Preparing for success under the Comprehensive Care for Joint Replacement model — before, during and after surgery

HHS declared lofty goals in January when it announced a historic overhaul to shift reimbursements from a fee-for-service to a value-based care model.

By the end of 2016, HHS aims to tie 30 percent of traditional fee-for-service Medicare payments to quality or value through alternative payment models, such as accountable care organizations or bundled payment arrangements. By 2018, this percentage will rise to 50 percent.

This content is sponsored by Surgical Directions

CMS showed it is serious about holding providers and hospitals more accountable for the quality and cost of care when it announced the Comprehensive Care for Joint Replacement Model in July, effective Jan. 1, 2016. CMS said the model will test bundled payment and quality measurement for an episode of care associated with hip and knee replacements, and is designed to incentivize hospitals, physicians and post-acute care providers to work together to improve quality and coordination from the initial hospitalization through recovery.

About the CCJR Model

The agency would implement the proposed model in 75 geographic areas, defined by metropolitan statistical areas — counties associated with a core urban area and a population of at least 50,000. The CCJR model has immediately higher stakes than past bundled payment models, which were voluntary, because hospitals in the 75 areas would be required to participate.

"There is a movement nationally toward value-based payment," says Jeff Peters, president of Chicago-based Surgical Directions. "The Comprehensive Care for Joint Replacement Model is a very loud and clear message that this is how CMS is looking to tie 50 percent of reimbursement to value. It's a test case for hospitals."

Under the CCJR model, participating hospitals would be held financially accountable for the quality and cost of an episode of care for hip and knee replacements, also called lower extremity joint replacements. The episode would include the 90-day period following discharge.

All providers and suppliers would be paid under Medicare's usual payment system rules and procedures for episode services throughout the year. At the end of the performance year, each hospital's actual spending for the episode would be retroactively compared to Medicare's episode price for the responsible hospital, which is based on a blend of hospital- and region-specific costs. Depending on the hospital's quality and spending, the hospital could receive additional reimbursement from Medicare, or it could be required to repay Medicare for a portion of the episode spending.

According to Mr. Peters, joint replacement surgery is a good procedure to test bundled payments on because of its high frequency, relative standard process and variable cost.

Indeed, hip and knee replacements are two of the most common surgeries among Medicare beneficiaries. According to the latest CMS data, in 2013, there were more than 400,000 inpatient primary procedures for Medicare beneficiaries, incurring more than $7 billion in hospitalization costs alone.

Outcomes and costs for these surgeries are vastly different across providers. Rates of complications, such as infections and implant failures post-surgery, could be up to three-times higher at some facilities than others, and the average cost to Medicare for surgery, hospitalization and recovery can range from $16,500 to $33,000 across geographic areas. Additionally, complications can result in hospital readmissions, extended rehabilitative care and pain, which contribute to negative patient experiences and unfavorable HCAHPS scores.

How can hospitals prepare to succeed under the CCJR Model?

The program includes three quality measures: 30-day readmission rate, risk-standardized complication rate and the patient experience. Since payment to participating hospitals is retroactively adjusted, hospital executives and clinical leaders must take the necessary steps to optimize costs, reduce complications and readmissions and ensure a positive patient experience, according to Mr. Peters.

"The fact that this program is not voluntary makes it more challenging for hospitals," says Mr. Peters. "Before you had the ability to prepare and get ready on your time. Now CMS is saying, 'This is what we're going to do.'"

Mr. Peters suggests the following strategies to develop improved clinical management pathways.

Develop a surgical home and a governance structure to bring the whole care team together
The first step to prepare for the CCJR model is to evaluate and restructure the governance model to ensure it will bring together the surgeons, anesthesia, nurses and case coordinators to develop a coordinated model to care for CCJR patients. The care model should extend from the point of scheduling through pre-surgical optimization, surgery, hospital recovery and the 30-day discharge period.

The team ensures there is organizational buy-in for best practices, standardization of clinical pathways, workflows and order sets. A common organizational model for this is a surgical home, which is responsible for the continuum of a patient's care and ensures cost, quality and patient satisfaction metrics are achieved.

Use information dashboards to encourage improvement
Surgeons may vary greatly in their expenditure and clinical outcomes. However, it is hard to communicate the urgent need for surgeons to change without providing them and other OR staff with concrete information regarding their personal performance, according to Mr. Peters.

"The only way to change behavior is to show individuals their performance levels," says Mr. Peters. "To address this, we suggest developing dashboards so surgeons can see how their performance compares to the national benchmark, as well as their peers in the same facility."

Cost-per-case dashboard reports that show surgeons exactly how their costs compare with reimbursement and to their peers can have a significant influence on their supply choices and surgery time, the latter of which is highly associated with their rates of deep vein thrombosis, surgical site infections and 30-day readmissions.

These quality outcomes will have a direct influence on CMS' retrospective payment adjustment at the end of each performance year under the CCJR model, so it is in hospitals' best interest to work with individual surgeons and OR teams to take the necessary steps to prevent surgical and post-op complications, and keep surgical costs as low as possible.

These dashboards can also be used to educate nurses and other clinical staff about the cost of common supplies, which reinforces the focus on reducing waste.

