This is a video that was submitted in a contest by a 20-year old. The contest was titled “u @ 50″ by AARP. This video won second place. When they showed it, everyone in the room was awe-struck and broke into spontaneous applause. So simple and yet so brilliant. Take a minute and watch it. Then apply the concept to healthcare reform? Enjoy!

Introduced nearly 30 years ago, bundled payments would essentially provide one payment to Acute Care Hospitals (ACHs) for both acute and post acute services and allow the ACH to determine the amount of post acute care a patient needs and the most cost effective care provider. Under this scenario, the CBO estimates a $0.7 billion reduction in federal outlays between 2010 and 2014 and by 2019 they estimate a reduction of almost $19 billion.

The reintroduction of the concept raises many questions for ACHs, long term acute care hospitals (LTACHs), home health agencies, skilled nursing facilities (SNFs), and inpatient rehabilitation facilities (IRFs) and how they will be reimbursed for treating Medicare recipients. Also questioning this potential manner of reform are the lawmakers.

In a recent white paper entitled “To Bundle or Not To Bundle: Lawmakers Explore the Question,” released by three attorneys at McGuire Woods, LLP, Jason S. Greis, R. Brent Rawlings, and J. Brian Jackson explore the questions that the implementation of bundled payments raise. The three comprehensively explain the concept, its history, and how it would affect the various types of acute and post acute facilities from the time of implementation through 2019 when the reform measure will reach the outcome envisioned by the CBO.

They further investigate the questions industry leaders are raising, the pros and cons of the option and what companies are doing now in preparation for the proposed legislation. An interview with Tom Clarke, President & CEO of Kissito Healthcare resulted in the explanation that “[s]ome organizations have already begun planning for the bundling trend by creating integrated post-acute care and senior living campuses with a full array or long-term care services, or by developing post-acute care facilities capable of catering to more acutely ill patients in more cost-effective settings.” Kissito Post Acute is one of said organizations in that its “SNF facilities provide ventilator weaning programs, which are commonly found in LTACHs, while achieving comparable clinical outcomes and Medicare costs savings.”

Kissito Post Acute, a division of Kissito Healthcare, prides itself on remaining patient-centered and physician-driven. Existing for the care and betterment of human life, Kissito Post Acute realizes the current paths patients take from hospital to home and redefines that, attempting to eliminate many of the unnecessary trips to various types of facilities. Their Collaborative Patient Care Model™ fosters the best environment for successful outcomes. This unique, industry-leading approach involves partners in a cohesive team that enables patients to return to their lives and function at the highest level.

Clinical Pathways were tested in a variety of Italian health care organizations in 2000-2002 to measure performance in decreasing process and outcome variations. Reductions in length of stay and diagnostic and therapeutic prescriptions were demonstrated where pathways were implemented successfully.

Then European Pathway Association performed an international survey in 23 countries utilizing Clinical Pathways. They found that they ‘improved the quality of Evidence Based Care and improved communication between professionals to manage and standardize outcome oriented care.’

Based on these results, Kissito Post Acute’s interdisciplinary team developed Collaborative Care Pathways as a proprietary patient management tool. They outline the process, timeline, and benchmarks for meeting the needs of a patient as they transition to home.  The Pathways were based on research, Best Practices and Evidence Based Medicine. They help Kissito achieve its goal – returning the patient home quickly, safely, and effectively.

The Pathway serves as a tool to guide the direction of care. It is a visual indicator that depicts the pathway to home, define the care plan and helps to keep all members of the Total Care Medical Team on the same page. It is like a flow chart of the decisions to be made and the care to be provided for a patient for a given condition in a step-by-step sequence.

The benefits of Collaborative Care Pathways include:

• Improve multidisciplinary communication, teamwork and care planning
• Support continuity of care across different clinical disciplines
• Provide well-defined standards for care (reduce variations in patient care)
• Improve clinical outcomes
• Ensure quality of care and provide a means of continuous quality improvement
• Empower patients
• Reduce risk
• Reduce costs by shortening acute hospital and post acute stays

Care transitions is at the core of what Kissito Post Acute is all about, as it is one of the four centers of excellence of the Collaborative Patient Care Model ^TM.  Care transitions, is the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. It is rapidly gaining recognition  nationally in the light of recent healthcare reform discussions. Researchers have found that 20 percent of Medicare beneficiaries return to a hospital within 30 days of discharge, increasing the cost of care for people in their later years.  Dr. Eric Coleman, creator of the Care Transitions Program℠, found that a transition intervention care program reduces the incidence of rehospitalization for up to 180 days.

