Introduction
Changes in healthcare reimbursement mechanisms will require innovation to adequately care for future brain injury populations. The American Recovery and Reinvestment Act of 20091 included the Health Information Technology for Economic and Clinical Health (HITECH) Act which provided incentives to encourage electronic health record implementation. This was intended to address the adoption and meaningful use of health information technology. The Affordable Care Act2 established the Center for Innovation to explore new care models. Taken together, these initiatives established a foundation of technology infrastructure as well as exploration of more at risk and bundled payment mechanisms. This article will explore the impact of these changes as well as describe a specific example of how two academic medical rehabilitation providers collaborated to respond to the new challenges.
Brain Injury Throughout the Continuum
According to the Centers for Disease Control and Prevention statistics,3 traumatic brain injury accounts for approximately 2.5 million emergency department visits, hospitalizations or deaths. Data on the leading causes of brain injury from 2006-2010 include falls (40.5%), assaults (10.7%), motor vehicle traffic (14.3%), struck by/against assault (15.5%) and unknown/other 19%.3 The data revealed that there are three peaks in the age distribution for brain injury occurrence including children aged 0 to 4 years old, adolescents aged 15 to 19 years and adults age greater than 65 years.4 Regardless of the etiology, brain Injury rehabilitation necessitates a comprehensive interdisciplinary model of delivery through the continuum of care. This includes addressing medical, physical, cognitive, communication, psychosocial, behavioral, vocational, educational, accessibility, and leisure needs in order to minimize the impact of impairments and reduce secondary complications as well as activity limitations, improve participation in the community and impact quality of life.5
Brain injury rehabilitation services can be offered in a variety of care settings including the acute hospital, inpatient rehabilitation, skilled nursing facility, home health, outpatient rehabilitation, residential, and the community. Traditionally, Medicare has provided separate reimbursement to providers at each level of care during a single illness or course of treatment. Often patients with complex acute or chronic conditions are not prepared for the transitions that occur during the course of treatment. This approach may result in fragmentation of care including limited coordination across providers and healthcare settings as well as increased risk for readmissions and compromise in patient health. Since poor care transitions affect patients, families, clinicians, and the health care delivery system, an increasing number of health care organizations and professional organizations have identified alternatives to improve patient care and safe discharges as core care transition issues that require performance measures and public reporting requirements. Quality incentives are also based on care from providers versus quantity of care provided. Historically, commercial payers and workman’s compensation payers have attempted to address this fragmentation with assignment of case managers for catastrophic cases to administer benefits in a cost efficient manner. With the recognition of disincentives for coordinating care across settings, MedPAC6 recommended creating a program to test the feasibility of bundling payment policies that would pay for care that spans across provider types and would hold providers accountable for quality over the course of the episode of care.
Bundled payment initiatives assist in the alignment of provider incentives across the continuum of care (e.g. acute care hospital, post-acute settings, physicians and other healthcare providers). Under a bundled payment arrangement, Medicare pays a single provider entity an amount intended to cover the costs of providing the full range of necessary care. In the following example, bundled payment begins with an index hospitalization and continues for a defined period of time. The index hospitalization is the first event in the sequence that begins an episode. All care that is related to the index hospitalization over the selected period of time is funded as part of the bundle. Within the Affordable Care Act2 are proposals to bundle acute and post-acute payment into one payment for services. This would redesign the way in which brain injury rehabilitation would be managed from the time of injury through the various post-acute care venues. New post-acute protocols and workflow dynamics will need to be developed in order to communicate continuum wide care coordination.
To illustrate, a patient with traumatic brain injury with a moderate Glasgow Coma Scale at the time of the initial hospitalization may require a short stay in the intensive care unit followed by stabilization on the neurological floor. If fluctuating levels of arousal and fatigue with therapy treatment are present, the case manager for the clinical team would consider the optimal venue for the next phase of rehabilitation. This patient has a tracheostomy and gastrostomy tube, desaturates with upright activity, and requires hourly suctioning due to pneumonia secretions. Given these patient characteristics, admission to a long term acute care facility where specialty-care services for patients with serious medical problems that require intense, special treatment for an extended period of time is warranted.
The goal of the long term acute care hospital (LTACH) will be to have the patient stabilize medically, initiate progressive therapeutic interventions including physical therapy, occupational therapy, and speech-language pathology to increase the patient’s ability to participate in an intensive rehabilitation program. As the medical issues resolve and tolerance improves, the patient’s ability for full participation in an intensive inpatient rehabilitation level of care evolves. The next step in the continuum would likely include admission to the inpatient rehabilitation facility. During this phase of recovery, the tracheostomy and gastrostomy tubes would be weaned, patient’s functional level would likely improve in daily activities and mobility however with continued deficits in cognition. Transition to home with an intensive home and community program would be justified. Another proposed option is a redesign of care structure such as a continuing care hospital for transitions between levels of care. In a continuing care hospital, after discharge from the acute care hospital, the LTACH level services and inpatient rehabilitation services would be deployed to the patient as the patient’s medical and functional levels improve without physically moving the patient. Under bundled payment, this type of innovative model has the potential to improve efficiencies, effectiveness, and patient/family experience.
