

Unanticipated ED Arrival

Should an unanticipated ED visit occur here is a list of steps to be followed and items that should be considered.

• Identify BPCI patients by their Green Card or recent hospitalization.

• If they are a transfer from SNF, Hospitalists and the ED should be notified of the patient’s status.

• Consider options for care other than readmission, eg. return/ admit to SNF or observation for stabilization and development of an alternative care plan.

• There is a three day waiver in place for BPCI patients, this should be reviewed.

• Hospitalists can admit to SNF rather than to Inpatient if medically appropriate for patients failing in home care.

Future Vision

We have begun collecting data on our performance and the patient's experience with this approach to the management of acute episodes of care. Those elements of our interventions that contribute to increased value of care (higher quality and/or reduced cost) will be generalized to all high risk Medicare discharges. We are currently subject to penalties for Readmissions and excessive Medicare Spend per Beneficiary, in addition to Value Based Reimbursement incentives, for all Medicare discharges.

Page 3 Medical Staff Newsletter Fall 2015

St. Joseph Hospital has been designated a Lung Cancer Screening Center by the American College of

Radiology (ACR). This designation recognizes St. Joseph Hospital’s commitment to practicing safe,

effective diagnostic care for individuals at the highest risk for lung cancer.

Beginning September 1, 2015 St. Joseph Hospital will be offering a state-of-the-art Lung Cancer

Screening Program that will include using low-dose CT scan, community education and a personalized

treatment plan for patients at high risk for lung cancer.

Low-dose CT scans and appropriate follow-up care can significantly reduce deaths associated with lung

cancer. Screenings are recommended for adults aged 55 to 80 years who have a 30 pack-year smoking history and currently

smoke or have quit within the past 15 years. If you are interested in seeing if you qualify for this program please contact your

primary care provider.

New Lung cancer screening program achieves accreditation

St. Joseph Hospital’s ACR accredited PET/CT and MRI services

By choosing to send your patients to St. Joseph Hospital’s ACR accredited PET/CT and MRI services, you will ensure that your patients are

receiving the best possible care close to home. We are conveniently located at the hospital, 172 Kinsley St., Nashua, NH. Our commitment to

providing the best diagnostic imaging services in the area includes:

Advanced Diagnostic Technology

St. Joseph Hospital offers a mobile PET/CT service weekly on Tuesdays. PET stands for Positron Emission Tomography and CT stands for

Computed Tomography. Combined into one exam, this state-of-the-art technology is vital in staging various forms of cancer, as well as

diagnosing other conditions such as Alzheimer’s disease. Hester Rock, our PET/CT representative, may be coming by your office to introduce

herself to you. She is an extension of the St. Joseph community, so please take the time to meet with her. If you need to reach her for any

reason, please call her directly on her cell: (609) 781-7860.

St. Joseph Hospital’s newest MR technology is the Siemens Magnetom Aera 1.5T, which is a wide bore scanner. Wide bore magnets are able

to deliver high-quality, high field diagnostic scans while enhancing patient comfort and increasing image quality. The clinical and operational

advantages compared to traditional bore are many, including: reduction of outpatient IV sedations, reduced patient rejections (due to

claustrophobia) and improved patient positioning particularly in obese patients. Should you have any questions, concerns or issues, please

call Ken Kelly at: (603) 579-5626.

Convenient Access to Radiology Reports—Both PET/CT and MRI scans are interpreted by board certified St. Joseph Hospital Radiologists

and images/reports are available in PACS shortly after the study is completed.

Easy Scheduling —Call Central Scheduling at (603)598-3323 to schedule an appointment for a PET/CT or MRI scan. PET/CT appointments

are available on Tuesdays, while MRI appointments are available Monday-Friday 7:30am to 7:00pm and Saturday and Sunday 8:30am

to 4pm.

Our commitment to providing the highest quality of care along with our ease of access for your patients’ needs makes us the best choice for

your diagnostic imaging.

