Euclid Hospital CMS BPCI Episode

Transcription

1 Euclid Hospital CMS BPCI Episode

2 Two Paradigms in Health Care Reform Managing population 1 health, 2 PCMH Managing episodes of care, Bundled payments Health Status Baseline Episode Total Spend: Commercial & Government Health Maintenanc e 40% Episodes 60% Source: Ohio.gov, McKinsey 2

3 Center for Medicare & Medicaid Innovation (CMMI) ACO Affordable Care Act Charged CMS to Explore Innovative Payment Models Bundled Payments for Care Improvement (BPCI) 4 Models Model 2: Retrospective Acute Care Hospital Stay & Post Acute Care 3

4 Value is Created by Care Redesign Traditional fragmented delivery Cost Value creation New Model of Care Time 4

5 Contracting through BPCI, CC Retains Most of Value Created Savings CMS cost savings contracted at 3% Cost Facility opportunity Care Improvement New model of care Time 5

6 Care Improvement is a Pre Requisite for Bundled Payment 1. Care Path Implementation 2. Care Coordination 3. Connected Care BPCI readiness was enabled by integration of enterprise care redesign efforts 6

7 Financial Evaluation of the Opportunity CMS provided historic hospital specific MSPB* for the episode and required a 3% discount Financial impact of: Reductions in post acute spend Reductions in readmissions Key Findings: Significant portion of unwarranted variation in episode spend occurs in post acute utilization Euclid s historic discharge to home rate: 22% *Medicare Spend per Beneficiary 7

8 Euclid Hospital BPCI Summary Bundle MS DRGs 469 & 470 Primarily Total hip/knee replacements Episode Duration 7 days prior, 30 days post Target Price $ (DRG 470) / $ (469) Contract 3 years (10/1/13 9/30/16) extension to

9 Key Provisions: Waivers and Gainsharing Waivers 3 day hospital stay for PAC payment Home bound status for Home Care Gainsharing Opportunity to share risk and reward among providers Our integrated system allowed us to move forward with or without gainsharing 9

10 Care Redesign Total Joint Complete Care Patient Selection Patient Optimization Operative Intervention Post Operative Hospital Stay Post Hospital Long Term Maintenance

11 Euclid Hospital s Implementation Program for BPCI Care Advocate Patient Education & Engagement Compliance Program Care Path Implementation Clinical and Financial Database Quality Score Card Monitor Financial Performance Optum Bundling Tool 11

12 Episode value scorecard Clinical Outcomes Patient Safety Process measures Physical Therapy day of surgery Decrease in pain medications needed Compliance with Care Path Core measures Patient optimization prior to surgery Outcomes measures PRO, Koos/Hoos Return to work/sports Range of motion PT test, Pain free Pt safety indicators, SSI, Readmissions, Reoperations, Post Operative falls, Post Op Nausea/vomiting Transfusion Process measures Outcomes measures Patient Experience Patient and family education Engaged and activated patients Family/Support person involvement Quality shared decision making Appt. when wanted Feel prepared for discharge Joint Class HCAHPs Return/second surgery Efficiency Resource utilization Cost of care Utilization Review: avoiding unnecessary tests, Reduced LOS, Discharge disposition Rapid Recovery program Total cost of care Contributions to cost (acute, post acute venue, complications, readmissions) 12

13 Care Coordinator As the Orthopaedic Care Coordinator I reach out to patients prior to surgery and introduce myself I ensure we have accurate information on: Their care partner Their Home environment Their understanding of the journey they are about to embark on The home care agency or skilled nursing facility they would prefer

14 Care Coordinator Educate the patients during the Total Joint Replacement Group Class. Visit with the patients while they are in the hospital and address any needs that arise. Works very closely with the Nurse Manager, Nurses, Physical and Occupational Therapists, Case manager and the Social Worker. There is a Huddle Meeting every morning on the orthopaedic floor and discuss the patients and what their needs are.

15 Follow Up Phone Calls After the patient is discharged I conduct a follow up phone call asking about their: Pain Level Physical therapy at the home Appetite, Nausea, Vomiting Constipation Chest Pain/SOB Incision Site Any additional questions that they may have are also addressed

16 The Orthopaedic Surgeon s Office How things have changed..

17 The Office Visit The surgeon will discuss the patient s options with the patient and decide if surgery is right for that patient. The surgeon will determine the patient s readiness for surgery

18 Patient Optimization BMI Under 40 is a MUST HgA1C Less than 7 and being managed by primary care Anemia management Identifies patients early for time to choose treatment options, other than transfusion MRSA decolonization Completed preoperatively to allow for prophylaxis Smoking Cessation Referrals are given to assist cessation Information about infection risk, increased risk of clots and wound healing given to patients Some surgeons refuse to operate on smokers

19 Patients need to understand that is an Elective Surgery The patient will be able to plan and prepare their body and mind for a successful outcome. Medical conditions can be optimized Education is not at the time of surgery, but in advance for preparation and time to consider any additional questions We encourage our patient s to attend one of our Total Joint Replacement Group Classes. This is a 2 hour class conducted with a physical therapist and a nurse. The class goes through important information about presurgery preparation, the hospital stay and rehabilitation needs.