In this example, if the bundled payment was based on ninety days, at the point of discharge to home, it would be approximately two-thirds of the way through the bundle. This would leave only one third of available days, not to mention where one would be with the cost portion of the bundle. A recent literature review on the cost of mild and moderate traumatic brain injury demonstrated the paucity of research in this area.7 Considerations for designing a traumatic brain injury bundle would include: intensity of medical care, need for medical oversight, level of participation, cost of readmissions from any setting balanced with outcome, family support, serving clients needs would drive transitions and movement through various venues of care.
Integration of catastrophic care throughout the continuum of care has significant opportunities to enhance patient care while reducing cost. Bundling has the potential to incentivize various providers to determine the most effective and efficient mix of services and settings of care in order to reduce fragmentation, encourage collaboration and improve accountability and quality of care.
Health Care Partnerships Throughout the Continuum
Health system initiatives are focusing on the patient’s journey following the acute care hospital in order to bridge inpatient to community care to prevent readmission and address total cost of care including penalties and incentives directed at coordination and collaboration of care. Resource allocation requires selection of the appropriate treatment level for the severity and phase of brain injury recovery. Partnerships with other providers in local communities may require innovative information transfer for proper care to be provided. For example, having access to transition of care documents, providing view access in the electronic health record to care partners, and enhancing patient portals are effective methods. Many home health providers and skilled nursing facilities have operationalized these avenues to obtain patient specific information to ensure continuity for the patient. Another tactic is to deploy staff such as nurse practitioners or physicians to the home or skilled nursing facilities to assure carry-over of the established plan of care. This may be beneficial for brain injury patients with low arousal. A short term skilled nursing facility placement may be utilized until the patient improves to the level appropriate for an inpatient rehabilitation admission. Medical management and oversight for these complex brain injury patients and prevention of secondary complications in skilled nursing facilities requires close medical management and therapy intervention with progressive intensity.
Developing creative options that deliver superior value is a tactic that has been utilized effectively for inpatient rehabilitation units and hospitals. One mechanism to align common goals can be a joint venture or new entity. Recently, two academic inpatient rehabilitation providers were faced with a high cost position, a lack of inpatient rehabilitation bed availability as well as an increasing demand for rehabilitation service delivery. Challenges for resolution of the problem included high project costs for any expansion, a lack of suitable space to accommodate growth and the inability to lower the overall cost of care under an expansion scenario. These institutions were brought together by a third party who proposed a joint venture to create a world class rehabilitation institute. Potential strengths included collaboration between two Level I trauma centers, the ability to leverage academic expertise and infrastructure, community benefit for rehabilitation capacity and enhancement of program specialization, concentration of high caliber resources and technology, and the ability to lower the cost position. The potential benefits included a decrease in the total cost of care for the rehabilitation population, the ability to contract at a lower cost per patient per day, expanded bed capacity, improved ability to provide specialized population specific care, and consolidation and improved efficiency of services.
The overarching goal of the current healthcare reform is the provision of high quality and efficient care that results in desired patient outcomes, referred to as the Triple Aim.8 The Triple Aim goals of improving individual health care (patient experience of care), improving population health and lowering costs were established to motivate health care systems to stretch beyond traditional clinical roles and work towards broad population health management. In the example previously illustrated, the patient experience will improve with expanded services in a facility dedicated to comprehensive rehabilitation recovery and restoration of function. The cost structure in the new hospital will significantly lower the per capita expenditure for the patients served. The concentration of rehabilitation services has the ability to elevate the expertise in the brain injury and other impacted populations in this community. A recent study sponsored by the American Medical Rehabilitation Providers Association (AMRPA)9 compared over 5,000 matched brain injury cases treated at inpatient rehabilitation facilities matched on demographics and clinical severity with similar patients treated at skilled nursing facilities. For the brain injury population this study revealed a significantly reduced mortality and reduced readmission rate but at an increased overall cost. In order to continue to admit patients to inpatient rehabilitation for these critically important services with demonstrated improved outcomes, lowering the cost per patient per day, ensuring access to rehabilitation care and enhancing outcomes for this population is crucial.
Summary
There has been varied support from payers and the Centers for Medicare and Medicaid Services (CMS) for rehabilitation in areas outside the traditional levels of care. Innovative outpatient day treatment programs as well as cognitively based home and community programs may provide alternatives in the provision of efficient care. Unfortunately many of these options are limited due to financial barriers or in the ability to exist as an option in today’s health care environment. In a bundled payment system, these could potentially be developed and integrated into a seamless system of care for the patient with a brain injury. Health care systems of care will continue to explore the value equation and determine solutions based on the market and patients within their community. Regardless of the participants, there is a need for action and innovative solutions including redesigning of brain injury care in order to meet the new value goals.
