Becker's Hospital Review

64 Executive Briefing: "There are numerous comorbidities that affect clinical out- comes, so you want to identify them to reduce risk," says Mr. Peters, "We know what contributes to bad outcomes: people who are smokers, people who have high BMIs, diabetics and those with cardiac disease." The goal is to manage these patient populations preoperative- ly. While hospitals typically aim to control these comorbidities for a short period immediately ahead of surgery, Mr. Peters suggests extending that time period farther ahead of the scheduled surgery date can lead to better outcomes. Mitigating risks such as these will likely require interventions by the patient's care team, such as help- ing patients who are smokers find smoking cessation programs, discussing the benefits of bariatric surgery with obese patients and close monitoring of glucose levels for diabetics. Thorough pre-admission testing and identification of risks helps the surgery team address patients' individual needs and prepare for potential complications with their hip and knee proce- dures. The better prepared the surgery team is, the less likely it is for the patient to have a long length of stay, early readmission and costly post-acute care. Prepare for post-operative care Hospitals participating in the CCJR model will aim to reduce patients' length of stay as a means of cost reduction. However, post-acute care admission to rehabilitation centers is among the highest costs associated with hip and knee joint replacement procedures. Annually, $6 billion is spent on post-acute care for joint replacement patients. Sometimes you can justify an extra day in the hospital if it will reduce the need for a patient to go to a rehabilita- tion facility, according to Mr. Peters. To reduce the need to send patients to inpatient rehabilitation centers, surgeons and nurses must carefully prepare for discharge prior to surgery. Nurses or care managers should visit certain cate- gories of patients in their homes to assess the environment they will be discharged to. The patients assessed would be those that have the potential to avoid admission to a post-surgery rehabilitation facility. "When looking at a patient's home, you should be looking for ways to make it easier for the patient to function there, as opposed to needing to go to a rehab facility," says Mr. Peters. "Maybe it's providing equipment to help him or her ambulate, such as a walker or assisted toilet seat." Patients will need continued support once they are discharged from the hospital. Nurses can pre-empt post-op complications or injuries by visiting patients in their home and ensuring they are complying with their medications. Regular communication — via phone calls and/or email — is vital during this stage, for if prob- lems arise, patients will likely go to the emergency room if no one answers their questions promptly. "It's essential to convey the message that, 'Just because we've discharged you doesn't mean we don't care about you anymore and that we're not willing to help you,'" says Mr. Peters. Case study: Hospital for Join Disease at NYU Langone Medical Center The Hospital for Joint Diseases at New York City-based NYU Langone Medical Center was an early adapter to the government's voluntary bundled payment initiative. HJD's success under the Bun- dled Payment for Care Improvement initiative and its specialization as a joint facility makes it a prime example for other hospitals under the CCJR model. HJD's results under bundled payment To bolster coordination among surgeons, nurses, anesthesia and other OR staff, HJD created the Total Joint Episode Manage- ment Group. This new governance structure ensured the respec- tive staff worked together under established best practices for clinical and management pathways from the moment surgery was scheduled, through pre-admissions testing, surgery, discharge and recovery. At the end of its first year under the bundled payment initiative, HJD decreased average length of stay to 3.58 days from 4.27 days, with a median of three days. Discharge to inpatient facilities after discharge decreased on average from 63 percent to 44 percent. Overall, the hospital saw significant reduction in inpatient costs, and it achieved positive margins compared to CMS' target price. HJD's hospital cost per case decreased between $7,000 and $6,300 under the bundle. HJD realized 17 percent savings on MS-DRG 470 — major joint replacement or reattachment of lower extremity without major complications or comorbidities — and 8.1 percent savings on MS-DRG 469 — major joint replacement or reattachment of lower extremity with major complications or comorbidities. HJD's keys to success The hospital achieved a high degree of success in its first year under BPCI because it was committed to improving its clinical man- agement workflow, according to Mr. Peters. After building the Total Joint Episode Management Group, the hospital had an authori- tative body to oversee the full spectrum of care provided to joint replacement patients. Central to this was improving communication with attending physicians, residents, fellows, social workers, nurse practitioners and clinical care coordinators. In its new inpatient workflow, the hospital zeroed in on length of stay as a top area for improvement, and set clear expectations that lengths of stays should be between two and three days. If it needed to be longer, the patient's admission was reviewed by the care team. HJD also initiated an aggressive approach to pain manage- ment, to ensure patients could ambulate early and often after surgery. This is important for reducing complications such as DVTs and cardiac events, and helps patients return to their normal lives sooner. The hospital focused heavily on the post-acute care period. Clinical care coordinators checked in with patients regularly for the 30-day period following discharge to monitor their progress and ensure patients complied with their medication regimens. Home nurses greet patients identified as high-risk for post-op difficulties at their homes after they are discharged to ensure they are fully oriented and understand how to take their medications. Additionally, HJD implemented targeted medical follow-ups by internists for high-risk patients. HJD's progress in one year under bundled payments shows hospitals can achieve significant savings if they invest in the neces- sary cultural, clinical and workflow changes. The proposed CCJR model opens the door to new challenges for hospitals, given it is mandatory, but it also presents a great opportunity for hospitals to achieve substantial improvements in both quality and cost reduc- tion. n Sponsored by: Surgical Directions LLC is a national consulting firm based in Chicago that assists hospitals in improving the operational, financial, and market performance of perioperative and anesthesia services. Our consulting team is led by nationally-recog- nized, practicing anesthesiologists, surgeons, and surgical service professionals experienced in organizational design, block time, surgical scheduling, patient throughput, materials, staffing, strategic planning, and physician relations. Team mem- bers have successfully helped over 500 hospitals nationally increase surgical volume, improve clinical outcomes, improve surgeon satisfaction, improve anesthesia satisfaction, and enhance overall perioperative performance. Preparing for Success under the Comprehensive Care

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