Standards of care, quality measures development,
improved outcomes, pay for performance
Gene Gantt RRT
THE EVENTA GROUP
Eventa=Latin for outcomes
Long Term Care Market
16,000 SNFs
1724 new vent
beds in SNF
from 2009 to
2013 -US total
9500
U.S. shipments of sub-acute
ventilators 6,789 units in
2017, up 41 percent from 4,805
in 2013, according to IHS
Technology (NYSE: IHS
1.5 million
residents
25-30% with
lung disease
Predicted Increase in
PMV cases - 490,000 in
2010 to over 600,000
cases in 2020
The need to cut down
on readmission has
spurred the
expansion of subacute ventilator
market
Past Model in Long Term Care
 Prior to the early 1990s Complex Respiratory patients were cared for in the





hospital and in the ICU, especially those on mechanical ventilation
Skilled Nursing Facilities (SNFs) were primarily custodial care sites until the
mid 1990s when more complex patients began to be transferred to unorganized
“Sub Acute” units with little technology available
In 1998 with the advent of PPS, SNFs eliminated most high acuity programs
leaving hospitals with no downstream discharge options except home
Many patients were being discharged home on mechanical ventilation with no
chance of liberation and at a high cost to the state and federal payers
The SNFs who did accept ventilated patients offered little or no hope of
liberation from the vent nor had any emphasis on outcomes
State Medicaid's had the concept that these patients had been unweanable and
therefore paid SNFs a very low rate per day and as a result this population most
often became “warehoused”, and still are today in most states
Shift of Complex Respiratory Care to
Skilled Nursing Facilities
 With approximately 16,000 nursing homes in the US comprising 1.7 million beds





(1.5 million residents) the LTC segment is undoubtedly the largest single
expansion site for the care of the complex respiratory population.
Approximately 25% of these 1.5 million residents have underlying pulmonary
disease or compromise.
The American Health Care Association reports a growth 0f 1724 vent beds in
Skilled Nursing Facilities from 2009 to 2013 bring the US total to 9500.
In from 2002 to 2010 there were 3 vent units in TN with 48 beds. From 2010 to 2014
the number of sites tripled to 9 and number of beds quadrupled to 222.
The shift in sites of care has preceded the efforts to improve quality and standards
of practice
The pressure on hospitals to discharge and avoid readmissions has become a
struggle as SNFs were and are still somewhat unprepared for the complexity of the
population especially in light of often low Medicaid rates
Current US standards
 No state to state consistency in standards for complex respiratory and
ventilator care
 Standards and payments vary by state
 There has been little focus on quality metrics and oversight
 The major shift from ICU and hospital to Skilled Nursing Facilities proceeds at
a furious pace and SNFs have little guidance
 SNFs lack standards requiring advanced noninvasive technology (high flow
systems, airway clearance devices, and monitoring.
 Many lack appropriate personnel (Medical Direction and Respiratory
Therapist)
Our journey to improve outcomes
Timeline
 2002 opened first SNF vent unit in TN – 85% pts weaned first year
 Reported results to Governor –gained support for reimbursement
 2004 Developed standards of care – endorsed by TSRC
 2005 standards endorsed by TN Board of Respiratory Care
 2009 standards adopted as rules for NF by Board of Health Care
Facilities and TN Medicaid
 2010 standards developed into national recommendation - position
statement by AARC
 2011 TN SNF vent program maintains 63% wean rate recognized by
ACCP as Best Practice/Center of Excellence
 2014 Engaged by TN Medicaid to develop quality metrics and design a
Pay for Performance model
Enhanced Respiratory Care
In Tennessee ERC refers to the following special
levels of reimbursement for services in a NF:
Chronic Ventilator Care
Ventilator Liberation or Weaning
Tracheal Suctioning
History of Enhanced Respiratory Care
Pre-ERC Program (1998 – 2002)
• SNFs unwilling to accept high acuity, high-cost patients needing
ventilator care due to:
 Medicare conversion from cost-based reimbursement to RUGbased per diem prospective payment system
 Medicaid facility-wide cost-based payment methodology that
failed to cover higher costs of residents needing ventilator care
• The first SNF based ventilator unit was established in 2002
 During the first year liberated 60 out of 92 patients were
liberated from ventilators (deemed “un-weanable”)
 Led to research of best-practice and cost-effective approaches
to ERC
History of Enhanced Respiratory Care
• Development and Evolution of ERC Program (2003-2010)
 Standards of Care developed and incorporated into HCF rules for
SNFs providing ventilator care
 Two additional ventilator units began operations
(1 in each Grand Region); rates negotiated with MCOs
 Liberation rates at 65%
• Recent History (2010-2013)
 In 2010, Medicare revised per diem rates from average of $350 to
$700
 During that same year, as part of CHOICES program, TennCare
established ERC rates to SNFs delivering ERC services
•
2010-2014
 Number of sites grew from 3 - 9
 Beds from 48 - 222
Current initiative
 Although TN adopted standards of care in 2004 we are currently
engaged in the next step which is to require accountability and quality
monitoring in facilities receiving TennCare funds
 TennCare is currently evaluating metrics to be utilized in a pay for
performance model in SNF ventilator units encouraging outcomes and
the use of noninvasive technology.
 Currently a review and redesign of the medical necessity for ventilator
care is underway in conjunction with the CMO of TennCare
 Additionally there is a review of patient data of those on home
ventilation
Value Based Purchasing
Payment Reform – specific amounts TBD
Threshold Measures - required in order to be eligible to receive
ERC payments (base rates and P4P components)
 Facilities must continue to meet 100% of Threshold Standards of
Care
 Includes Timely Reporting of Key Performance Indicators
Quality Measures
 Pay for Performance component that incentivizes Ventilator
Weaning and improved quality performance and outcomes may
be earned in addition to base rates
Key Performance Indicators
 Census by type (vent or trach)
 Number of ERC patient referrals vs. admissions
 Number of out-of-state referrals
 Number of admissions by payer source
 Number of admissions by diagnosis (vent or trach)
 Number liberated from ventilator
 Number decannulated
 Number discharged from ERC services and disposition
 Number transferred to hospital (and whether or not they
returned to the SNF)
 Sentinel events + Unexpected death in facility
 Number of patients with respiratory infection requiring
isolation
Pay for Performance Component
Quality Measures consisting of Quality Indicators and Technology
Indicators will be used to determine quality payments (thresholds,
point values and payments to be established).
Quality Indicators (to incentivize quality performance and outcomes)







