Bundled payment success: Managing the patient care journey

The best-laid plans of mice and men often go awry.

For healthcare professionals, this Robert Burns’ line, has never been more fitting. Many professionals are feeling uncertain as to where healthcare is headed. There are more questions than answers and a lot of plans have gone awry. The current CMS delay in bundled payments is causing anxiety. No one knows what value-based care will look like under the Trump Administration. The delay gives providers time to take a breather, step back, and evaluate healthcare plans that weren’t working.

Effectively lowering costs can be tricky. Despite improved clinical and surgical protocols, readmissions for many hospitals are still too high, and ED usage is not declining. We are missing a key component of patient care and the problem is costing us dearly. Something is breaking down after patients leave the hospital. Do we need more human connection?

Take Janice, for example. Her story represents many patient experiences. She led an active life and was enjoying retirement. Her husband died years earlier and she lived alone. When her son accepted a job in another state and asked her to move with them, she opted to stay put. She felt independent and happy. And then it happened - she slipped and fell. She broke her hip and was scheduled for hip replacement surgery.

Her surgery went well. Janice’s son flew in and helped get her settled back at home, stocked her fridge and pantry with food, and filled her prescriptions. When left to return to his family, Janice was on her own. She had instructions and therapy plans from her doctor, and a follow-up appointment. But recovering from hip replacement surgery is difficult, and doing it alone is a recipe for trouble. She had difficulty preparing her meals and she stopped taking the pain meds because they made her nauseated and unstable. She didn’t want to worry her son, and when he called, she didn’t talk about how hard it was. A week after her surgery, Janice ended up in the ED with pain and swelling. Her surgery was a pass, but her recovery was a fail.

Janice’s story is a familiar one. Procedures are successful and get passing grades yet recovering at home is failing too many people which results in unnecessary readmissions. Hospitals will always have readmissions but when there are too many unnecessary readmits, there’s a problem somewhere.

Recently, one hospital set out to discover what was happening with their patients – people who didn’t seem to be at risk for a readmission were being readmitted. The staff committed to having mandatory pre-op sessions for every patient with their surgeon and a nurse. They provided educational pamphlets with descriptions of what to expect following surgery and spent time explaining what their new normal would be. They even experimented with keeping patients an additional day or night in the hospital. It didn’t work. Despite successful surgeries, readmission rates were still too high.

Finally, they figured it out. And what a difference the simple step made. In addition to their mandated pre-op sessions with the patient and care team, they began to require that a friend or family member join the session. They decided to include the person who knew the patient and would be able to help support them once they returned home. That changed everything. The loved ones asked more questions and anticipated things that the patients had not. They discussed barriers and things like narrow bathrooms and the cost of prescription meds. Their conversations stopped being about the procedure and techniques and more about how the person, not the patient, would be affected. The discussion focused on the Social Determinants that were going to influence their health and recovery. The patient left their session with a friend or loved one who knew what to anticipate and with plans on how to communicate with their care team once they returned home.

For this hospital, truly engaging with their patients and loved ones made all the difference. The surgeries still went well, but now the recovery was equally successful. Almost overnight, readmission rates dropped. This is real “patient engagement.”

The bundled payment models will require providers to act in similar ways. They will need to do more than just treat individual illnesses in isolation – no longer “The hip in Room 404, scheduled for a Thursday discharge,” providers will know “Janice in Room 404, who can’t wait to get home to see Lilly, her Dachshund, and is going to need help because she lives alone.” This is what solving for Social Determinants of Health is all about.

According to Cara James, Director of the Office of Minority Health at CMS, There are estimates that as much as 80% of the disparities in health come from social determinants such as poverty, crime, housing, food, and security. Many communities of color have much higher rates of poverty and that contributes to their inability to afford coverage, housing, and access to healthy foods.1 In addition to communities of color, immigrant communities struggle in similar ways. All of these things affect recovery. When patients are recovering at home, the ability to access community services and related support has a positive impact on how quickly they get back to their lives.

Value-based care is here to stay and the bundled payment systems are likely to be reinstated by the Trump Administration. We may not know what it will look like, but we do know that all eyes are on unnecessary readmissions and reducing costs. Bundling payments will require a new level of collaboration among healthcare teams. As we wait out the delay, providers can begin to look at the journey their patients take and make plans to continue communication and care once patients leave the hospital. It may seem like a small step, but it’s a significant one.

1. Source: Dr. Cara James. “Q&A: Building the business case for achieving health quality.” Modern Healthcare. 2016

Jamo Rubin, M.D., Founder and CEO, TAVHealth
Dr. Rubin is a trained cardiac transplant anesthesiologist whose professional goal is to help people improve lives. By considering the Social Determinants of Health, Dr. Rubin leads TAVHealth to help deliver value to healthcare’s new customer – the patient and the family – by educating and supporting providers.

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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