By: Dr. Boehler & Diagnostic Imaging Services

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PROVIDER NEWS St. Joseph Hospital welcomes new providers:

S t. Joseph Hospital and the Cancer Center welcome

board-certified Internal Medicine provider Umit

Tapan, MD to the medical staff. He received his medical

degree from Hacettepe University School of Medicine,

Ankara, Turkey. Dr. Tapan completed his internal

medicine residency at Hacettepe University Hospital,

Ankara, Turkey and Steward Carney Hospital in Boston, MA. He

recently completed a Fellowship in Hematology/Oncology at Boston

University Medical Center, Boston, MA. Dr. Tapan’s clinical interests

include gastrointestinal cancers, lung cancer, head and neck

cancers, prostate cancer, breast cancer, general hematology, lymphoma,

myeloma. To learn more about Dr. Tapan or to make an appointment

please visit www.stjosephhospital.com or call (603) 880.3408.

S t. Joseph Hospital and Merrimack Valley Pediatrics

welcome board-certified Pediatrician Michele

Mandel, MD to the medical staff. She received her

medical degree from the University of Massachusetts

School of Medicine in Worcester, MA. Dr. Mandel

completed her pediatric residency at the University of

Connecticut Pediatric Residency Program, Connecticut

Children’s Medical Center in Hartford, CT. Her clinical interests include

general pediatrics, preventative care, childhood obesity and nutrition. To

learn more about Dr. Mandel, or to make an appointment please visit

www.stjosephhospital.com or call Merrimack Valley Pediatrics located

at 387 East Dunstable Road in Nashua at (603) 880.1440.

Medical Staff Newsletter Fall 2015

DNV GL is a world leading certification body. By earning accreditation, St. Joseph Hospital has demonstrated

it meets or exceeds patient safety standards (Conditions of Participation) set forth by the U.S. Centers for

Medicare and Medicaid Services. DNV GL’s accreditation program is the only one to integrate the ISO 9001

Quality Management System with the Medicare Conditions of Participation.

St. Joseph Hospital Receives DNV-GL Accreditation

Published by the Planning and Marketing Department for the Medical Staff of St. Joseph Hospital. Please send your comments or

suggestions to Dr. William Stephan at wstephan@sjhnh.org.

Forward news information and articles to Tiffany Sullivan at tsullivan@sjhnh.org.

Fall 2015

Healthy Habits: Childhood Obesity

Tuesday, September 29, 6:00 to 8:00 pm

Presented by Christine FitzGerald, MD,

from Merrimack Valley Pediatrics

Pelvic Pain—A Problem for both Men and Women:

Awareness and Knowledge of Pudendal Neuralgia

Tuesday, October 6, 6:00 to 8:00 pm

Presented by Mark Conway, MD, FACOG,

and Antonia Winefield, APRN,

from OB/GYN Associates of Southern NH

Cataract Surgery Update

Wednesday, October 7, 6:00 to 8:00 pm

Presented by Timothy Blake, MD,

from Nashua Eye Associates

Testosterone Talk

Thursday, October 15, 6:00 to 8:00 pm

Presented by Boris Golosarsky, MD,

from St. Joseph Hospital Internal Medicine

Dinner with the RDs—Mediterranean Meals

Wednesday, October 28, 6:00 to 8:00 pm

Presented by our registered dietitian.

Get into Glaucoma

Tuesday, November 3, 6:00 to 8:00 pm

Presented by Sonalee Desai-Bartoli, MD,

from Nashua Eye Associates

Dig Deeper into Diabetes

Thursday, November 19, 6:00 to 8:00 pm

Presented by Melanie Baker, RD; Elizabeth Spatola,

MD; and Laurie Terrio, RN, BS, CDE

A fee of $10 includes dinner. Pre-register at

www.stjosephhospital.com or call (603) 595.3168.

Advances in Multispecialty Cancer Care Friday Oct. 30, 2015 | 7:30AM– 3:30PM | Crowne Plaza Nashua

For a complete list of speakers and topics please visit the Education &

Professional Development section of the St. Joseph Hospital intranet.

Continuing education credit will be awarded for attendance at this

conference.

For more information contact Jan Degulis

(603) 882.3000 Ext. 66060 or jdegulis@sjhnh.org