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5 methods to help change discharge patterns: Understanding and shifting away from the post-acute culture in light of CJR

Cathy Jerow, RN, MSN, MBA, Senior Program Manager, SLD Clinical Informatics, Stryker Performance Solutions, catherine.jerow@stryker.com


History: Beginning in the early 1990s, the number of patients discharged from acute care to a Skilled Nursing Facility (SNF) began to rise due to inpatient improvements such as surgical technique, decreased length of stay and an increase in payments for the post-acute care (PAC) settings1. Throughout the decade, hospitals and PAC facilities increasingly took advantage of this new discharge paradigm. Hospitals were able to collect full payment from Medicare for a much shorter inpatient length of stay and PAC facilities collected full payment on their end for care that had previously been provided in the acute care setting.

Payments going to acute and post-acute facilities put a financial strain on the health care payment systems and in response Congress implemented changes to the Balanced Budget Act of 1997. Congress charged the Health Care Finance Administration with identifying 10 DRGs to extend the transfer policy to include acute to PAC transfer. (Previously these only included transfers from one acute setting to another.) In Oct of 1998, the first PAC transfer DRG policy, which included the DRGs for total joint replacements (TJR), was implemented. This new policy penalized the acute care facilities by decreasing payment for early discharges to PAC facilities2.

In the years since, there have been iterations, additions and revisions, and new laws in legislation regarding CMS alternative payment models. On November 16, 2015 the Comprehensive Care for Joint Replacement (CJR) program received final approval. Although the CJR mandate is new, it continues to include payment disincentives for acute to PAC transfer.

The Post-Acute Culture: Within this historical framework, it is understandable that a cultural preference to discharge to post-acute care settings, including SNFs, still exists – even with payment disincentives in place. Stryker Performance Solutions’ Hospital Reported Outcomes database houses claims data from over 250 hospitals and over 400,000 distinct patient records. In review of this data, the high volume of patients being discharged to skilled facility appears to be due to a regional culture and is not necessarily reflective of the acuity of the patient population.

Below are the top 10 states in the Hospital Reported Outcomes database with highest SNF utilization:
STATE SNF Year # of SNFs
New Jersey 57.96% 2014 364
Connecticut 46.83% 2014 229
Massachusetts 38.85% 2014 420
Arizona 33.33% 2014 145
Alabama 27.35% 2014 226
Tennessee 25.15% 2014 295
Washington 24.49% 2014 224
Virginia 23.55% 2014 286
California 23.34% 2014 1220
Nebraska 23.11% 2014 216

There will always be patients that meet medical criteria and have a true need to go to a SNF. Examples may include patients with multiple co-morbidities, those having slow progress in the inpatient setting and those requiring assistance in care prior to surgery.

Changing Culture: For those that do not medically need this extended care, how do we change the mindset of a community? How do we alter the notion that both history and a culture have propagated? How do we change a culture that permits the belief among patients that going to a SNF after a total joint replacement is a not only necessary, but a patient’s right?

Transforming a culture is difficult, but it can be done. It requires changes across the continuum of care and consistent application of those changes by every surgeon and every provider that delivers care to this patient population.

Here are 5 methods to help manage your post-acute discharge patterns:

1. Consistent Messaging Across The Continuum

a. Surgeon’s Office: Surgeon and staff set the stage regarding where the patient will be going after hospital discharge. Be honest with the patient; recite literature which states patients going to a SNF post-acute discharge have higher readmission rates and higher infection rates. Make the patient feel comfortable with going home and not cheated because he or she does not “get to go” to a post-acute facility.

b. Pre-op Education Class: It is imperative that nurses, physical therapists and other ancillary staff leading the pre-op education class will reiterate the same information. They can explain the comforts of being home, reduced chance of infection (because they are accustomed to the microorganisms that live in their home), etc. Being positive and firm on this messaging is key. Some patients think of a SNF as a spa or vacation destination, which is certainly most often not the case.

2. Pre- & Post-hospital Conditioning

a. Patients will rely on upper body strength post-surgery. Therefore, providing demonstrations and instructions on various exercises will help build arm strength and show the proper use a walker or cane post procedure. Since a separate physical therapy appointment may not be feasible, educational materials, such as pictures or videos with descriptions, can be distributed and reviewed during the pre-operative education class.

b. In the same effort, a copy of exercises that will be done post-operatively should also be provided. Having the patients practice these exercises under your observation is important. Caregivers should also be involved so they understand the correct way to perform these exercises and how to assist the patient as well.

3. Standardize a Care Delivery Model Based on Best Practices: Develop a standardized care delivery model based on current best practice to provide consistent care to your patient population. Work with your surgeons and staff in each department to develop protocols, order-sets and standards of care that reduce variability between providers. This produces expertise, consistency in application and implementation, and helps eliminate waste.

4. Standardize Rehab Protocols: Implement a standard rehab protocol to be used during the inpatient stay as well as orders for outpatient therapy, as appropriate for each level or provider of post-acute care. By developing relationships with post-acute rehab providers, program rehab initiatives can continue and remain constant even after discharge.

5. Discharge Planning: Make sure discharge planning is involved even before the patient is admitted. This begins the process of assessing the post-discharge needs of the patient, whether it is outpatient physical therapy or SNF. Care Management should be involved in the pre-operative education class to reiterate the post-discharge options and to identify those patients at high risk for discharge to an acute or subacute care facility.

Summary: Patients are thriving with the implementation of these changes to discharge patterns and practices. Higher patient and staff satisfaction scores, increased volumes, lower length of stay and an increase in patients going home are some of the enhanced performance metrics we observe with the employment of patient education, consistent processes and care delivery, utilization of protocols to reduce variability by providers, and the encouragement of patient and families to participate in their own care.

Focusing on the continuum of care, especially in the post-acute setting, is critical in ensuring post-operative outcomes success as well as success under bundled payment programs such as CJR. Facilities that can redesign care to maximize the 90 day total joint episode will be best positioned for alternative payment models and care transformation.

1 Buntin et al, 2005
2Cromwell, 1998

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