7 key areas to address under the Comprehensive Care for Joint Replacement Model

In the past, healthcare providers' pay was primarily driven by the volume of patients and services rendered, with weaker correlation to outcomes. However, the healthcare industry — led by initiatives enforced by CMS — has embarked on a permanent departure from this approach.

Under a value-based system, healthcare organizations are rewarded for care that produces the best possible outcomes for the lowest possible cost. Bundled payments are central to such a system. Under this model, providers are paid a set amount for an entire episode of care, from pre- to post-operative care. They either share in savings or absorb the extra costs associated with complications, extended length of stay or readmissions.

The Comprehensive Care for Joint Replacement Model, CMS' first mandatory reimbursement model of its kind, focuses on hip and knee replacement. About 800 hospitals across 67 markets are participating in CJR, which took effect April 1, 2016. During the five-year program, hospitals are still paid according to existing Medicare fee-for-service rules throughout the year. At the end of each performance year, however, CMS compares a hospital's spending for a care episode to the target episode price. An episode begins from the time a patient is admitted to surgery through 90 days post-discharge, including care in skilled nursing facilities.

Depending on the participant hospital's quality and spending performance, the hospital may receive an additional payment from Medicare or be required to repay Medicare for a portion of the episode spending.

This content is sponsored by Pacira

In July, CMS proposed new provisions to CJR, which would extend the model to include hip and femur fractures. Under the proposal, the hospital in which a patient is admitted for surgical hip or femur fracture treatment would be accountable for the cost and quality of care during the inpatient stay, as well as for 90 days after discharge. Hospitals would receive a fixed payment for each care episode. Those that deliver care for less than the target price while meeting or exceeding quality standards would keep the savings achieved. Hospitals with costs exceeding the target price would have to repay Medicare.

To succeed under CJR, participating hospitals must make structural and cultural changes. Many of these changes can be borrowed from institutions that thrive under older bundled payment initiatives, such as the 2013 Bundled Payment for Care Improvement Initiative. Here are seven key areas upon which hospital leaders and clinicians must focus.

1. Empower physician leaders to drive change. One critical culture change imperative for success under CJR is creating a structure that aligns physicians and hospital administrators, while also providing clinicians with necessary education of the new model.  "Allowing physicians and hospitals to align in any bundle situation is critical to the success of the initiative," Richard Iorio, MD, chief of adult reconstruction at the Department of Orthopaedic Surgery at NYU Langone Medical Center, said during a webinar hosted by Pacira Pharmaceuticals.

Indeed, the importance of strong leadership among surgeons, anesthesiologists and nurses under the CJR model cannot be overstated. However, clinicians need sufficient education on the changes they are required to make before they will be willing to alter their approach to care delivery, let alone act as leaders of change.

Surgeon education is particularly pertinent. According to Jeff Peters, CEO of Chicago-based Surgical Directions, effective surgeon education efforts must include an overview of bundled payments, with attention paid to their effects on reimbursement and a breakdown of what services are included in the target price. Hospitals should also illuminate how they compare with other hospitals' clinical, financial and patient satisfaction outcomes.

In addition to bolstering physician education, it is critical for hospitals to develop strong governance models that include clinical stakeholders. One such example is a Surgical Services Executive Committee, which brings a variety of leaders —  senior administrators, medical directors, surgeons, anesthesiologists, nurses and ad hoc members — to the table to refine clinical pathways. "The SSEC brings together all of the disciplines affected by bundled payment so there are representatives at the table when decisions are made," Mr. Peters said during a webinar sponsored by Pacira.

2. Develop metrics that quantify operational, financial and patient satisfaction improvement opportunities. Physicians are methodical creatures and their behavior is driven by evidence-based reasoning. To fuel surgeons' intrinsic desire to improve,leaders should share concrete data on individual and hospital performance.

"Data, clarity and transparency of data are critical for this whole process," said Dr. Iorio. "Both financial and quality metrics need to be communicated to the physicians; this reinforces good behavior and penalizes bad behavior."

NYU Langone physicians receive quality and financial metrics on a biweekly basis. The data is completely transparent — it is even posted online, according to Dr. Iorio. Physicians see their quality and financial performance compared with their peers. As a result, surgeons' inherent sense of competition drives them to improve — whether that is choosing more cost-sensitive implants, reducing OR time or reducing readmissions.

Hospitals have also found surgeon scorecards drive change, according to Mr. Peters. Surgeon scorecards record data on various metrics — including clinical, financial and patient satisfaction measures — for each individual physician and compare those results to peers in the hospital as well as regional or national benchmarks. However, Mr. Peters stressed that surgeon scorecards should facilitate a nurturing, educational process, not a punitive one. "You want an ongoing collaborative working relationship with the surgeon," said Mr. Peters.

3. Educate patients on what to expect ahead of surgery. At NYU Langone Medical Center's Hospital for Joint Diseases, clinical care coordinators identify and assess patients who qualify for the BPCI Initiative before they are admitted for surgery, according to Deserie Duran, RN, assistant director in HJD's department of care management and social work.

