Becker's Hospital Review

27 Q: How do you define the episode of care and what should be measured? DM: The episode of care starts from the time a surgeon first sees the patient and decides they need surgery, and it follows through to 90 days after surgery. It's about a six-month period total since our surgeons are booked fairly well in advance, and we do a lot of work on the front end to reduce comorbidities, such as referring overweight patients for weight loss, working with our cardiologists and mitigating dental issues. We also do aggressive preoperative education and physical prehabilitation to optimize post-operative rehabilitation. SS: A typical episode for a primary total hip or knee arthroplas- ty begins on admission to the hospital and extends 90 days post-discharge. We define the episode in explicit and gran- ular detail, likely the most important step in implementing a bundled payment program. For example, it is critical to define what's included and excluded from the bundle and what are the duties and responsibilities of the parties to the agreement. We have a bundle for primary total knee and primary total hip arthroplasty. At the present time, our bundle is offered to patients under the age of 70 with no or minimal systemic dis- ease and who do not have any of our 10 exclusions, including uncontrollable diabetes, sleep apnea, anemia and alcoholism. MK: It begins before the patient chooses to have surgery and goes for two-plus years after they go home. That said, we are responsible for a shorter period during and after the inpatient stay; however, we want to make sure that the end-to-end expe- rience is consistent and exceptional, and that we are collecting long term outcomes on our patients to ensure their procedure was successful. Q: How do you identify savings opportunities in the inpatient setting, as well as in skilled nursing facilities and post-acute care settings? Are there any products or services that you have found helpful in generating savings? DM: For us, one is micro-invasive technology. Another is our anesthesia. Our anesthesia team uses a very unique group of anesthetic agents that is their own 'secret sauce' — it has really helped our patients control sleepiness, post-operative nausea and other side effects. We don't use regional nerve blocks, only ultrasound-guided direct blocks so patients don't experience rubbery legs that make them unsteady. We also use intraoperative medications — Exparel, which is methodically injected directly into the muscle, is one — which may add cost inside the hospital, but helps achieve tremen- dous savings in the post-operative period because it reduces the need for SNFs and complications related to immobility. SS: When you go through the care redesign process for the en- tire episode, the opportunities for reducing costs and improv- ing quality become obvious. Three years ago, we reevaluated our entire bundle using the time-driven, activity-based costing analysis. TDABC was introduced by Professor Robert Kaplan, PhD, from the Harvard Business School in 2006. TDABC is a method of cost accounting that determines the unit cost of de- livering segments of care and the time necessary to deliver that care. It was quite a robust process that was completed in a year and presented a perfect opportunity to strip away unnecessary, low-value services to further reduce costs. As a result of such analysis, we concluded inpatient physical therapy presented a glaring opportunity to reallocate resources. We implemented a program that we call a certified mobility technician program, through which we trained our CNAs to mobilize patients, get them out of bed safely, teach them to walk and navigate stairs — services that did not require the skill level of licensed physical therapists. We don't have a shortage of these 'mobility techs' and virtually all our patients are up walking on the day of surgery and getting home a day sooner. The savings based on that initiative were in the tens of thousands of dollars. MK: Inpatient savings are basic — they can mostly be found around devices and disposables. We also are focusing on decreasing our length of stay and ensuring discharges to the appropriate setting. Because the hospital is not caring for the patient in the post-acute settings, we have less influence over the care; however, we have begun to partner with various post- acute partners, have regular meetings and conversations, and treat the patient as an expanded care team to make sure their experience is consistent across treatment locations. Q: What role does pain management play in bundles? DM: Pain management plays a huge role. If our patients are in pain, they don't ambulate and they have a greater chance of infection. Increased cortisol decreases immunity and blood sugar stays higher when a patient is in pain. Managing pain is the single most important thing you can do. SS: Controlling post-operative pain is extremely important. Our anesthesiologists play a pivotal role in our mission and vision. In fact, in 2009 we recognized their importance and therefore included anesthesia in our original bundle. As this relationship developed, their value became even more apparent and there- fore we recently voted to add our two lead anesthesiologists to membership of CJRS. Our anesthesiologists are at the cutting edge of develop- ing regional blocks for total knee arthroplasty and the results are quite remarkable. This is an ultrasound-guided technique that starts with a femoral nerve block with short acting mepiva- caine. This is done to minimize pain of subsequent infiltration in an awake patient. This followed by an adductor canal injection and a 'ring block' (infiltration) above the knee with liposomal bupivacaine under ultrasound guidance to confirm proper spread of local solution. The majority of patients are up walking on the same day of surgery. As we move to shorter hospital stays and some outpatient total joint surgery, these 'rapid recovery' protocols become critically important. In addition to pain control, mitigating nausea, swelling and dehydration are essential elements of 'rapid recovery' protocols . The overall impact? Our patient satisfaction scores remain at the 99th per- centile, to a large extent directly related to anesthesia input. MK: Pain management is critical. We worked with our orthope- dic surgeons to develop a standardized multi-modal pain pro- tocol in collaboration with our pain management specialists. The results have been phenomenal. Two years ago we changed our approach to pain by utilizing a locally injected liposomal bupivicaine, a long-acting local anesthetic. This has allowed us to eliminate epidural and femoral nerve catheters. Patients are up and out of bed earlier in their stay. They have less pain and are able to begin their recovery much more quickly. n 27 Executive Roundtable: Bundling for the Best

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