Expand and enhance pre-admission testing
Pre-admission testing is one of the most impactful factors that will contribute to hospitals' success under the CCJR model, according to Mr. Peters.

"There are numerous comorbidities that affect clinical outcomes, so you want to identify them to reduce risk," says Mr. Peters, "We know what contributes to bad outcomes: people who are smokers, people who have high BMIs, diabetics and those with cardiac disease."

The goal is to manage these patient populations preoperatively. While hospitals typically aim to control these comorbidities for a short period immediately ahead of surgery, Mr. Peters suggests extending that time period farther ahead of the scheduled surgery date can lead to better outcomes. Mitigating risks such as these will likely require interventions by the patient's care team, such as helping patients who are smokers find smoking cessation programs, discussing the benefits of bariatric surgery with obese patients and close monitoring of glucose levels for diabetics.

Thorough pre-admission testing and identification of risks helps the surgery team address patients' individual needs and prepare for potential complications with their hip and knee procedures. The better prepared the surgery team is, the less likely it is for the patient to have a long length of stay, early readmission and costly post-acute care.

Prepare for post-operative care
Hospitals participating in the CCJR model will aim to reduce patients' length of stay as a means of cost reduction. However, post-acute care admission to rehabilitation centers is among the highest costs associated with hip and knee joint replacement procedures. Annually, $6 billion is spent on post-acute care for joint replacement patients. Sometimes you can justify an extra day in the hospital if it will reduce the need for a patient to go to a rehabilitation facility, according to Mr. Peters.

To reduce the need to send patients to inpatient rehabilitation centers, surgeons and nurses must carefully prepare for discharge prior to surgery. Nurses or care managers should visit certain categories of patients in their homes to assess the environment they will be discharged to. The patients assessed would be those that have the potential to avoid admission to a post-surgery rehabilitation facility.

"When looking at a patient's home, you should be looking for ways to make it easier for the patient to function there, as opposed to needing to go to a rehab facility," says Mr. Peters. "Maybe it's providing equipment to help him or her ambulate, such as a walker or assisted toilet seat."

Patients will need continued support once they are discharged from the hospital. Nurses can pre-empt post-op complications or injuries by visiting patients in their home and ensuring they are complying with their medications. Regular communication — via phone calls and/or email — is vital during this stage, for if problems arise, patients will likely go to the emergency room if no one answers their questions promptly.

"It's essential to convey the message that, 'Just because we've discharged you doesn't mean we don't care about you anymore and that we're not willing to help you,'" says Mr. Peters.

Case study: Hospital for Join Disease at NYU Langone Medical Center
The Hospital for Joint Diseases at New York City-based NYU Langone Medical Center was an early adapter to the government's voluntary bundled payment initiative. HJD's success under the Bundled Payment for Care Improvement initiative and its specialization as a joint facility makes it a prime example for other hospitals under the CCJR model.

HJD's results under bundled payment
To bolster coordination among surgeons, nurses, anesthesia and other OR staff, HJD created the Total Joint Episode Management Group. This new governance structure ensured the respective staff worked together under established best practices for clinical and management pathways from the moment surgery was scheduled, through pre-admissions testing, surgery, discharge and recovery.

At the end of its first year under the bundled payment initiative, HJD decreased average length of stay to 3.58 days from 4.27 days, with a median of three days. Discharge to inpatient facilities after discharge decreased on average from 63 percent to 44 percent.

Overall, the hospital saw significant reduction in inpatient costs, and it achieved positive margins compared to CMS' target price. HJD's hospital cost per case decreased between $7,000 and $6,300 under the bundle.

HJD realized 17 percent savings on MS-DRG 470 — major joint replacement or reattachment of lower extremity without major complications or comorbidities —  and 8.1 percent savings on MS-DRG 469 — major joint replacement or reattachment of lower extremity with major complications or comorbidities.

HJD's keys to success
The hospital achieved a high degree of success in its first year under BPCI because it was committed to improving its clinical management workflow, according to Mr. Peters. After building the Total Joint Episode Management Group, the hospital had an authoritative body to oversee the full spectrum of care provided to joint replacement patients. Central to this was improving communication with attending physicians, residents, fellows, social workers, nurse practitioners and clinical care coordinators.

In its new inpatient workflow, the hospital zeroed in on length of stay as a top area for improvement, and set clear expectations that lengths of stays should be between two and three days. If it needed to be longer, the patient's admission was reviewed by the care team.

HJD also initiated an aggressive approach to pain management, to ensure patients could ambulate early and often after surgery. This is important for reducing complications such as DVTs and cardiac events, and helps patients return to their normal lives sooner.

The hospital focused heavily on the post-acute care period. Clinical care coordinators checked in with patients regularly for the 30-day period following discharge to monitor their progress and ensure patients complied with their medication regimens.

Home nurses greet patients identified as high-risk for post-op difficulties at their homes after they are discharged to ensure they are fully oriented and understand how to take their medications. Additionally, HJD implemented targeted medical follow-ups by internists for high-risk patients.

HJD's progress in one year under bundled payments shows hospitals can achieve significant savings if they invest in the necessary cultural, clinical and workflow changes. The proposed CCJR model opens the door to new challenges for hospitals, given it is mandatory, but it also presents a great opportunity for hospitals to achieve substantial improvements in both quality and cost reduction.

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