The document provides guidance on establishing a Joint Quality Committee between acute care hospitals and skilled nursing facilities/long-term acute care hospitals to improve quality outcomes and care transitions, with steps including engaging leadership, establishing shared quality metrics and goals, collaboratively reviewing performance data, and ensuring open communication between organizations.

1. Success Through Relationships
with Acute Care Providers:
A Guide to Initiating Joint Quality Committees
1

2. Speakers & Panel
Speakers Panel
• Michael Felver MD • Shelly Szarek-Skodny LNHA
• Seth Vilensky MBA • David Johnson, MBA
• Leslie Vajner RN MHA • Dan Blechschmid, LNHA
Disclosures
• All Speakers & Panel Members have no Financial Disclosures to Reveal/Present
• Cleveland Clinic and Kindred have no financial relationship.
• Both Cleveland Clinic & Kindred have developed these types of relationships with other
providers. This presentation highlights one example of an integrated care model.
2

3. Learning Objectives
• Review the healthcare reform and the impact on traditional
organization and level of care relationships
• Describe a model for partnering between the hospital and SNF focusing
on quality outcomes, transparency and successful transition of clinical
care.
• Provide the guide to create your own Joint Quality Committee.
• Share the “foundational” components that will generate meaningful
dialog between the partnering organizations.
3

4. Discussion Agenda
 Driving Forces & Market Overview
 Joint Quality Committee…Getting Started
 Monitoring Quality and Performance Indicators
 Collaborative Process Improvement
 Return to Acute Care
 Timeline & Accomplishments- Key Lessons Learned
 Joint Quality Committees in Multiple Settings
 5 Steps to Starting Your Own Joint Quality Committee
 Panel Discussion
4

5. Tremendous Opportunities Exist to Better Manage
Patient Care for Patients Discharged to Post-Acute
Medicare Patients’ Use of Post-Acute Services Throughout an “Episode of Care” (1)
Higher Intensity of Service Lower
SHORT-TERM LONG-TERM SKILLED HOME
INPATIENT OUTPATIENT
ACUTE CARE ACUTE CARE NURSING HEALTH
REHAB REHAB
HOSPITALS HOSPITALS FACILITIES CARE
Patients’ first site of
discharge after acute 2% 10% 41% 9% 37%
care hospital stay
Patients’ use of site
during a 90 day episode 2% 11% 52% 21% 61%
35% of Medicare beneficiaries are discharged
from acute hospitals to post-acute care
(1)
Source: RTI, 2009: Examining Post Acute Care Relationships in an Integrated Hospital System
5

6. The Cleveland Clinic & Kindred Healthcare
in Northeast Ohio
Cleveland Clinic Foundation Kindred Hospital Fairhill and Co-Located Hospital-Based SNF
 1,300 beds located at the Cleveland  Located approximately one mile from the Cleveland
Clinic Main campus Clinic
 Regarded as one of the top 4 hospitals  68 Bed LTACH with 6 Special Care Beds
in the United States  40 co-located Sub Acute SNF Beds
 System comprised of its main campus  Over 85% of Fairhill’s nearly 1,000 annual admissions
and eight regional hospitals in come from 5 nearby hospitals, with 65% from the
Northeast Ohio (4,400 total beds) Cleveland Clinic
 Employs more than 2,700 salaried  Kindred also has the Gateway Long-term Acute care
physicians and scientists Hospital, 3 Transitional Care Nursing Centers, and 2
 Owns home health service line and IRF Assisted Living Facility in the Cleveland Market
 Highest acuity hospital in the country
6

7. The Cleveland Market:
Kindred & Cleveland Clinic
7

8. Driving Forces: SNF Concentration - CC + Regional Hospitals
Cleveland Clinic Sentn= 22,735 placements in 2010 in 2010
Patients providersSNFs
860 unique >800
100%
860 Facilities in Total
90%
150 Facilities make
Cumulative % of SNF Placement Volume
up 90%of activity
80%
80 Facilities make
70% up 80%of activity
60%
40 Facilities make
up 60%of activity
50%
40%
30%
20%
CCHS SNFs make up
~10% of activity
10%
0%
6
6
6
6
1
1
1
6
1
1
6
1
6
1
1
6
1
1
6
1
6
1
1
6
1
6
1
6
6
1
6
1
51
26
76
10
12
15
17
20
25
27
32
42
45
52
57
60
67
70
72
75
77
82
85
22
30
35
37
40
47
50
55
62
65
80
SNF Facilities
(1)
Source: Cleveland Clinic Health System internal data
8