In 2007, the California HealthCare Foundation (CHCF) initiated a year-long, $650,000 project to bring the Coleman Care Transitions Initiative (CTI) to ten centers to improve transition care. The use of CTI resulted in lower readmission rates and researchers estimated that for every 350 patients receiving an intervention, costs were cut by nearly $300,000. With 800 patients reached in the CHCF effort, the intervention nearly paid for itself.

Kissito Post Acute staff are being trained on the Coleman Care Transitions Program℠, which is a four-week program encouraging patients to take a more active role in their healthcare. Patients receive tools and skills to assist in their self-care and are reinforced by a transition coach, who follows patients across settings for the first four weeks after leaving the hospital. The transition coach will emphasize:

• Medication self-management
• A patient-centered health record to guide patients through the care process
• Follow-ups by specialists and primary care providers
• “Red flag” awareness of indicators of worsening conditions and “next steps” for patients.

The patient-centric focus of the program includes measures for families and caregivers to ensure their comfort with the care regimen and the self-activation of the patient. The care delivery tool kit also includes a personal health record and medication discrepancy tool. After the intervention, patients are empowered and more capable and willing to manage their daily healthcare.

We have 9 facilities in Texas, Arizona and Virginia and are diligently studying and researching a single point of entry model to further enhance our Collaborative Post Acute Care Model^™ and our ability to improve outcomes and quality in the healthcare delivery system. We are currently developing more collaborative partnerships with Long Term Acute Care Hospitals and Home Health Agencies to provide a Total Post Acute Solution in several of our locations. All of our facilities provide speech, occupational, and physical therapy, long term care extensive nursing, and promote  aggressive return to home therapy programs based on systems and processes that help reduce hospital readmissions and mortality rates in both the acute and post acute setting.

Kissito Post Acute is a division of the Kissito Healthcare Family. This not-for-profit organization includes Kissito Post Acute, Kissito Long Term Care and Kissito International.

Phase 1

Joint Case Management & Pre- Admission Review (Pre-Admission)

Transition always presents risk. To eliminate the risk of re-hospitalization and medical error our model provides for a formalized system and HL7 compliant Electronic Medical Record, developed by physician staff to obtain specific information based on individual diagnoses pre-admission. This in turn allows Kissito Healthcare to provide a safe care transition that leaves minimal risk for hospital re-admission and medical error. As a bi-product of this system Kissito Healthcare is able to take a more medically complex patient earlier from the hospital.

Phase 2

Orientation & Assessment (First 24-48hrs)

ORIENTATION is conducted using a comprehensive easy to understand guidebook that helps to set the goals and expectations for both the patient and the family. Each patient and family is seen by their interdisciplinary team via what we call Collaborative Care Rounds. The interdisciplinary team is made up of therapists, nurse practitioners, social workers, nurses, and dietitians. The orientation process ensures that both the patient and family know they will be active participants in the rehabilitation process day one.

Phase 3

Treatment Phase (48hrs – 3 days prior to discharge)

TREATMENT planning is a crucial phase in the model. No one patient has the same treatment plan. A comprehensive tool called the Collaborative Care Pathway™ was developed to help guide the development and execution of purposeful treatment plans designed individually with the goal of returning the patient back to home. Based on 12 months of research and constant collaboration with healthcare providers, the Collaborative Care Pathway™ consists of staff competency and skills training, templated documentation, and use of industry best practices. This ensures that the staff and medical team are in tune with the patients every need and are equipped with the skills and knowledge to identify red flags and problems early enough to prevent hospital re-admissions.

Phase 4

Transition (3 days prior to discharge)

TRANSITION U is a program created for the patient and the family that allows the patient to start to takeover their care. Once this transition has begun the interdisciplinary team is able to step outside the box and really see where the patient’s progress really is and identify potential failures or areas that need to be addressed. Transition U not only prepares the patient to go home but it also includes processes like home safety evaluations and teaches medication management.

TRANSITION U introduces the patient and family to their Transition Coach. The Transition Coach becomes their key contact for preparing them to be able to not only go home, but remains their contact once they get home.

Phase 5

Home (Post Discharge): Home Phase is being implemented in early 2010

HOME but it’s not the end of the road. It’s the beginning of a new road, and not one that leads back to the hospital. Once the patient returns safely to home they are visited within 24-48 hours after discharge by their Transition Coach to ensure they are comfortable self administering and managing their medications, completing any exercises or therapy related items that were assigned, but most importantly to make sure they can function in the actual home.

Each patient is given the number to the Kissito Care line and the direct number to their Transition Coach. The Kissito Care line is simply a channel for the patient to ask questions related to their transition and care. No medical information or advice is given; however the care line attendant will refer them to a medical doctor should they ask for medical advice.