Patient Selection, Optimization and Disposition: Tools for Success in Orthopedic Bundles

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1 Patient Selection, Optimization and Disposition: Tools for Success in Orthopedic Bundles Luann Tammany Tribus, PT, MBA SVP, Clinical Strategy & Innovation Remedy Partners John Kilgore, MD Orthopedic Surgeon & President OrthoCare Florida Bud Langham, PT, MBA Chief Clinical Officer Encompass October 2017

2 Presenters Luann Tammany Tribus, PT, MBA John Kilgore, MD Bud Langham, PT, MBA SVP, Clinical Strategy & Innovation Remedy Partners Orthopedic Surgeon & President OrthoCare Florida Chief Clinical Officer Encompass 10/13/17 Tools for Success in Orthopedic Bundles 2

3 About Our Partners Located in Tampa, FL 6 orthopedic practices 16 hospitals 56 physicians Headquartered in Dallas, TX 240 home health and hospice branches nationally 10/13/17 Tools for Success in Orthopedic Bundles 3

4 Agenda 1. Preparing and Engaging Patients Throughout Their Recovery 2. Home Health: Keeping Patients Safe at Home 3. Q&A 4

5 Objectives Examine how bundled payments affect the delivery of elective orthopedic care Learn about factors that inform patient selection, optimization and disposition for joint replacement procedures Review transitional care workflows that surgeons and the healthcare team can employ to engage patients and their families to coordinate care across settings Demonstrate how patients undergoing elective total joint replacements can recover safely in the home setting 10/13/17 Tools for Success in Orthopedic Bundles 5

6 Orthopedics in Bundled Payments Orthopedic procedures account for a large volume of bundled procedures among providers. They are currently implemented for Medicare patients under 2 programs: Bundled Payments for Care Improvement (BPCI) Voluntary participation with providers selecting any of 48 bundles Supersedes, or trumps participation in mandatory bundling programs Comprehensive Care for Joint Replacement (CJR) Mandatory participation for large providers in 34 Metropolitan Statistical Areas (voluntary in 33 other areas) Exclusively for joint replacement Both programs seek to improve value Improve quality of services delivered Reduce price variation and absolute cost for procedures 10/13/17 Tools for Success in Orthopedic Bundles 6

7 Remedy s Elective Total Joint Replacement Workflow This workflow is designed to facilitate efficient, comprehensive delivery of care to patients undergoing elective total joint replacements with the goal of recovery at home SELECTION OPTIMIZATION DISPOSITION FOLLOW-UP Identify patients who will benefit from surgery Prepare patients both medically and functionally for optimal outcomes Identify the most clinically appropriate next site of care pre-operatively. Manage comorbidities and reduce risk of readmission 10/13/17 Tools for Success in Orthopedic Bundles 7

8 Physician Group Practice Performance: Lower Major Joint Bundles Patients go home with fewer readmissions % Discharged Home 90-Day Readmissions % Discharge Home 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 43.2% 70.9% Percentage of Episodes with Readmission 20% 16% 12% 8% 4% 0% 11.7% 8.1% Historic Period= Post Go-Live = Q Q /13/17 Tools for Success in Orthopedic Bundles 8

9 Preparing and Engaging Patients Throughout Their Recovery Dr. John Kilgore 9

10 Current Payment System VOLUME Based Fee for Service Costs are DOUBLE those In U.S. vs Other Countries 10/13/17 Tools for Success in Orthopedic Bundles 10

11 Shift to VALUE BASED Payments VALUE = QUALITY COST 10/13/17 Tools for Success in Orthopedic Bundles 11

12 BPCI: Bundled Payments for Care Improvement Improve Quality of Care Decrease Cost of Care 10/13/17 Tools for Success in Orthopedic Bundles 12

13 QUALITY: A Changing Paradigm THEN: Surgery Hospital Care 10/13/17 Tools for Success in Orthopedic Bundles 13

14 QUALITY: A Changing Paradigm NOW: Patient Selection Preparation /Optimization Surgery & Hospital Care Appropriate Disposition Post-acute Management Reduction of Complications and Readmissions 10/13/17 Tools for Success in Orthopedic Bundles 14

15 Where are the Costs? Post-Discharge Space Disposition (SNF, Rehab) ER visits Readmissions Part B Charges 10/13/17 Tools for Success in Orthopedic Bundles 15

16 PAYMENT MODELS: Volume Based vs. Value Based VOLUME ONLY 10 $1000/case = $10,000 50% overhead = $5000 OPTIMIZED VALUE BASED 7 $1000/case = $ % overhead = $3500 PLUS 50% gainsharing bonus ($3500) = $ /13/17 Tools for Success in Orthopedic Bundles 16

