Lynn Spragens, MBA Spragens and Partners, LLC Durham, NC Lynn@LSpragens 919-309-4606 capc.

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NHWG; Adapted from work of Canadian Palliative Care Association & F. Ferris, MD ... Palliative consideration set to turn into an official sub-strength of inward medication in 2007 ...
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Compelling Hospital-Based Palliative Care Programs: Staffing Needs and Cost Savings West Virginia Center for End-of-Life Care September 13, 2006 Lynn Spragens, MBA Spragens & Associates, LLC Durham, NC 919-309-4606

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Objectives Provide a structure for showing monetary effect Present case of system results and "developing measurements" Suggest functional operational and budgetary measures Help all of you work on project sway objectives

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Comments on WV Center Great (!!) statewide contribution Thorough information accumulation by the individuals who report – extremely amazing Statewide effect re EOL measures Legislation – COOL Concerns Penetration, Sustainability, Depth, $$$ EOL Brand and center

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National Perspective: Chronically Ill, Aging Population Is Growing The quantity of individuals over age 85 will twofold to 10 million by the year 2030. The 63% of Medicare patients with 2 or more endless conditions represent 95% of Medicare spending. US Census Bureau, CDC, 2002.

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NHWG; Adapted from work of Canadian Palliative Care Association & F. Ferris, MD Palliative Care: Bridging Restorative and Comfort Care Disease Modifying Therapy Curative, or therapeutic purpose Life Closure Death & Bereavement Diagnosis Palliative Care Hospice

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Needs met by Palliative Care Communication re objectives of consideration, plan of consideration: patient, family, numerous masters, and so on. Specialists in torment and manifestation administration Providing proactive treatment that offers trust when guess is inauspicious TIME, ability, and aptitude

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Palliative Care in 2006 Over 25% of doctor\'s facilities now have a palliative consideration program US News & World Report incorporates palliative consideration in its criteria for "America\'s Best Hospitals" Palliative consideration set to wind up an official sub-claim to fame of interior solution in 2007 Referral rates at set up projects are developing every year Billings JA et al J Pall Med. 2001, AHA Survey 2002, Pan CX et al J Pall Med. 2001

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Indicators of Fast Growth Hospitals with palliative consideration – In 2000, 632. In 2004, 1102 % of aggregate healing facilities, from 15% to 27% ABHPM guaranteed MDs now 2140 60 projects are putting forth cooperations, versus 17 in 2000 - a 200% expansion in 6 yrs.

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Implications of Growth Expected acknowledgment as ABIM claim to fame by one year from now Fellowships Grandfathering of ABHPM affirmation Competition for MDs and NPs Growing requirements for clinical preparing Strengthening of projects versus solo offerings Need to cover distinctive settings, not simply doctor\'s facilities

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Components of the Formal Strategy Define the need (Support Study) Identify the "business sectors" – CAPC + Define the item – National Consensus Project ( ) Promote efficient "system" execution versus development – Tech Asst. ( ; ) Create "push" and "draw" advertising techniques Advisory Board JCAHO Business case and MEASUREMENT

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Public Awareness is Growing

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March 10, 2004

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Palliative Care IS: Re-characterizing Your Brand Palliative Care Is NOT: Excellent, proof based medicinal treatment Vigorous consideration of torment and manifestations all through disease Care that patients need in the meantime as endeavors to cure or drag out life "Surrendering" on a patient set up of therapeudic or life-dragging out consideration The same as hospice

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A Few of Our "Learnings" People are not in the business sector for a "decent demise" Providers need to offer something constructive to patients and families (which delays anticipation dialogs) Lack of time and shared discussions is biggest giver to inaction

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Where are you NOW? Introductory evaluation Started administrations Got occupied… Who are you NOT got notification from? What required administrations are not yet accessible? Where would you like to go beside help patients? Have you put forth the business defense? Time to "reassess" and push forward wt certainty!!

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Ways to Find Gaps Patients >75 with 4+ affirmations Patients with LOS > 10 or 14 days Patients conceded from SNF with various confirmations Patients with "danger of mortality" score of 4 (review) Patients with LOS > 4 days and who kicked the bucket without palliative consideration Other???

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Mid-Stream Assessment Alignment open doors – key activities of the healing center Rapid Response Teams 100,000 lives Campaign Medication Management "Moves" Geriatric nursing activities? Plane Tree

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Political Capital/Budget Control Case Management "Difference days" – your effect? Readmissions? Drug store Home consideration and Hospice? Nursing – staffing and fulfillment (CNS model) MDs? Hospitalists?

