Shifting of Complex Respiratory Careto

Skilled Nursing Facilities

Standards of care, quality measures development,

improved outcomes, pay for performance

Gene Gantt RRT THE EVENTA GROUP

Eventa=Latin for outcomes

Long Term Care Market

16,000 SNFs

1724 new vent beds in SNF from

2009 to 2013 -US total

9500

Predicted Increase in PMV cases - 490,000 in 2010 to over 600,000 cases in 2020

1.5 million residents

U.S. shipments of sub-acute ventilators 6,789

units in 2017, up 41 percent from 4,805 in

2013, according to IHS Technology (NYSE: IHS

25-30% with lung disease

The need to cut down on

readmission has spurred the

expansion of sub-acute ventilator

market

Past Model in Long Term Care Prior to the early 1990s Complex Respiratory patients were cared for in the

hospital and in the ICU, especially those on mechanical ventilation Skilled Nursing Facilities (SNFs) were primarily custodial care sites until

the mid 1990s when more complex patients began to be transferred to unorganized “Sub Acute” units with little technology available

In 1998 with the advent of PPS, SNFs eliminated most high acuity programs leaving hospitals with no downstream discharge options except home

Many patients were being discharged home on mechanical ventilation with no chance of liberation and at a high cost to the state and federal payers

The SNFs who did accept ventilated patients offered little or no hope of liberation from the vent nor had any emphasis on outcomes

State Medicaid's had the concept that these patients had been unweanable and therefore paid SNFs a very low rate per day and as a result this population most often became “warehoused”, and still are today in most states

Shift of Complex Respiratory Care to Skilled Nursing Facilities

With approximately 16,000 nursing homes in the US comprising 1.7 million

beds (1.5 million residents) the LTC segment is undoubtedly the largest single expansion site for the care of the complex respiratory population.

Approximately 25% of these 1.5 million residents have underlying pulmonary disease or compromise.

The American Health Care Association reports a growth 0f 1724 vent beds in Skilled Nursing Facilities from 2009 to 2013 bring the US total to 9500.

In from 2002 to 2010 there were 3 vent units in TN with 48 beds. From 2010 to 2014 the number of sites tripled to 9 and number of beds quadrupled to 222.

The shift in sites of care has preceded the efforts to improve quality and standards of practice

The pressure on hospitals to discharge and avoid readmissions has become a struggle as SNFs were and are still somewhat unprepared for the complexity of the population especially in light of often low Medicaid rates

Current US standards No state to state consistency in standards for complex respiratory

and ventilator care

Standards and payments vary by state

There has been little focus on quality metrics and oversight

The major shift from ICU and hospital to Skilled Nursing Facilities proceeds at a furious pace and SNFs have little guidance

SNFs lack standards requiring advanced noninvasive technology (high flow systems, airway clearance devices, and monitoring.

Many lack appropriate personnel (Medical Direction and Respiratory Therapist)

Our journey to improve outcomes

Timeline 2002 opened first SNF vent unit in TN – 85% pts weaned first

year Reported results to Governor –gained support for

reimbursement 2004 Developed standards of care – endorsed by TSRC 2005 standards endorsed by TN Board of Respiratory Care 2009 standards adopted as rules for NF by Board of Health

Care Facilities and TN Medicaid 2010 standards developed into national recommendation -

position statement by AARC 2011 TN SNF vent program maintains 63% wean rate

recognized by ACCP as Best Practice/Center of Excellence 2014 Engaged by TN Medicaid to develop quality metrics and

design a Pay for Performance model

Enhanced Respiratory Care

In Tennessee ERC refers to the following special levels of reimbursement for services in a NF:Chronic Ventilator CareVentilator Liberation or WeaningTracheal Suctioning

History of Enhanced Respiratory CarePre-ERC Program (1998 – 2002)

• SNFs unwilling to accept high acuity, high-cost patients needing ventilator care due to:

Medicare conversion from cost-based reimbursement to RUG-based per diem prospective payment system

Medicaid facility-wide cost-based payment methodology that failed to cover higher costs of residents needing ventilator care