17 PAYMENT MODELS: Volume Based vs. Value Based VALUE BASED, NOT OPTIMIZED 10 $1000/case = $10,000 50% overhead = $5000 BUT: not optimized so costs $5000 in excess of target ($5000) = $0 10/13/17 Tools for Success in Orthopedic Bundles 17

18 Opportunity Proper Patient Selection, Optimization and Disposition Will lead to Improved Quality of Care at a Lower Cost and therefore a HIGHER VALUE Manage the post-discharge space preemptively 10/13/17 Tools for Success in Orthopedic Bundles 18

19 Patient Selection The right procedure for the right patient. Know when NOT to offer an Operation. 10/13/17 Tools for Success in Orthopedic Bundles 19

20 Patient Selection Bilateral Elective Total Joint Arthroplasty 10/13/17 Tools for Success in Orthopedic Bundles 20

21 Optimization Modifiable Comorbidities Diabetes Obesity Anemia 10/13/17 Tools for Success in Orthopedic Bundles 21

22 Our Dirty Laundry 71% of readmissions with the diagnosis of CKD, Anemia, and/or DM. Average LOS >3 days Majority readmitted from a SNF Many were poor surgical candidates Uncontrolled DM Hgb < 11.0 Morbid Obesity 10/13/17 Tools for Success in Orthopedic Bundles 22

23 Diabetes Independent Risk Factor for PJI HbA1c over 7.0 is associated with an increased risk of postoperative complications Harris, et al: Hemoglobin A1C as a marker for surgical risk in diabetic patients undergoing total joint arthroplasty. J Arthroplasty 2013; 28; /13/17 Tools for Success in Orthopedic Bundles 23

24 Diabetes Increased 30-day wound complications after TJA reported in patients with average in-hospital blood glucose levels of >200 mg/dl Marchant Jr MH. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am 2009; 91 : /13/17 Tools for Success in Orthopedic Bundles 24

25 Obesity Independently associated with complications: Infection (risk increases exponentially with BMI) Delayed Wound Healing MI Stroke VTE 10/13/17 Tools for Success in Orthopedic Bundles 25

26 Obesity Associated with Increased Readmission Risk Obese patients had a 32% higher likelihood of readmission than non obese. Morbidly Obese (BMI > 40) patients had a 74% higher likelihood of readmission than non obese patients. CORR 2015 Nov; 473(11) 10/13/17 Tools for Success in Orthopedic Bundles 26

27 Anemia 29% of our readmitted patients had a history of anemia, and 5/7 of those patients required a transfusion upon readmission. 10/13/17 Tools for Success in Orthopedic Bundles 27

28 Anemia Elective Total Joints at MPH: February September 2016 (6 months) Surgical Procedure Number Arthroplasty Hip Total 236 Arthroplasty Knee Total 402 Total 638 Hgb # Patients # Transfused % Total % Transfused < = % 21.0% > % 1.35% 10/13/17 Tools for Success in Orthopedic Bundles 28

29 Summary For Optimization BMI < 40 HbA1c < 8.0 Hgb 11.0 or greater Note: this is not a denial of care but an opportunity to improve quality of care through patient optimization. 10/13/17 Tools for Success in Orthopedic Bundles 29

30 Optimization: Education Class Attendance has been proven to decrease risk, reduce anxiety and increase patient satisfaction Only 50% of our 2016 readmissions attended class According to AAHKS, standard of care for elective TJA patients is to create a mandatory class attendance policy 10/13/17 Tools for Success in Orthopedic Bundles 30

31 Disposition DISCHARGE Inpatient Rehab Facility (17 18K) Skilled Nursing Facility (5-10K) Home with Home Physical Therapy (1 3K) Descending Cost 10/13/17 Tools for Success in Orthopedic Bundles 31

32 Disposition PARADIGM SHIFT IN THINKING: More is Better Less is MORE HOME is usually the most appropriate discharge destination 10/13/17 Tools for Success in Orthopedic Bundles 32

33 Disposition- HOME SWEET HOME Comfortable, Familiar Environment Increased Activity Level Reduced VTE risk Faster Recovery Improved Patient Confidence Better Pain Control Reduced Infection Risk 10/13/17 Tools for Success in Orthopedic Bundles 33

34 Disposition Potential for 90% of patients to be discharged HOME Good Support (Friends, Family) Age and Health Status are considerations TUG AND RAPT Scores can help guide decisions 10/13/17 Tools for Success in Orthopedic Bundles 34