9. Nursing Home Reimbursement Outlook for 2012
Medicaid:
The outlook for 2012 is extremely
bleak. According to Kaiser Survey, Combined Medicare/Medicaid Shortfall for 2012
42 states face budget deficits,
Payer 2012 Days in Margin/ Net margin/
collectively totaling 103 billion at Avg. million Shortfall % Shortfall
the start of 2012. rate s revenue in billions
Medicare $457.59 67.4 18.10% $5.58
Medicare: Medicaid $176.49 322.9 -14.00% ($7.96)
A combined shortfall for 2012 Net shortfall ($2.38)
taking into account Oct. 1, 2011
reduction in Part A to SNF’s of 3.87
billion or 11.1%.
Sources: MedPAC report to congress Medicare Payment Policy, AHCA Reimbursement and Research Department SNF PPS Model
based upon FY 2012 Medicare Rates and SNF claim data, A Report on Shortfall in Medicaid Funding for Nursing Home Care,
ELJAY, LLC December 2011.
9

10. Driving Forces
Value Based Purchasing Episode-based / Bundled payment
Readmission Penalties pilots
 Look back period began October,  Released on August 23, 2011
2011  Four Models to Propose
 Initial focus on CHF, AMI,  Eligible Awardees: Hospitals,
Pneumonia Physician Groups, Post-Acute
 Targeted DRG reduced by Providers
adjustment factor based on  Applicants have significant latitude
readmissions deemed “excessive” to propose:
or above the national average  Length of Episode
 Will allow for a 1%- 2% reduction in  Clinical conditions targeted and
total Medicare Payments to services included
Hospitals– 2013 – 2017
 Expected discount provided to
 Projected $7.1B in reduced
Medicare
payments (2013 – 2019)
 Quality metrics will be developed to
track results
10

11. Driving Forces:
The Affordable Care Act - Implementation Timeline
2012 2013 2014
• Hospital Value-Based • Improving Preventive Health • No Discrimination Due to Pre-Existing
Purchasing program (VBP). Coverage to expand the Conditions or Gender.
Financial incentives to number of Americans • Eliminating Annual Limits on
hospitals to improve the receiving preventive care. Insurance Coverage.
quality of care. • Expanded Authority to • Ensuring Coverage for Individuals
Bundle Payments; a national Participating in Clinical Trials.
• Encouraging Integrated pilot program to encourage
Health Systems. Incentives • Improving Quality and Lowering
hospitals, doctors, and other Costs: tax credits to make it easier for
for physicians to form providers to work together the middle class to afford insurance.
"Accountable Care to improve the coordination
and quality of patient care. • Establishing Health Insurance
Organizations”.
• Increasing Medicaid Exchanges to easily shop for more
• Reducing Paperwork and affordable private insurance.
Administrative Costs Payments for Primary Care
Doctors. • Small Business Tax Credit.
through Electronic Health • Increasing Access to Medicaid.
Records. • Additional Funding for the
Children's Health Insurance • Promoting Individual Responsibility;
• Understanding and Fighting Program individuals who can afford it will be
Health Disparities. required to obtain basic health
• Providing New, Voluntary insurance coverage
Options for Long-Term Care
Insurance.
Source: http://www.whitehouse.gov/healthreform/timeline
11

12. Why Are These Relationships So Important?
 Complicated Healthcare Environment
 Lack of Continuity between Care Site & Provider Office
 Lack of Clinician Communication
 CMS Payment Penalties for Re-Hospitalization
 Pending Healthcare Reform – “What will really happen?”
Changing Environment Changing Strategy
• Health Reform, PPACA • Hospitals reducing SNF capacity
• Episode-based Bundled Payments • Emerging pilots of Post-Acute partnership
across the country in many structural
• Readmission Penalties
variations
• Continuing Care Hospital demonstration
• IT as “enabler”
• Public Quality Metrics
12

