Beaumont ACO Solving the Puzzle of Readmissions From SNFs

Michigan-based Beaumont ACO has been working with a Chicago-based company called Puzzle Healthcare to lower readmission rates from post-acute settings. Ahzam Afzal, Pharm.D., co-founder and CEO of Puzzle Healthcare, and Belal Abdallah, M.D., CEO and board chairman of the Beaumont ACO, recently spoke with Healthcare Innovation about their work together. 

Beaumont ACO is a joint venture between Corewell Health (formerly Beaumont Health) and nearly 2,000 physicians with a network of over 4,500 physicians participating in its contracts. 

Abdallah has been CEO since the ACO’s inception in 2012. The Beaumont ACO is one of the most successful Accountable Care Organizations in the United States, saving Medicare hundreds of millions of dollars in the Medicare Shared Savings Contracts over the last 10 years. 

Healthcare Innovation: Dr. Abdallah, could you talk about the history of the ACO and how you got into doing this work on readmission reduction? 

Abdallah: When we first formed, we wondered what are we supposed to do? Where do we start? It turns out that there was a lot of low-hanging fruit, just organizing the physicians and the practices to do very simple things, like make sure the patients are seen on time, or rather than go to the emergency room, have them come to the office. Make sure their medications are reviewed regularly, so that they're not prescribed the wrong medications. That was primary care-driven. They were being gatekeepers, but not like the old gatekeeper of the HMO days. This was a new way where the doctors were independent of an administrator telling you what to do and not to do. It worked out really well for us. Our guiding principles have been physician leadership. 

We've been very transparent with our physicians on how we do things and how we earn the dollars from CMS. We have to build a lot of trust between all the all the stakeholders, especially the physician practices. We've been very successful over the years. We've saved Medicare a little over $200 million between 2012 and today, and CMS has shared at least half of that with us. 

The last couple of years, we started to take a deep dive to identify where the highest costs are with our population. What we found was the post-acute, post-discharge, from the hospital setting to the skilled nursing facility setting and other settings were really high cost, and it was mainly due to that transition and then the patients not being followed up with appropriately, or being in the wrong setting, or not being taken care of as well as they should have been, so patients were being readmitted back to the hospital. 

HCI: Did you often find that you didn't have much visibility into what was going on with the patients in the skilled nursing facility setting?

 Abdallah: Absolutely. Until we started to look into it, we were just kind of blind. The patient is discharged from from the acute care settings, and then we don't know what happens. We knew where they were located, because we had something called Patient Ping, but we didn't have insight as to what was going on there. 

HCI: Why were you interested in working with Puzzle?

Abdallah:  Ahzam told me that Puzzle was standardizing physiatry care. When I was the medical director of a nursing home 20 years ago, the physiatry care was just all over the place. And the reason many patients are there is to receive physical therapy post-discharge so they can get stronger and get better and go home. When the physical therapy is not consistent and there's no true guidance as to what the plan is, then the patients end up staying there longer because they're not improving their physical ability. And then they end up getting some other new illness, and get sick.

I thought that if we know that the facilities that our patients are going to have standardized physiatry like Puzzle, that's going to help us. 

HCI: Ahzam, can you talk about how you work with the skilled nursing facilities? How do you build trust with them?

Afzal: Let me give you a little bit of background. With Puzzle, we're a readmission prevention company, and our team has been embedded in this value-based care arena for the last decade. When we engage with a system like Corewell, we take a close look at the readmission penalties for the system in its entirety. Typically, what we find is that a high proportion of these readmissions are coming from the post-acute care space, as they're typically sicker and higher acuity patients being discharged to a SNF.

Although most health systems have a post-acute preferred network of SNFs that they discharge their patients to based on quality measures, their SNF readmission rates are still very high due to SNF staffing challenges, which result in inadequate discharge planning. 

We work very closely with the health system partners to engage their post-acute SNF partners. The SNFs listen because they want to keep their referral sources happy. They also want to drive up the quality of care. We come in and implement our readmission prevention program, which couples physiatry and care coordination, We deploy physiatrists as quarterbacks of care in the SNF as they're typically evaluating those patients that are at highest risk for readmission. 

A multidisciplinary virtual care management team follows the patient from the point of hospital discharge through the SNF admission, through the entirety of the SNF stay, and then also for a period of 90 days post-SNF discharge when the patients are home. Our care managers will connect with every patient that leaves a SNF, and they'll go through disease-specific assessments that are designed to identify exacerbations and get a clear, subjective picture as to how the patient is doing and if there are any sort of exacerbation risks. Then for our high-risk patients, we deploy remote patient monitoring sensors that help us track in real time, heart rate, respiration, movement activity levels. 

HCI: When you say the physiatrist is the quarterback, is that a Puzzle employee, or is that the physiatrist that's already in the SNF? 

Afzal: We'll deploy our own physiatrist to the facility. And when we do that post-discharge follow-up, with our health system partners we develop readmission avoidance pathways that will triage patients to the appropriate site of care to mitigate a readmission. 

One of our partners, Illinois-based OSF Healthcare, set up eight high-acuity clinics that our care management teams can route those patients to during the point of exacerbation, post-discharge. We work closely to develop those avoidance pathways, and we're doing the same thing with Beaumont ACO. All of the work that we do is aggregated into a post-discharge tracker that risk stratifies all of our patients that have been discharged, and that's shared with the health systems, the ACO, the SNFs, and it's discussed during readmission meetings, and it ends up being a great tool to drive awareness and also drive behavioral change at the health system.

HCI: Does Puzzle get paid out of the shared savings? Or do health systems pay the company for its services? 

Afzal: We enter into a lot of shared savings agreements with payers. As we start working closely with those payers, we don't charge the health system anything. We also don't charge the SNFs anything for our services, because we're able to provide our services on a fee-for-service basis as well. From our perspective, fee-for-service covers some portion of our costs. It ends up being a pretty break-even type of service on the true cost side, but we always are hopeful for that shared savings. With OSF Healthcare, we brought their readmissions from 29% down to 9% just in one year.  

HCI: Dr. Abdallah, have you been doing this long enough at Corewell and the Beaumont ACO, where you can see some early results as far as cutting down the readmission rates?


Abdallah: Definitely. In 2023 it looks like our profit and loss is positive again with MSSP. In 2022 we noticed an uptick in the post-acute claims, and we saw a downtick in 2023. Now we don't have our final results yet from MSSP, but everything looks positive for 2023 since we started using Puzzle. 

HCI: Are there still things you need to adjust as you develop the relationship further?

Abdallah: Building relationship with all the SNFs has been the challenge for us. We're a joint venture with Corewell Health, but not all of Corewell Health patients are in our ACO. We manage about 325,000 lives in southeastern Michigan, and Corewell Health probably has a lot more than that that they admit to their hospitals. Together, we decided to form a high-performance skilled nursing facility network that Corewell Health discharges to, and then we have certain criteria for them to be in that network.

The criteria include things like readmission rates, star ratings, quality. We've added now things like — do they use Puzzle? If they use Puzzle, they get extra points to be in the network. The physiatrists that Puzzle uses are employed by Puzzle, so they can standardize the care. But when we have facilities that utilize other physiatrists, then we don't really get a consistent readmission status from there, so that's the challenge. But I think as the SNFs start to understand how Puzzle works and the reduction in readmissions, the buy-in has been greater. Those facilities that are utilizing Puzzle are showing statistics of improved readmission rates compared to the other ones. 

In 2024, we've had more buy-in, and I think that trend is going to continue. When we get our shared savings in early October, then we'll really show everyone that our post-acute costs have come down.