CMMI, CCJR, SNF Performance Network, CJR, Bundled Payments, Episodes of Care, Comprehensive Care for Joint Replacement, Care at the Right Location, CARL Tool, CMS

Medicare Signals Permanent Moves Toward Episodic Accountability

Remedy helps older Americans recover from hospital stays through aligned provider incentives, care coordination services, information sharing, software integration and transitional care networks.

Last week, the Centers for Medicare & Medicaid Services (CMS) announced proposed revisions to discharge planning practices required for participation in all Medicare and Medicaid programs that support Remedy’s technology-empowered discharge planning.

The proposal encourages early discharge planning and outlines the importance of active care coordination between facilities, patients, caregivers, and community support networks. Simply put, this rule indicates that these clinical activities are no longer just essential for value based care – they will soon be mandatory for all IPPS hospitals.

Many providers across the country are adopting Remedy’s next site of care decision support tool – the Care At the Right Location (CARL) Tool – concurrently with Remedy’s SNF Performance Network as a powerful and effective strategy that meets proposed CMS conditions, while immediately helping patients and caregivers select the optimal next site of care.

Built for the Bundled Payment for Care Improvement (BPCI) initiative, the CARL Tool was created by an interdisciplinary team with over 3 centuries of cumulative discharge planning experience. It is gaining fast adoption as a malleable recommendation tool that promotes thoughtful discussion and sparks innovative thinking around transitional care.




Specifically, CARL meets the proposed discharge planning requirements under 42 C.F.R.'s 482.43 (condition of participation: discharge planning) that a "hospital must consider the following in evaluating a patient's discharge needs:"

(i) Admitting diagnosis or reason for registration;
(ii) Relevant co-morbidities and past medical and surgical history;
(iii) Anticipated ongoing care needs post-discharge;
(iv) Readmission risk;
(v) Relevant psychosocial history;
(vi) Communication needs, including language barriers, diminished eyesight
and hearing, and self-reported literacy of the patient, patient's representative
or caregiver/support person(s), as applicable;
(vii) Patient's access to non-health care services and community based care providers; and
(viii) Patient's goals and treatment preferences.

Consistent with these proposed regulations, Remedy's discharge planning decision support tool, CARL, is designed to identify, structure and simplify the essential information for next-site-of-care decision-making and planning. The CARL tool is comprised of 17 evidence-based questions in three domains: (1) independence, (2) therapies and (3) skilled nursing services. These questions target the post acute needs identified by Medicare, and use validated evidence from peer-reviewed literature.

The CARL Tool enables informed, innovative discharge discussions that allow the care team to: identify the patient's discharge goals and service needs, to maximize available resources (including caregivers), to support a safe transition and to prevent unnecessary readmissions.

The results from Remedy’s retrospective evaluation of 1,500 episodes using the CARL Tool indicates that utilization of post acute facilities is reduced by an average of 50%, without any increase in readmission rates. Use of the CARL Tool, on its own, can materially improve the cost and outcomes for ACOs, bundled payment programs and hospital readmission reduction efforts. The CARL Tool may also be used by payers to manage pre-certification and service authorization programs.




Remedy’s SNF Performance Network serves as the perfect complement to the CARL Tool
in the discharge planning process and to help our providers across the country satisfy
new requirements under Medicare’s proposed discharge planning rule.

Specifically, Medicare proposes under 42 C.F.R. s 482.43 (condition of participation: discharge planning) that:

“The hospital must assist the patients, their families, or the patient's representative in selecting a post acute care provider by using and sharing data that includes but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The hospital must ensure that the post acute care data on quality measures
and data on resource use measures is relevant and applicable to the patient's goals of
care and treatment preferences.”

To bolster the ability of clinicians to convey quality-of-care information, Remedy develops profiles of skilled nursing facilities in each hospital service area. Remedy’s data scientists and clinicians assess each facility’s overall clinical and operational performance, quality of care performance, and the strength of each facility’s partnership with the hospital and Remedy. To better understand relative performance of each facility, Remedy’s analysis includes data from Nursing Home Compare, Medicare claims payment data and surveys
of facility administrators. We also conduct patient experience research with a focus on finding providers committed to continuous, productive communication around results-oriented patient care.

Remedy develops and continuously refines a separate performance profile for each category of clinical need, addressing each of the factors associated with high-quality care. Remedy selects quality-of-care information to share with patients based on a clinical judgment that high-quality care can be consistently delivered by facilities that: (1) maintain appropriate levels of nurse staffing; (2) insist on regular, intensive physician oversight; and (3) invest
in specialized units and capabilities to address patients’ clinical needs.

Remedy believes that the patient’s selection of post-hospital care should emerge from an individualized collaboration among the clinicians, patient and caregivers. Remedy facilitates and informs this process with technology and data delivered at the bedside, and through our Episode Connect Patient Portal. With Remedy's Episode Connect technology and associated applications, the care team can better evaluate the patient’s needs and, in
the words of Medicare, “assist patients as they choose a high quality PAC provider.”

Tagged: CMMI, CCJR, SNF Performance Network, CJR, Bundled Payments, Episodes of Care, Comprehensive Care for Joint Replacement, Care at the Right Location, CARL Tool, CMS