"The BPCI clinical care coordinator calls the patients and families," Ms. Duran said during the webinar. "This call is the Guided Patient Services call. In this call, the care coordinator or nurses set the expectations for the hospital stay to the patient and their family."

Patients also fill out questionnaires and meet with the surgeon in advance to identify possible comorbidities, undergo additional tests if needed and discuss risk management strategies. If patients are flagged as high risk, coordinators make home visits and more frequent phone calls to ensure the patient is prepared for surgery and recovery.

Care coordinators also work with the patient and the clinical team to plan the patient's discharge prior to admission to facilitate a smooth transition to the next phase of care, whether in the home or a post-acute care facility.

4. Design a hip fracture workflow. Given the latest changes CMS has proposed making to the CJR model, it is especially pertinent for hospitals to design a robust hip fracture workflow, as these cases are not preplanned but incur equally high costs to elective hip and knee replacements.

"The hip fracture patients that fall into BPCI are trauma-induced diagnoses," said Ms. Duran. "These patients do not have the benefit of having a planned surgery or planned discharge disposition." Often, hospitals are not sure if such patients — who are typically older with more serious comorbidities — will enter the bundle until after the surgery takes place. With CJR, they will no longer have a choice.

NYU Langone's Hospital for Joint Diseases identifies hip fracture patients prior to admission if they come in through the emergency department or from an outside hospital. The clinical care coordinator meets with them at the bedside, reviews an informational brochure on the bundle, completes a risk-assessment survey and identifies the appropriate disposition.

5. Optimize care management during the hospital stay. An essential element of optimizing care during the inpatient stay is continuous quality improvement, a theory-based, data-driven management system that looks at processes and outcomes and tries to determine common causes for variation. The key elements of CQI include teamwork and continuous review of progress. In terms of the CJR model, enhanced recovery protocols are also integral to CQI. ERPs, which aim to manage patients' pain and get them ambulating as soon as possible, are critical to optimizing the inpatient period of the episode of care.

"Surgeons must work closely with nurses, social workers and care managers to monitor the patient's progress and readiness for discharge and ensure the post-discharge services are in place," said Ms. Duran. The team must also work together to stay on track for the expected discharge date and address any barriers as needed.

While patients who are able to discharge to the home after surgery typically experience faster recoveries with lower rates of post-operative injuries or infections, not all patients are ideal candidates for home. Some may need a skilled nursing facility or another post-acute care provider. In other situations, it may be necessary to move a patient from the home to a SNF to address issues that arise.   

6. Minimize narcotics in pain management. The anesthesiology team's primary goals under a joint replacement bundle include adequate pain relief, faster mobilization and decreased length of stay, according to Milad Nazemzadeh, MD, clinical assistant professor and associate director of anesthesiology at the Department of Anesthesiology, Perioperative Care and Pain Medicine at NYULangoneMedicalCenter.

It is integral to provide a multimodal approach to pain management during and after surgery and minimize use of narcotics, Dr. Nazemzadeh explained during the webinar. Patient-controlled analgesia, peripheral nerve blocks, indwelling epidurals and femoral nerve catheters have been eliminated at NYULangoneHospital for Joint Diseases. In a multimodal approach to preoperative oral preemptive analgesia, which reduces pain and enables faster ambulation after surgery, Dr. Nazemzadeh said the anesthesiologists use oxycodone controlled release (10 mg), acetaminophen (1,000 mg), celecoxib (200 mg) and pregabalin (50 mg). They minimize narcotic use by using intraoperative periarticular injections, such as EXPAREL® (bupivacaine liposome injectable suspension), administered by the surgeon.

"There are important benefits of using regional anesthesia over general anesthesia," said Dr. Nazemzadeh. These benefits include lower incidence of venous thromboembolism and decreased need for intraoperative narcotic use.

7. Optimize fluid management. Optimizing hemodynamics — fluid management —  during surgery allows for more stable blood pressure and heart rate, as well as faster recovery room times, according to Dr. Nazemzadeh. It also enables early ambulation and rapid rehabilitation. NYULangoneHospital for Joint Diseases' goal is to give patients about three liters of IV fluid from the time surgery starts until the patient leaves the recovery room. However, the total IV volume is determined by patient history, length of surgery and estimated blood loss during surgery. 


The CJR model imposes high demands on the entire care team, making coordination of care and communication all the more critical to success. The post-discharge period is an especially critical time for the care team to maintain communication with one another and the patient, as it comprises the vast majority of the episode of care under CJR bundle. Although the patient is either in another medical facility or at home, the hospital is still on the hook for his or her outcomes.

If administrators and staff work together to empower physicians and design new clinical care pathways, each can share in the benefits while improving the health of the patients who trust them with their care.  

Full Prescribing Information is available at www.EXPAREL.com

Important safety information:

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia  
  • EXPAREL has not been studied for use in patients younger than 18 years of age 
  • Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Formulations of bupivacaine other than EXPAREL should not be administered within 96 hours following administration of EXPAREL 
  • Monitoring of cardiovascular and neurological status as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products 
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations
  • In clinical trials, the most common adverse reactions (incidence ≥10%) following EXPAREL administration were nausea, constipation, and vomiting 

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