13. Discussion Agenda
 Driving Forces & Market Overview
 Joint Quality Committee…Getting Started
 Monitoring Quality and Performance Indicators
 Collaborative Process Improvement
 Return to Acute Care
 Timeline & Accomplishments- Key Lessons Learned
 Joint Quality Committees in Multiple Settings
 5 Steps to Starting Your Own Joint Quality Committee
 Panel Discussion
13

14. You Can Develop These Relationships in Your Market
Disclaimer…
The Cleveland Clinic & Kindred are:
• Large Organizations
• With Corporate Resources and
• Focus on information technology infrastructure
These Relationships DON’T Need ANY of the Above!
What you do need:
• The willingness to take on this type of partnership
• A commitment to patient outcomes and care across the continuum
• Short term commitment (time, resources) for a long term benefit
14

15. Establishing a Joint Quality Committee
Leadership Physician Complementary Tracked & Robust
Engagement & Engagement & Clinical Transparent Communication
Commitment Alignment Capabilities Outcomes Protocols
 Establish mutual  Educate key  Identify key needs of  Establish shared  IT Linkages
objectives physicians and hospital quality and  Education of all key
 Articulate Goals & obtain buy-in  Focus on clinical operating measures
constituents on
Objectives in  Invest in physicians outcome and quality  Build dashboard collaborative
charter with leadership roles indicators  Establish baseline  Formation of Joint
 Identify and  Establish mutual  Identify parallel performance Quality Committee with
empower key privileges and competencies to measures monthly meetings
leaders on both education on post- establish in post-  Set targets  Review dashboard of
sides acute setting (billing, acute partner
 Track and trend clinical and operating
 Initial focus on utilization, etc.)  Implement post- data metrics
high impact  Engage physicians in acute staff training
 Celebrate  Establish change of
outcomes (e.g., re- post-acute staff and competency
milestones condition
hospitalizations) training and validation protocols communication
 Longer term goals establishing  Avoid temptation to protocols
(eg, participate in communication
discuss referral  Establish patient
CMS ACO demos) protocols
patterns and volume transitions protocols
 Review  Foster integration of that does not have a related to quality/safety
relationship/ physicians across quality component
affiliations  Transparency is KEY
charter with your
legal counsel
Source: Advisory Board interviews and analysis.
15

16. Getting Started: Aligned and Clearly Articulated Goals
• Develop and enforce processes, procedures, and workflow that
contributes to high-quality and efficiency
• Provide a forum for sharing clinical quality data and improvement plans
• Address day-to-day issues including: admissions, nursing, therapy, IT,
physician relations, ancillary services, etc.
• Discuss medical staff privileges/faculty and training of physicians
(fellows and residents)
• Communicate other corporate-level initiatives and changes that may
impact the project
16

17. Getting Started: Administrative Processing
• Business Associates Agreements
• Executive Leadership Sponsors
• Credentialing
• Membership: Key Players & Stakeholders
Cleveland Clinic Kindred Healthcare
• Executive Leadership • Executive Leadership
• Clinical Leadership • Local/Facility Specific Leadership
• Quality • Clinical Leadership
• Case Management • Quality
• Special Project Program Leadership • Case Management
• Physicians • Rehabilitation
17

18. Getting Started: Meeting Structure
• Meeting Times & Locations
• Standing monthly meetings
• Ad-hoc meetings / conference calls can be called by chairs at any
time to solve immediate issues
Proposed Standing Agenda
• Facilitator, Agenda, Minutes
• Successes –milestones achieved, things
that went well
• Assigned Deliverables • Monthly Quality Scorecard Review
• Review list of key challenges
• Special Projects
• Action Items – team to identify specific
actions that need to happen and who is
responsible
18

19. Getting Started
Understand & Align Culture Troubleshooting
• Understand Current Clinical Candidly Discuss
Competency
Issues & Concerns ASAP!
• Optimize patient transfers between
• Attendance and Participant
levels of care
Engagement
• Share of Drug Formularies & • Quality & Customer Service
Pharmacy contacts Performance
• Use of Referral Source for • Pertinent Data/Outcome Review
Continued Care (appointments & • Incomplete Data
urgent care)
• Need for Deeper Analysis
• Collaborate on Special Patient • All members need to avoid
Population defensiveness or excuses when issues
arise- focus on the patient &
outcomes
19