• The first SNF based ventilator unit was established in 2002 During the first year liberated 60 out of 92 patients were

liberated from ventilators (deemed “un-weanable”) Led to research of best-practice and cost-effective approaches

to ERC

History of Enhanced Respiratory Care• Development and Evolution of ERC Program (2003-2010)

Standards of Care developed and incorporated into HCF rules for SNFs providing ventilator care

Two additional ventilator units began operations (1 in each Grand Region); rates negotiated with MCOs

Liberation rates at 65%• Recent History (2010-2013)

In 2010, Medicare revised per diem rates from average of $350 to $700

During that same year, as part of CHOICES program, TennCare established ERC rates to SNFs delivering ERC services

• 2010-2014 Number of sites grew from 3 - 9 Beds from 48 - 222

Current initiative Although TN adopted standards of care in 2004 we are

currently engaged in the next step which is to require accountability and quality monitoring in facilities receiving TennCare funds

TennCare is currently evaluating metrics to be utilized in a pay for performance model in SNF ventilator units encouraging outcomes and the use of noninvasive technology.

Currently a review and redesign of the medical necessity for ventilator care is underway in conjunction with the CMO of TennCare

Additionally there is a review of patient data of those on home ventilation

Value Based PurchasingPayment Reform – specific amounts TBD

Threshold Measures - required in order to be eligible to receive ERC payments (base rates and P4P components)

Facilities must continue to meet 100% of Threshold Standards of Care

Includes Timely Reporting of Key Performance Indicators

Quality Measures Pay for Performance component that incentivizes Ventilator

Weaning and improved quality performance and outcomes may be earned in addition to base rates

Key Performance Indicators Census by type (vent or trach)

Number of ERC patient referrals vs. admissions

Number of out-of-state referrals

Number of admissions by payer source

Number of admissions by diagnosis (vent or trach)

Number liberated from ventilator

Number decannulated

Number discharged from ERC services and disposition

Number transferred to hospital (and whether or not they returned to the SNF)

Sentinel events + Unexpected death in facility Number of patients with respiratory infection requiring

isolation

Pay for Performance Component

Quality Measures consisting of Quality Indicators and Technology Indicators will be used to determine quality payments (thresholds, point values and payments to be established).

Quality Indicators (to incentivize quality performance and outcomes) Annual Ventilator Wean Rates Average Length of Stay to Wean Infection Rates Unplanned Hospitalizations Decannulation Rate Unplanned Deaths Denial Rate

Pay for Performance Component

Technology Indicators (incentivize use of modern technology)

Cough Assist High Flow Molecular Humidification Alarm paging or beeper system Non-Invasive Ventilation (volume) Non-Invasive Open Ventilation High Frequency Chest Wall Oscillation or IPV Heated Wire Circuits Incentive Spirometer or any PEP Therapy

Weaning rates in SNFWe, along with others have demonstrated that a majority of the patients deemed ventilator dependent can still be liberated for the mechanical ventilation. This effort requires appropriate personnel, technology, monitoring, mobilization and nutrition. 1996-Latriano B , Chest 51%

2000-Gracey DR, Mayo – 60%

2002-Gene Gantt, Report to Governor Bredesen, TN initial vent program 85%

2004 Dr. Mark Lindsay, Mayo 67%

2011- Gene Gantt, ACCP Chest Conference Center Of Excellence presentation, TN vent program 65% statewide

SummaryIt has become a mission to change the paradigm of complex respiratory and ventilator care in the post acute arena. As clinicians, we have seen first hand the positive effect of appropriately modeled care in the post acute space.

We take pride in the fact that Tennessee is a leader in developing quality long term care programs. Other states have taken interest and are following our lead or contemplating engaging us to develop similar programs with them.

In addition to the high complexity population, we recognize the potential to dramatically decrease hospital admissions in the general SNF population. We feel there are tremendous opportunities for low cost interventions that will greatly reduce the incidence of aspiration pneumonias and other respiratory issues in the general resident of the SNF.

The EndQuestions?