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Opportunities for Support Board of Directors Hospice and group offices Payers/Insurance/Pay for Performance Philanthropy Demonstration Projects Billing AND "COST AVOIDANCE"

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Variables for Direct Support Patient volume Degree of Impact and Duration of Impact = Savings every day LOS sway (maintained a strategic distance from anomalies) Billing and different incomes Cost of administrations

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Defining Need: Volume is key Variable Which patients have unmet needs? Where are they? In what manner would you be able to get to them? At the point when do you get to them? What do you do? For to what extent?

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"Top Down" % Medicare # of passings # wt long stays Comparative Data 2 – 7% of patient affirmations = evaluated request "Base Up" Patients wt certain DRGs Multiple confirmations With LOS > xxx Admitted from SNF Deaths Certain areas (MICU) Volume – Two Methods

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"Spragens" Volume Estimator

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"Spragens" Staffing Rules of Thumb For projects of 150 informal lodging, REALLY a smart thought to run with no less than 1.5 ftes, 200+new patients Capacity of NP, MD, MSW group with great specially appointed group backing is 300-400 new patients for each year Assume (unpleasant) 700-1000 visits for every year per MD or NP supplier (blend of new and f/u) Impact and development is identified with staffing

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Adequate Staffing To create and take care of demand Dilemma: Chicken or Egg? Satisfactory Volume to exhibit reserve funds and legitimize the system

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Methodology prescribed Use gauges from different projects for the "professional forma" stage Use neighborhood cases and particular information Get purchase in and refinements from your own particular pioneers and back staff Measure results, and bit by bit redesign the model with your own information. Check in, and get credit!

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Baseline "Needs: Approach "We\'ve been working truly hard and have dealt with 100 patients this year. Without us, their expenses would be higher, and LOS longer. We require $100k to reserve continuation." Where are the funds from this work in the YTD genuine budgetary results? What will need to happen to discover this cash?

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"Opportunity Cost" Approach "We\'ve had any kind of effect without including staff – we\'ve seen 100 patients this year, and here are the outcomes. We\'ve spared at any rate $125,000 for the doctor\'s facility on these patients. One year from now, we think we could twofold this effect, on the off chance that we could submit $100,000 to devoted assets." What is distinctive? How might this be subsidized?

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"Cost Avoidance" Challenge If we do this, then the undesirable result does NOT happen… How would we get kudos for what DID NOT happen???

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Strategy: Avoid the "Case Management" Cycle… Stage 1: Invest to Change Outcomes Stage 2: Get comes about and keep up Stage 3: Baseline spending weight, "What have you accomplished for me recently?" Stage 4 = CUTS and steady disintegration of results Stage 5:Reinvest and start the cycle once more…

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Example of Financial Results A clinic wide counsel administration with 1.5 to 3 ftes serving a 300 bed doctor\'s facility may see 300 - 600 +patients/year Estimated cost reserve funds (direct cost shirking and some quality to LOS investment funds) range from $250,000 to $750,000 contingent upon suspicions and techniques. ($200-$400/day) Professional part B charging may create another $65k-$120k of income, contingent upon staff and model

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Total Costs FIXED COSTS Those costs that don\'t fluctuate straightforwardly with volume. Over a predetermined period these expenses would be acquired paying little heed to volume. As demonstrated as follows, settled expenses have two segments. VARIABLE Costs that fluctuate specifically and proportionately with the volume of patient administrations gave. These costs may vacillate everyday and would not be caused if no administrations were utilized. As demonstrated as follows, variable expenses have two parts. Settled INDIRECT Costs that can\'t be particularly followed to an individual office and don\'t shift with volume. These expenses are designated to all divisions. Cases: utilities, healing facility organization. VARIABLE DIRECT * Costs that can be followed to a particular item or administration. These costs increment or reduction as indicated by the volume of administrations. Cases: nursing care, supplies. VARIABLE INDIRECT The expenses or costs that can\'t be particularly followed to an individual patient yet which do differ with volume. Cases: social administrations, therapeutic records. Altered DIRECT Costs that can be followed to or related to a particular item or administration however that don\'t fluctuate with volume. Cases: supervisory work force, hardware. The primary wellspring of potential reserve funds connected with cost evasion endeavors. Obligingness of Kathleen Kerr, UCSF, 2/1/05

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4 3 Work Teams 2 1 0 10 20 30 40 Volume Semi-variable cost conduct for Savings and Revenue Using midpoints Reality = "Breakpoints"

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Per day costs: pre-and post-referral Making the Financial Case Costs Pre & Post Palliative Care Referral Charts kindness of J Brian Cassel, PhD, Massey Cancer Center, Virginia Commonwealth University Smith et al. J Pal Med 2003

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Palliative Care: Sources of Direct Cost Saving

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