20. Discussion Agenda
 Driving Forces & Market Overview
 Joint Quality Committee…Getting Started
 Monitoring Quality and Performance Indicators
 Collaborative Process Improvement
 Return to Acute Care
 Timeline & Accomplishments- Key Lessons Learned
 Joint Quality Committees in Multiple Settings
 5 Steps to Starting Your Own Joint Quality Committee
 Panel Discussion
20

21. Getting Started:
Jointly Established Quality Goals & Benchmarks
Long-Term Nursing &
Sub-Acute
Care Hospitals Rehabilitation Centers
Admissions * * *
Discharges * * *
Length of Stay * * *
Return to STAC (short term acute care) * * *
Restraints * * *
Falls Rate * * *
Aquired Pressure Ulcer Rate * * *
Nocomial Infection Rate
BSI * * *
VAP * N/A N/A
UTI * * *
C-Diff * * *
Ventilator Wean Rates * N/A N/A
Retun to Prior Level of Functioning (PT& OT) N/A * *
Patient Satisfaction "Would Recommend" * * *
Home Health: 30 day disposition * *
21

22. Getting Started:
Jointly Established Quality Goals & Benchmarks
Nosocomial Pressure Wounds
Definitions in Acute Care Match
Definitions in Post Acute Care
Inclusion Process Completed for All
• Numerator:
• New nosocomial (developed after Day 3 of admission) Reported Data
• Stage II or higher Pressure wound(s). Pressure wounds with eschar will be considered Stage II or higher for these
purposes.
• Follow guidelines for identifying and documenting “unstageable” wounds such as Deep Tissue Injuries (DTI).
• Include applicable DTIs once the wound becomes stageable. If a Stage I advances to Stage II or higher, count as a
new pressure wound.
• Numerator EXCLUDES: Wounds that develop within the first 3 days after admission, skin tears, surgical wounds,
rashes, or any non-pressure related wounds.
•Denominator
• Every patient contributes every day of stay to the denominator.
Jointly Determined Quality
Exclusions Performance Target
No exclusion for hospice, pre-death condition, non-compliance, etc.
Rate of 3.0/1,000 patient days
22

23. Getting Started:
Jointly Established Quality Goals & Benchmarks
Partner Specific Data
• Breaking out data can be cumbersome!
• Must understand current information systems
• Have dedicated resource/time to parse information
Suggested Partner Specific Data
• Administrative
•Admission/Discharges
•Length of Stay
• Outcomes
•Discharge Disposition
•Return to Acute Care
23

24. Year Over Year Statistics
Cleveland Clinic Physician Group
Admissions for Kindred Facilities
# of Patient Admits
1,000 957
900
800
700 675 527 LTAC
600
262
500
400
300
383 SAU
200 413
100 63
63 47 Greens TCU
0
2009 2010 2011
24

25. Collaborative Process Improvement: Case Study
Kindred LTAC Patient Satisfaction
Would You Recommend Kindred
to a Friend or Family Member?
10.0
9.5
9.0
8.5
8.0
7.5
7.0
6.5
6.0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Cleveland Clinic 2010 2011
Kindred Health Care
• High expectations & monitoring • Historical monitoring without large
of patient experience change in performance
• Feedback of Patient Experience • Use of Cleveland Clinic best practice
resulted in increased scrutiny due from Office of Patient Experience
to Kindred relationship
* Process Improvement Includes:
 Collaborative process improvement initiatives
 Use of Administrative Rounding Program; daily visit by leadership team
 Implementation of Hourly Rounding, flexible visitation policy
Efforts to understand patient/family needs prior to Kindred Admission
 Streamlined communication of issue or concern with swift resolution
25

26. Getting Started: Collaborative Process Improvement
Kindred Subacute Unit
Nosocomial C-Diff
2
1.6
1.2
0.8
0.4
0
1stQ 2010 2ndQ 3rdQ 4thQ 2010 1stQ 2011 2ndQ 3rdQ 4thQ 2011
2010 2010 2011 2011
Kindred Subacute Unit
Nosocomial Pressure Wounds
8
7
6
5
4
3
2
1
0
1stQ 2010 2ndQ 3rdQ 2010 4thQ 2010 1stQ 2011 2ndQ 3rdQ 2011 4thQ 2011
2010 2011
26

