Prepare for bundled payments by improving pre-operative processes

As 2016 approaches, hospitals across the country are looking ahead to January 1 and the start of a mandatory bundled payment initiative.

Called the Comprehensive Care for Joint Replacements (CCJR) program, the initiative applies to hospitals in 75 markets, holding them accountable for the cost and quality of care they deliver to patients who undergo a total knee or hip replacement.

According to the Centers for Medicare and Medicaid Services, hip and knee replacements are some of the most common surgeries Medicare beneficiaries receive, affecting more than 40,000 Medicare patients in 2013 at a cost of more than $7 billion for hospitalizations alone. In addition, there is wide variation among hospitals in the cost of the procedures and rate of complications.

The CCJR is designed to prompt hospitals to work with physicians, home health agencies and nursing facilities to make sure beneficiaries get the coordinated care they need with the goal of reducing costly avoidable re-hospitalizations and complications. Hospitals will be held accountable for the quality and cost of the entire episode of care, from the time of surgery through 90 days after discharge.

As a result, many hospitals are looking for ways they can pro-actively improve outcomes for patients who receive joint replacement surgery. Of course, CCJR will require much coordination with other care settings. But there is much that hospitals can do within their own walls to reduce the likelihood of complications and readmissions. One important area of focus is in the pre-operative process, including optimizing a patient's health prior to surgery to achieve the best possible outcomes and least complications. Once the surgeon and patient agree on proceeding with surgery, having the patient immediately readied with respect to addressing comorbidities such as obesity, glycemic index, anemia, and smoking, for example, will decrease potential complications and give the patient the best chance at a good outcome.

Speeding time to surgery
Particularly for patients who have a fractured hip, getting to surgery quickly is key. The longer they wait in the hospital for the procedure, the greater their risk of infection, complications or even mortality.

To combat this issue, some hospitals are adopting a model of care that allows patients with hip and other common bone fractures to speed to surgery, often the same day. In the case of a patient who presents to the emergency department with a hip fracture, the emergency department would activate a clinical care pathway to immediately notify the anesthesia, hospital medicine and surgery departments to simultaneously begin the processes of admitting the patient and having him or her scheduled and prepared for surgery. Currently much of the process occurs in a consecutive sequence instead of simultaneously.

This type of " fragility fracture program" has been shown to lower length-of-stay, reduce the likelihood that a patient will need a blood transfusion, and lessen the risk of post-operative infection, which consequently reduces inpatient costs and cuts the rehabilitation time the patient needs before returning to a normal level of activity.

Optimizing pre-operative testing
Before patients can be optimized for surgery, they often need some level of pre-operative testing – such as blood work, imaging and consultations with a cardiologist or other specialist – to make sure they are ready and healthy enough for the procedure. To better understand what tests their patients need and avoid the wasted cost and time associated with unnecessary or duplicate testing, some providers are adopting clinical support tools.

For example, a new mobile app called the PreOpGuide uses a sophisticated algorithm to help anesthesiologists and other surgical team members determine what tests a patient needs, based on the answers to a series of questions about the patients' surgical procedure and current medical condition. Tools like this are helping eliminate costly unnecessary testing, surgery delays and cancellations, thereby reducing the cost of that episode of care and improving the likelihood of positive outcomes.

Preparing for discharge
In addition, hospitals involved in the CCJR must think about strategies to keep their patients healthy after they are discharged from the hospital. Ensuring patients follow post-discharge orders and get the support they need post-surgery are critical components to avoiding readmissions and complications.

Hospitals should begin the discharge planning process when the patient is admitted prior to surgery, working to determine when the patient can safely leave the hospital and identifying the most appropriate setting for him or her – whether it's another care setting or their home. By being pro-active about discharge planning, and working collaboratively with the patient and family to ensure everyone understands the patient's condition, procedure and post-discharge instructions, hospitals can help patients recover and avoid post-surgery problems.

Conclusion
The CCJR is just one way the healthcare system is pushing hospitals to improve quality of care while reducing costs. Hospitals involved with the program must think proactively about ways to improve outcomes and increase efficiency of care for patients receiving knee and hip replacements. Improving the pre-operative process for these patients will have an impact on CCJR performance and provide valuable lessons that can be applied to other episodes of care. Most importantly; hospitals should always do what's right for the patient.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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