About the Authors
Dr. Richard Riggs is Vice President and Chief Medical Information Officer (CMIO) for the Cedars-Sinai Health System, Chairman and Medical Director Department of Physical Medicine & Rehabilitation, Cedars-Sinai Medical Center, Chief Medical Strategy Officer of the soon to be opened, California Rehabilitation Institute. Dr. Riggs serves on the CSHS Board of Directors as well as on the Executive Committee of the Board. Dr. Riggs is a Professor at CSMC and UCLA. Dr. Riggs has published and lectured nationally and internationally on clinical and administrative rehabilitation research and topics, as well delivered lectures on physician leadership skills and health informatics. Dr. Riggs completed his medical education at the Medical College of Georgia, and he trained in Philadelphia in conjunction with the University of Pennsylvania.
Pamela Roberts, PhD, MSHA, OTR/L, SCFES, FAOTA, CPHQ, FNAP is the Program Director of Physical Medicine and Rehabilitation and Neuropsychology at Cedars-Sinai Medical Center, Los Angeles, California. Dr. Roberts has worked throughout the continuum of care as a clinician, administrator, educator, and researcher. She teaches at local universities, a national FIM trainer and a CARF surveyor. She is involved in the American Congress of Rehabilitation Medicine, American Occupational Therapy Association, and National Quality Forum committees, past chair of the California Hospital Association (CHA) Center for Medical Rehabilitation Services and past member of the Post-Acute Care board. Dr. Roberts is Chair Elect of the American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group and ACRM Program Committee Chair. Additionally, she is Chair-Elect for the Accreditation Council for Occupational Therapy Education (ACOTE). Dr. Roberts has published and provided workshops and consultations on rehabilitation and health services research topics regionally, nationally, and internationally.
References
1. American Recovery and Reinvestment Act of 2009, Pub. L. No. 111-115, 123 Stat. 115, 516 (February 19, 2009).
2. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 3502, 124 Stat. 119, 124 (2010).
3. Centers for Disease Control and Prevention Injury Prevention and Control: Traumatic Brain Injury. Retrieved from the World Wide Web on March 21, 2015: http://www.cdc.gov/traumaticbraininjury/get_the_facts.html.
4. Faul M, Xu L, Wald MM, Coronado VG. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006 Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010.
5. CARF Medical Rehabilitation Standards Manual. Brain Injury Specialty Program. Commission on Accreditation of Rehabilitation Facilities: 2015.
6. MedPAC. Report to Congress: Medicare and the Health Care Delivery System. Approaches to bundling payment for post-acute care (Chapter 3). June 2013. Retrieved from the World Wide Web on March 21, 2015: www.medpac.gov/documents/reports/jun13_ch03.pdf?sfvrsn=0
7. Humphreys J, Wood RL, and Macey S. The costs of traumatic brain injury: a literature review. Clinicecon Outcomes Res 2013; 5: 281-287.
8. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs 2008; 27(3):759-69.
9. DaVanzo JE, E-Gamil A, Li JW, Shimer M, Manolov N, and Dobson A. Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities (IRFs) and After Discharge Final Report 2014; Dobason DaVanzo & Associates, LLC: 1-46.
ABOUT THE AUTHORS
Dr. Richard Riggs is Vice President and Chief Medical Information Officer (CMIO) for the Cedars-Sinai Health System, Chairman and Medical Director Department of Physical Medicine & Rehabilitation, Cedars-Sinai Medical Center, Chief Medical Strategy Officer of the soon to be opened, California Rehabilitation Institute. Dr. Riggs serves on the CSHS Board of Directors as well as on the Executive Committee of the Board. Dr. Riggs is a Professor at CSMC and UCLA. Dr. Riggs has published and lectured nationally and internationally on clinical and administrative rehabilitation research and topics, as well delivered lectures on physician leadership skills and health informatics. Dr. Riggs completed his medical education at the Medical College of Georgia, and he trained in Philadelphia in conjunction with the University of Pennsylvania.
Pamela Roberts, PhD, MSHA, OTR/L, SCFES, FAOTA, CPHQ, FNAP is the Program Director of Physical Medicine and Rehabilitation and Neuropsychology at Cedars-Sinai Medical Center, Los Angeles, California. Dr. Roberts has worked throughout the continuum of care as a clinician, administrator, educator, and researcher. She teaches at local universities, a national FIM trainer and a CARF surveyor. She is involved in the American Congress of Rehabilitation Medicine, American Occupational Therapy Association, and National Quality Forum committees, past chair of the California Hospital Association (CHA) Center for Medical Rehabilitation Services and past member of the Post-Acute Care board. Dr. Roberts is Chair Elect of the American Congress of Rehabilitation Medicine Stroke Interdisciplinary Special Interest Group and ACRM Program Committee Chair. Additionally, she is Chair-Elect for the Accreditation Council for Occupational Therapy Education (ACOTE). Dr. Roberts has published and provided workshops and consultations on rehabilitation and health services research topics regionally, nationally, and internationally.