27. Getting Started: Collaborative Process Improvement
Kindred Subacute Unit:
Return to Acute Care
40.0%
30.0%
20.0%
10.0%
0.0%
27

28. Return to Acute Care: Contributing Factors
Complex Discussion in the Post-Acute Care Setting
• Physician involvement and availability
• Diagnostic testing availability
• Nursing assessment skills
• Clinical competencies of staff
• Nurse / physician communication and understanding
• Advance Directives, Surrogate Decision making, End-of-Life planning
• Family expectations
• Transition issues – accurate transfer data and medical info, continuity
of care
28

29. Detailed Review of Each Return to Hospital Case
 Length of Stay
 Time of Discharge (day of week, time of day)
 Attending physician
 Physician ordering transfer
 Findings and intervention at facility
 Findings and interventions at acute care hospital*
 Evaluate if re-admission is Appropriate, Potentially Avoidable,
Avoidable
 Extenuating circumstances or other pressures impacting decision to
transfer
 Availability/timeliness of services, clinical assessment/intervention,
psycho-social or family pressures, etc.
29

30. Data Management & Analysis
Deeper Understanding of Performance
• Volume of patients
• Length of Stay
• Indicator of acuity
Physician • Discharge Disposition
Performance • Patients to lower level of care
• Return to Acute Care
• Mortality
• Medical Records compliance
Monthly • Highlight areas of pride & areas where process
improvement initiatives are required
Scorecards
• Monitor consistency of performance over time
Control Charts • Track impact of process improvement initiatives
30

31. Discussion Agenda
 Driving Forces & Market Overview
 Joint Quality Committee…Getting Started
 Monitoring Quality and Performance Indicators
 Collaborative Process Improvement
 Return to Acute Care
 Timeline & Accomplishments- Key Lessons Learned
 Joint Quality Committees in Multiple Settings
 5 Steps to Starting Your Own Joint Quality Committee
 Panel Discussion
31

32. Kindred - Cleveland Clinic Relationship
Timeline & Accomplishments
2009 2010 2011
• Monthly Joint Quality Committee • Collaborative process • Initiation of the Cleveland Clinic –
Information • Full-time Dedicated project
management
improvement initiatives
resulting in better
Kindred “Futures” Committee
• Interface for physician notes from
Sharing • Information technology
infrastructure in place
performance
EPIC to ProTouch goes live which
insures truly integrated care
• Relationship expands to “The Greens”
• Developed methodology to • 675 patients cared for under free-standing Transitional Care Center
Care determine examine and act this model of care.
on avoidable return to • Kindred Fairhill SAU & The Greens
Transitions acute care admit first patients to the “Heart Care
to Home” program
• Cleveland Clinic physician • Kindred Fairhill begins as an • Dr. Michael Felver Medical Dir. of
Physician coverage for both LTAC &
SubAcute level of care
academic site for Cleveland
Clinic residents & medical
Transitional Care Unit
• Caregiver group expands 100% to
Engagement • Cleveland Clinic physician
offices at Kindred Fairhill LTAC
students
include more internists, specialists &
mid-level providers
• Review of quality indicators, • Patient outcomes managed • Continued improvement in quality and
Quality & definitions and calculations by the Cleveland Clinic performance indicators
physician group reviewed • Collaborative, inter-organizational
Outcomes separately process improvement
Kindred Fairhill + Kindred’s The Greens
32

33. Key Lessons Learned
“Focus Locally, Succeed Locally”
 Merge culture through candid conversations and operational/clinical subgroups
Information  Information Technology projects require aligned priorities
Sharing  Enhanced information sharing requires understanding/comfort of compliance and
legal
 Understand current clinical competency and manage gaps
Care  Utilize experts to enhance knowledge and skill for highly acute/specialty patient
populations
Transitions  Access to patient historic information is a key enabler for smooth transitions of care,
though more exchange of information is needed to improve patient outcomes
 Dedicated and engaged physician leadership is cornerstone to relationship success
Physician  Physician engagement and communication strengthened with use of EPIC/physicians
on-site
Engagement
 Lack of key specialists directly impacts readmission rates
 Quality & outcome measures, including definitions, must be measured consistently
Quality &  Strong working relationships & the ability to communicate candidly can overcome
barriers and speed issue resolution
Outcomes
 Focus on key quality outcomes can help contribute to success
Italicized font depicts areas of continued focus
33