35 Discharge Disposition by Surgeon % Home with HHC versus SNF 100% 80% 60% 40% 20% 0% Surgeon Abdo, Cheong, Surgeon Cooper, Surgeon Cottrell, Surgeon Herrema Surgeon Richard A David B Andrew C William D, Mitchell E Hughes, Surgeon Kilgore, Surgeon Piazza, Surgeon W. Allen F John G Michael H Schwab, Surgeon Thomas I SNF 28% 7% 12% 18% 0% 28% 5% 10% 7% Home 72% 93% 88% 82% 100% 72% 95% 90% 93% 90% Average 10/13/17 Tools for Success in Orthopedic Bundles 35

36 Disposition Skilled Nursing Facilities (SNF) If necessary, use preferred facilities and minimize LOS Inpatient Rehabilitation Facility (IRF) Just Say NO 10/13/17 Tools for Success in Orthopedic Bundles 36

37 OrthoCare Florida Performance: Lower Major Joint All Bundles 2015Q4 2016Q3 Discharge to HHA 57.3% 67.7% Discharge to SNF 36.7% 26.2% Discharge to IRF 3.4% 1.4% % Readmits (90 day) 11.2% 8.5% Average SNF Days Savings Per Episode $1,343 $2,070 Source: Monthly Claims Data, At-Risk Bundle Selection for Quarters 2015Q4-2016Q3 10/13/17 Tools for Success in Orthopedic Bundles 37

38 OrthoCare Florida Performance: Lower Major Joint Medicare Claims Data Episode Connect All Bundles Pre-Go-Live 2015Q4 2017Q1 2017Q2 2017Q3 Discharge to HHA 53.5% 57.3% 74.3% 78.7% 77.5% Discharge to SNF 38.8% 36.7% 20.0% 17.8% 20.2% Discharge to IRF 5.0% 3.4% 0.3% 1.1% 0.9% % Readmits (90 day) 13.0% 11.2% 6.0% 4.7% 2.6% Average SNF Days Savings Per Episode - $1,343 $3, Source: Monthly Claims Data, At-Risk Bundle Selection for Quarters 2015Q4-2016Q3. Episode Connect Data accessed 09/27/2017 for Quarters 2017Q2-Q3. Savings Per Episode = NPRA / Episode Count 10/13/17 Tools for Success in Orthopedic Bundles 38

39 Summary Value Based Systems WORK and Reward QUALITY There is ROOM FOR IMPROVEMENT at every level of care These changes require a Shift in our PARADIGM Patient Selection, Optimization and Proper Disposition are Keys to early success True Success REQUIRES PHYSICIAN ENGAGEMENT 10/13/17 Tools for Success in Orthopedic Bundles 39

40 Keeping Patients Safe at Home Bud Langham, PT, MBA 40

41 Follow Up at Home Manage comorbidities and reduce risk of readmission Key Interventions Home Health Criteria Home Health Resources Build PAC Relationships Establish trust Hold accountable Engage Patients Review patient goals Set clear expectations Transitions Safely Standardize protocols Innovate together Are Patients Homebound? Require device or assistance, or leaving home is medically contraindicated and, Normal inability to leave home, and it is a considerable and taxing effort What does this mean? 1. Pre-op Engagement 2. Care Transitions 3. Standardized Protocols 4. Timely Initiation of Care 5. Comprehensive Care 6. Care Coordination 7. Discharge Planning 10/13/17 Transitional Care Institute Webinar - Orthopedic Success 41

42 OrthoCare & Encompass Case Study Patient centered care serves the best interests of the patient Action: Pre-op plan includes working with dtr. to stay with mom starting post op day 7 Result: Safe transition and recovery at home, physician, dtr, patient all satisfied SELECTION OPTIMIZATION DISPOSITION FOLLOW-UP Situation: 76 y/o female, lives alone, 18 meds, RAPT score of 6, went to SNF following previous TKA Action: Patient and dtr agree with home DC. High risk protocol triggered, aide b.i.d. x 3 days and Care Management Division/tech 90 Day Result: Problems proactively identified and addressed, no ER or ACH 10/13/17 Transitional Care Institute Webinar - Orthopedic Success 42

43 OrthoCare Florida and Encompass Home Health Metrics OrthoCare & EHH Dr. Kilgore and EHH (n=368)* Avg # of Visits Cost Per Episode $2,301 $1,720 % of Episodes w/readmits 4.9% 2.5% Despite a focus to reduce cost of care and the number of patient encounters Dr. Kilgore s patients show: 93% satisfaction compared to national average of 86% (n = 41 returned surveys) 95% improvement in outcome measures compared to 75% 36% LUPAs * Date from Jan 2016 June 2017, source: SHP and internal data sources 10/13/17 Tools for Success in Orthopedic Bundles 43

44 Questions? 44

The Pain or the Gain?

The Pain or the Gain? Comprehensive Care Joint Replacement (CJR) Model DRG 469 (Major joint replacement with major complications) DRG 470 (Major joint without major complications or comorbidities) Actual