Annual Ventilator Wean Rates
Average Length of Stay to Wean
Infection Rates
Unplanned Hospitalizations
Decannulation Rate
Unplanned Deaths
Denial Rate
Pay for Performance Component
Technology Indicators (incentivize use of modern
technology)








Cough Assist
High Flow Molecular Humidification
Alarm paging or beeper system
Non-Invasive Ventilation (volume)
Non-Invasive Open Ventilation
High Frequency Chest Wall Oscillation or IPV
Heated Wire Circuits
Incentive Spirometer or any PEP Therapy
Weaning rates in SNF
We, along with others have demonstrated that a majority of the patients deemed
ventilator dependent can still be liberated for the mechanical ventilation. This
effort requires appropriate personnel, technology, monitoring, mobilization and
nutrition.
 1996-Latriano B , Chest 51%
 2000-Gracey DR, Mayo – 60%
 2002-Gene Gantt, Report to Governor Bredesen, TN initial vent program 85%
 2004 Dr. Mark Lindsay, Mayo 67%
 2011- Gene Gantt, ACCP Chest Conference Center Of Excellence presentation,
TN vent program 65% statewide
Summary
It has become a mission to change the paradigm of complex respiratory and
ventilator care in the post acute arena. As clinicians, we have seen first hand
the positive effect of appropriately modeled care in the post acute space.
We take pride in the fact that Tennessee is a leader in developing quality long
term care programs. Other states have taken interest and are following our
lead or contemplating engaging us to develop similar programs with them.
In addition to the high complexity population, we recognize the potential to
dramatically decrease hospital admissions in the general SNF population. We
feel there are tremendous opportunities for low cost interventions that will
greatly reduce the incidence of aspiration pneumonias and other respiratory
issues in the general resident of the SNF.
The End
Questions?