20 The Total Joint Replacement Group Class The class walks the patient through the knee or hip replacement surgery using models Precautions to follow after surgery Preparing the body (exercises to do prior to surgery and healthy eating before surgery helps the patient heal and recover after surgery) Preparing the home

21 Joint Class Continued: The class also offers an opportunity for the patients and family members or friends to ask questions. The Total Joint Replacement Group Class was designed to optimize the success of surgery, rehabilitation and function for years to come. The Total Joint Class information is consistent throughout the Cleveland Clinic Enterprise in content and structure

22 EDUCATIONAL BINDER We also provide our patients with an educational binder called THE PATIENT S GUIDE TO TOTAL JOINT REPLACEMENT AND COMPLETE CARE. The binder is given to the patients in the physician's office. We encourage our patients to bring this binder with them to the Joint Class and to the hospital the day of surgery. The Guide is also standardized and used throughout the Enterprise

23 DVD We supply the patient with a DVD called THE TOTAL EXPERIENCE. It is also available as a web link The DVD is taken home and viewed by the patient and their care partner s at their leisure. The DVD reinforces education on expectations and processes beginning in the surgeon s office all the way through discharge.

24 EMMI Patients are assigned a computer program called EMMI. The patient or family can sign into a smart device and view videos about: What to Expect During Your Hospital Stay What to Expect During Knee or Hip Surgery These are all tools that we are providing our patients to use prior to having surgery.

25 The Surgery and Stay Other cultural changes All staff are aware of the plan of care for each patient, whether they are planning to go home in 2 days or to a facility Pain medications have significantly evolved over the last few years from every patient having PCA pumps to oral medications The surgeons are not the only ones that have changedanesthesia care for these patients have also changed modalities. Spinals and nerve blocks are now the norm Equipment changes also evolved CPM machines and ice mans to name a few Physical therapy now sees patients the day of surgery

26 Goals for Acute Physical Therapy Safety Promote Early Mobility Ambulate at least 150ft. Perform functional mobility at supervised level or better D/C Home POD #2 except UKA POD #1 Home PT D/C SNF early if needed POD #2

27 POD # 0 Evaluation bedside Discuss home environment, assist available at d/c and barriers to d/c Anti embolics and ROM therapeutic exercise Education WB, Precautions, POC, safety Attempt ambulation (minimally dangle at EOB) Out of bed in bedside chair Build confidence Address pt and family concerns

28 POD # 1 BID PT, Bedside and Department Decide appropriate ambulation device Gait training, therapeutic exercise, ROM, stairs Possibly issue equipment, car transfer Pt and family education and review D/C home for UKA Adductor block still affective for pt with TKA

29 POD # 2 Reinforce education Continue functional mobility training promoting independence 1 2 sessions depending on needs D/C home vs. requiring more time If appropriate, d/c to SNF (7 10 days) Adductor block no longer working for TKA

30 POD # 3 PT as needed to D/C can be BID OT usually 1 2 treatments through Acute stay

31 Barriers Limited to no Assist at D/C Poor prior functional level Decreased pain tolerance Medical Complications (i.e.: infection, confusion) not common Physiologic response Hypotensive Nausea Poor pain tolerance\comorbidities Fear

32 Assist Level Needed at d/c Minimally for transportation and lifting objects (laundry, shopping) Ideally assist 1 2 times per day for ADLs and IADLs Typically do not need assist for mobility of the pt Set up assist for exercise, and ADLs ideal Set up home safety prior to d/c home i.e.: RTS, throw rugs

33 Ways to promote home going Prepare before the surgery Exercise before the surgery Attend Joint Class Joint DVD has examples of exercises to be done after surgery for reference Ask questions

34 Transition the Continuum of care to Home Use of SNF risk assessment tool to predict referrals for homecare discharge disposition Internal process to track orthopedic patients in hospital Communication to hospital case managers during transition to home

35 Ongoing complete care Therapeutic exercise program strengthening/range of motion balance training ambulation training stair training Medication review Incision care Fall prevention

36 Ongoing complete care DVT management/edema control Vital signs Constipation education Pain management Pain medication prior to visit Ice area following visit Discharge planning Arrange outpatient services

37 Ongoing Care Preparing The Home for THA/TKA Recovery Adaptive equipment Ambulation aids Easy access /Traffic pattern Stair climbing

38 Integrated Team Communication Encourage family/caregiver involvement Interconnected electronic documentation To the surgical team for patient updates To the patient care advocates

39 But. Not all patients go Home. Why? No care partners Non conducive home environments Additional therapy requirements (Not Safe) Medical Conditions preclude it

40 Skilled Nursing Facilities Have met with our local SNF s to educate on the BPCI project and bundling Case Management works closely with the patients preferred facilities for early discharge (waiver) Care Coordinator reaches out to Skilled Nursing Facilities for updates on patient s progress The goal is to decrease LOS in these facilities as the patient condition allows. Target is 7 10 days. Historically stays were 23 days.

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42 The Future of Bundles Commercial Payers Medicaid SIMS project Medicare Expansion