Ep 64 – Creating Optimal Post Acute Care Networks in the New Value Paradigm, with Ian Juliano

The traditional definition of post-acute care (PAC) represents the legacy of a fragmented approach to healthcare that segments care into “silos” and finances institutions to care for a “slice” of the patient instead of incentivizing whole-person, coordinated care. As post-acute care is the largest driver of overall Medicare spending variation, establishing a coordinated, whole-person care network across the PAC continuum is essential for organizations to successfully operate under value-based payment models and to optimize patient outcomes. However, without transparent, market-wide data with longitudinal analytics, a comprehensive network, and relationships with hospitals, it seems like an  insurmountable challenge to overcome.

Our guest this week is Ian Juliano, founder and CEO of Trella Health. Trella Health, is dedicated to creating optimal care networks that yield superior outcomes and greater efficiencies. Employing sophisticated longitudinal analytics on its massive, proprietary database, Trella enables providers and payers to compete and thrive in the new world of Value Based Care. For Ian, value-based care and PAC network optimization is a personal calling. His individual commitment provides a clear path to follow in the race to value!

Episode Bookmarks:

05:00  Advocating the benefit of data democratization in VBC to Andy Slavitt
06:00 Working with Niall Brennan, the Chief Data Officer of CMS from 2010-2017
07:00 Building one of the largest proprietary databases of CMS claims data through a partnership with the CMS Virtual Research Data Center (VRDC)
08:40 “Transparency in data can lead to better treatment decisions that result in improved outcomes and lower costs”
09:40 How Trella’s massive database is helping hospital systems, post-acute providers, and ACOs make better decisions
11:30 The challenge of ineffective transitions of care post-discharge and the cost differentials between different PAC settings
13:00 Ian speaks about how hospital ownership of home health agencies or IRFs leads to inappropriate referrals post-discharge
14:40 “As a nation, we have been overly, myopically focused on the cost of a post-acute care setting versus the impact and cost trajectory of the patient.”
16:00 Ian provides an eye-opening example of how $1million in costs were saved (along with better outcomes) through appropriate transitions to home health instead of SNFs
18:30 Ian provides another example of a system saving $1-2M in spend by sending patients to on-time hospice at the  end-of-life
21:00 “In some academic medical centers, over two-thirds of inpatient discharges that meet high-acuity guidelines receive no post-acute care whatsoever! And one-third of those patients are back in the hospital within two days, leading to higher costs.”
23:00  Ian speaks about how ACOs and DCEs can ensure access to outstanding SNF and home health agencies by aligning incentives
25:00 “Developing the right post-acute care provider network is not all about narrowing.  It’s about finding the right network that meets all of the specialized needs, to get best-in-class care for all of the different categories of patients.
25:50 The importance of physician training in building an optimized PAC network
26:20 Using data to look at patient flows, identify gaps in care, and monitor cost performance KPIs over time
28:40 Ian speaks about the future of the skilled nursing industry in relationship to value-based care
30:30 “If I were an ACO, I would be quite mindful anytime a hospital recommends a hospital IRF. I would make sure to see whether a SNF is more appropriate.
31:30 How did occupancy rates in long-term care impact SNFs during COVID-19?
32:00 How do increased referral rates to home health instead of SNFs lead to lower adherence rates? How can home health agencies ensure that patients actually receive care?
34:40 Primary PAC Optimization Strategies: 1) Sending appropriate patients to SNF instead of IRF. 2) Sending home health appropriate patients who are at risk of non-compliance to SNF anyways (in order to ensure care)
36:00 The episodic mentality of the current fee-for-service home health model and how inadequate nurse staffing leads to patient stacking 
38:40 “To survive in this new era, home health needs to start thinking about how to demonstrate value and fight with hospitals for the rewards of that value capture.
42:30 Leveraging Telehealth in the home health setting – not every visit needs to be in person.
44:00 Ian speaks about the issue of fraud in the home health industry and why more consolidation is needed.
46:00 Referencing the ACLC Whitepaper on the Coordinated Care Model for patients with post-acute needs
47:00 A really well-managed ACO will have made a huge investment in data to understand network performance and developing optimal partnerships with post-acute providers.
51:00 The advantage of DCEs over ACOs in creating the right incentives to ensure optimal PAC network performance
55:00 Ian provides his parting thoughts on the moral imperative for value-based care and how that drives him as a leader