34. Highlighted Benefits
 Increased rigor around quality data collection and reporting
 Relationship may open up opportunities for your staff:
 Participate in hospital training
 Hospital sponsored community outreach events, task forces, or
process improvement committees
 Facility name recognition among hospital staff without added
marketing expense
 Immediate feedback on complaints that otherwise facility would be
unaware
 Insight into strategic plans, initiatives and programs of the
hospital/referral source; ability to better facilitate collaborative growth
34

35. Discussion Agenda
 Driving Forces & Market Overview
 Joint Quality Committee…Getting Started
 Monitoring Quality and Performance Indicators
 Collaborative Process Improvement
 Return to Acute Care
 Timeline & Accomplishments- Key Lessons Learned
 Joint Quality Committees in Multiple Settings
 5 Steps to Starting Your Own Joint Quality Committee
 Panel Discussion
35

36. Joint Quality Committees in Multiple Settings
Variations on a Theme
• Post Acute LTACH - Post Acute SNF
• Post Acute (SNF/LTACH) - Home Care
• Payors - Facilities
• Physician Practices - Facilities
36

37. Variations on a Theme: Expanding the Relationship
Kindred The Greens & Expanding the Relationship
Hillcrest Hospital with Specialty Services
• Top referring hospital within 2 miles • International Services
• 32% of patients admitted to Green’s
from Hillcrest
• Home Care- enhanced post
• Initiating JQC in 2012
acute linkages
• Specialty Programs: Orthopedic,
Cardiac and Pulmonary patients
• Physician Overlap: Pulmonologist and • Research Initiatives
Orthopedic surgeon from Hillcrest
round on patients. • Clinical Programs
• Hillcrest’s Lab, Infusion Therapy and
Emergency Services support care at the
Greens
37

38. Discussion Agenda
 Driving Forces & Market Overview
 Joint Quality Committee…Getting Started
 Monitoring Quality and Performance Indicators
 Collaborative Process Improvement
 Return to Acute Care
 Timeline & Accomplishments- Key Lessons Learned
 Joint Quality Committees in Multiple Settings
 5 Steps to Starting Your Own Joint Quality Committee
 Panel Discussion
38

39. 5 Steps to Starting Your Own Joint Quality Committee
1. Make Phone Calls: Physician to Physician Relationship will Facilitate
the Start Up
2. Focus on QUALITY
3. Commit to monitoring partner specific data
4. Initial Meetings MUST be VALUABLE
• Monthly (to develop the relationship)
• Use participants time wisely
• Delver on ALL promises/To-Do items
5. Address Concerns, Issues and Cultural Differences ASAP!
• Be Open, Candid & Transparent
39

40. Talking Points for First Meeting
 Highlight the Benefit of Partnering
 Reduced length of stay
 Ability to monitor shared patients outcomes
 Venue to impact hand-off and other quality indicators
 Commit resources to relationship development
 Jointly identified indicators to measure and monitor
 Ability to report statistics specific to Partner Organization
 Transparency, Transparency, Transparency
 Collaborative Process Improvement
 One point of contact for questions, ideas and issue resolution
• Specialty Programs
Highlight • Location & Highlights of Physical Plant
Your • Physician credentialing overlap
• 5-Star Rating & Survey Results
Facility • Leadership & Staff Consistency
40

41. Discussion Agenda
 Driving Forces & Market Overview
 Joint Quality Committee…Getting Started
 Monitoring Quality and Performance Indicators
 Collaborative Process Improvement
 Return to Acute Care
 Timeline & Accomplishments- Key Lessons Learned
 Joint Quality Committees in Multiple Settings
 5 Steps to Starting Your Own Joint Quality Committee
 Panel Discussion
41

42. Thank You
42