Know Your Facts Geoffrey Westrich, MD Professor of Clinical - - PowerPoint PPT Presentation

Knowing the Rules: Rehab in the Era of Bundled Payments

Know Your Facts

Geoffrey Westrich, MD Professor of Clinical Orthopedic Surgery Hospital for Special Surgery Cornell University Medical Center New York, NY

What is a Bundled Payment?

• A single payment to providers for defined services over a defined period of time.



Also known as episode-based payment, episodic payment, value-based payment

• CMS has implemented various models to promote bundled payments –



Bundled Payment for Care Improvement (BPCI)



Accountable Care Organizations (ACO)



Comprehensive Care for Joint Replacement (CJR)

• Payment Model –



“Retrospective” – providers reimbursed fee-for-service and end of the defined period, the total cost of care is reconciled against a set “target price”



If cost of care > expected “target price”, provider taking on the risk will be responsible for paying back the excess



If cost of care < the expected “target price”, provider taking on the risk will share in the savings

• Goals –



Promote quality and financial accountability of care



Reduce unnecessary expenditures while improving care



Aligning financial and other incentives for health care providers and suppliers during an episode of care



Improve coordination and transitions of care

Bundled Payment for Care Improvement Refresher

• CMS demonstration project with voluntary participation
• Major Joint Replacement of Lower Extremity
• Medicare Beneficiaries Only
• 90-day Episodic Bundle, beginning with surgery
• All services including those in a post-acute setting up to 90 days
• Retrospective Payment Model; all providers continue to be paid fee for service
• 6 months following end of quarter, CMS compares total payment of episode to a calculated Target Price
• Option to share internal (i.e. implants) & external program savings with Physicians

BPCI

October 2013 April 2014 July 2016 BPCI Program Start Date HSS voluntarily joins BPCI HSS voluntarily exits BPCI to join mandatory Comprehensive Care for Joint Replacement (CJR) program April 2016 CJR Program Start Date

BPCI vs. CJR

• Voluntary program with about 500

participants across all episode families

• Announced in 2011, with payments

beginning in 2013

• A variety of clinical conditions elected

by the participating hospital

• Acute and post-acute care episodes
• Retrospectively reconciled
• Target Prices set based on hospital’s

historical performance, updated using national trend factor

• Required CMS discount for a 90-day

episode is always 2%

BPCI

• Mandatory program for about 800

hospitals in 67 regions (NYC included)

• Announced in 2015, with payments

beginning in 2016

• Major joint replacement of the lower

extremity ONLY

• Acute and post-acute care episodes
• Retrospectively reconciled
• Target Prices set using a combination of

hospital-specific & regional historical experience

• Required discount varies from 1.5% - 3%

based on quality metric performance

CJR

HSS By The Numbers

• In key performance categories, a comparison of HSS between the BPCI baseline period and CY 2014

Volume Discharge to Home SNF LOS Readmission Rate

Baseline

9,378 34% 19.6 days 8.4%

2014

3,376 53% 20.6 days 5.8%

Q3-2009 to Q2-2012

CMS Covers 21 days in SNF

Three Main Areas of Opportunity

Increase % Discharged Home Reduce LOS at SNFs

n=249 n=247 n=197 n=195

Reduce Readmissions

Since the Preferred SNF Partner program went live in early 2016, SNF LOS at

• ur preferred

partners is currently ~8 days

Difference Between Home & Rehab Discharges

• Avg 90-day episode of acute/sub-acute discharge is almost $10,000 more than a discharge home with nursing services
• Patients discharged home, even when normalizing for severity of illness, have better outcomes
• For patients who can safely be discharged to home

 Fewer facility acquired infections  Accelerated improvement in functional status

• f 2,010 episodes
• f 358 episodes
• f 155 episodes
• f 835 episodes
• f 76 episodes

Discharge Planning: Encourage Patients to Go Home

• Preferred Approach



HSS recommends home-based rehab following primary TJA as preferred strategy to maintain high quality, cost-effective care.



Patients more likely to have complications and to be readmitted to a hospital when they go to a SNF or IP Rehab versus home.1

• Environmental Factors



Some patients are medically cleared to go home, but because of personal or environmental factors are not able to get home.

• Physician Alignment, Patient Engagement, and Increased Communication



Physician involvement in care coordination and patient management efforts



Actively include the patient and family caregivers in identifying post-acute care needs and resources



Educate patient and family caregivers about inpatient care and discharge planning process/transitional care plan

1. Fu, M. C., MD, MHS, Samuel, A. M., MD, Sculco, P. K., MD, MacLean, C. H., MD, PhD, Padgett, D. E., MD, & McLawhorn, A. S., MD,

• MBA. (2016, May 22). Discharge to Continued Inpatient Care After Total Hip Arthroplasty Is Associated With Increased Post-Discharge

Morbidity: A Propensity-Adjusted Cohort Study [Scholarly project]. Retrieved from New York, NY

Post-Acute Network Management – Secret For Success

• In Q2-2015 alone, there were 247 BPCI patients discharged to 99 different SNFs



The average length was 19.7 days



HSS’s TJA sub-acute pathway indicates an appropriate SNF LOS is 5-7 days, when medically appropriate

• Developed key relationships with select SNFs to enhance communication and care coordination – network

currently consists of 18 SNFs in key geographic areas



SNF Care Coordination Facilities were vetted and selected based on quality, geographic locations, and patient experience

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One of the major requirements of our Care Coordination Facilities is daily communication regarding patient care and progress

• Dedicated HSS Post-Acute Care Coordinator



Physical therapist that will monitor patients at nursing homes and ensure appropriate rehab protocol is put in place and followed



Coordinator follows-up with patients post-SNF discharge

~20.6

days

~8

days

2014 Since start of CCF program in early 2016 Average LOS at HSS Care Coordination Facilities (CCF)

Reducing Readmissions: Risk Stratification & Patient Management

• Explore patterns in comorbidities amongst readmitted patients & create preventative initiatives
• Risk stratification efforts, what’s currently being used, what are we exploring

 NSQIP, fragility index, LACE scoring tool for risk assessment of hospital readmission, etc.

• Monitor everyone, but use your resources to “manage” only those that need it

 Creation of criteria to identify high risk patient population & add to Nurse Practitioner call list for duration of care episode

Risk Factors Frequency of Calls d/c with draining wounds or with wound vac/drain placed Every Other Day (M, W, F) CHF during HSS stay 2 x 1st week then weekly d/c with Foley/Urinary Catheter 2 x week until Foley DC'd BMI>40 1 x 1st week then weekly Age > 80 1 x 1st week then weekly A1c>8 1 x 1st week then weekly LOS @ HSS >5 d 1 x 1st week then weekly Smoking 1 x 1st week then weekly CHD (+) stress test or Troponin @ HSS 1 x 1st week then weekly UTI in hospital 1 x 1st week then weekly dementia chronic 1 x 1st week then weekly

Pre-Operative Risk Assessment

High Risk Patients “Optimized Before Scheduled”

• 1. Identified using risk assessment
• 2. Aggressive pre-op assessment and preparation
• 3. Modifiable risk factors should be modified preop
• 4. Medical & social issues stabilized with detailed plan

Low Risk Patients “Fast Tracked”

• 1. Minimal pre-op work-up and preparation
• 2. Plan for rapid home discharge

Thank you