Outpatient Joint Replacement in the ASC; Service Line Approach

Outpatient Joint Replacement in the ASC; Service Line Approach Richard Conn, MD, Associate Medical Director, SPS Marita Parks, RN, BS, MHA, Project Manager, SPS TODAY S AGENDA Outpatient Joint Replacement (OJR) Historical Progression of TJA Procedures Industry Demand for Change Marshall Steele Approach Results OUTPATIENT JOINT REPLACEMENT: 5 FACTS! 1. The percentage of the M S joint database that represents outpatient joint replacements has doubled each year over the last 3 years (still less than 2 percent). 2. Outpatient joint replacement requires everything be perfectly executed! 1 3. Controlling overall cost of the continuum of care for a specific disease state is important when looking at reimbursement and payment reform changes. 4. Direct Costs for an outpatient versus inpatient joint replacement in a hospital can be 25% less. 2 5. Patient requirements of an improved experience, lower cost, reduced risk of infection, and efficient throughput may translate into the ultimate demand for an outpatient joint program. 1. http://www.aaos.org/news/aaosnow/may09/clinical4.asp 2. Comparative Safety and Resource Utilization of Total Knee Arthroplasty in Inpatient and Outpatient Settings; Scott D. Schoifet, MD; Journal of Managed Care Medicine, Vol. 14, No. 3 1

SAFETY - PATIENT SELECTION Patient less than 65 y/o unless a uni-knee candidate (Medicare) with definitive diagnosis and who has been pre-assessed by medical consultant Fully informed/educated patient/family regards surgical care process and discharge expectations No co-morbid medical conditions that might lead to hospitalization Motivated patient willing to aggressively pursue rehabilitation on an outpatient level Family support system for maintenance of home care Suitable for straight forward primary joint replacement SAFETY FACILITY REQUIREMENTS Staff adequately trained in the surgical care of a joint replacement patient Orthopedic implants and equipment suitable for joint replacement with backup Anesthesia protocols allowing same day or 23 hour discharge Pain management protocols Blood management protocols (pre, peri-op, and post-op) Transfer agreements with local hospital ( ASC) 23 hour permit for patient care with staff/facility to manage patient/family (ASC) Follow-up appointments confirmed prior to discharge TJR TIMELINE FROM A SURGEON PERSPECTIVE 1983: Mayo Clinic Fellowship: THA/TKA 5-7 days 1984: Return home: Total Hip Patients in bed 10 days in slings 1991: TVC program initiated: TKA stay reduced from 5 to 3 days 2002: Out-patient (23 hour stay) Uni-Knees performed in ASC 2011: In patient stay for THA/TKA average 2.4 days 2

WHY MOVE TJR TO OUTPATIENT SETTING? Improve Quality/Patient Safety Greater Surgeon Control Cost Savings Increased Revenue Outpace the Competition Patients are Asking New Option for Joint Replacement Anticipating the Future Direction of Healthcare (i.e. bundled payments) Other WHAT IS NEEDED TO ACHIEVE SUCCESS? Superior Clinical Outcomes Cost Savings For Insurance Companies and Patients Profitability For Surgeons/ASCS Extraordinary Patient Experience Positive Word of Mouth Marketing As Good or Better than Inpatient TJR Will Out-patient Joint Replacement in ASC Become Standard?... ENGAGING SURGEONS WIIFM? Patient Satisfaction Staff Satisfaction Reduced Complication Risk By Having Patients Return Home ASAP In ASC, Surgeon Control of Entire Care Process Including Time Management In ASC, Potential Financial Benefit Depending on ASC Ownership Structure and Payor Regulations 3

SURVEY What Colleagues are Saying Are You Currently Performing Outpatient Joint Replacement? Do You Believe Outpatient Joint Replacement is Here to Stay? 4 1 8 Yes No Would Like To 1 3 9 Yes No Not Sure Survey Taken: May 2014 Stryker Annual AMC Summit Outpatient Joint Replacement WHAT SURGEONS PERFORMING OJR ARE SAYING Q: To successfully bring total joints to an outpatient setting, what procedures and protocols must be in place? Chad Burgoyne, MD, The Spine & Orthopedic Surgery Center (Santa Barbara, CA): The most important factors in performing a joint replacement as an outpatient procedure are the coordination and protocols that allow the surgical team to provide streamlined service. The surgical team needs to be consistent and well trained in joint replacements; the shorter the surgical time, the less pain and subsequent anesthesia is required, and the more the patient is able to participate immediately in therapy comfortably. Second is the anesthesia team. With a combination of spinal, regional and local anesthesia, we are now able to have postoperative patients that need little to no pain medication in the first days after surgery. The nursing staff must also shift their focus to enable the efficient discharge of patients. Their role is as much coach as caregiver. They must care for, educate, facilitate and encourage all in one breath. All the resources and steps must be in place so they can focus on the task at hand. Finally, there is the therapy team. The therapists must organize their days around the operating room schedule to minimize down time. A patient cannot be allowed to sit in bed and simply recover. The therapists must be available to start ambulation within the first hour after surgery is complete. Source: http://www.optimhealth.com/what-will-it-take-for-total-joints-to-succeed-at-ascs/ SURGEONS DOING OJR Q: Are total joints trending outpatient or inpatient, and why? Dr. Burgoyne: Joint replacements are most definitely trending towards an outpatient model. At the most basic level, long inpatient stays are simply not necessary. Often my patients are bored, requesting discharge by the second day after surgery. The reality is that there is not much we do for patients during their two- to three-day hospital stay. If their pain is well controlled with the regional anesthesia, they are usually sitting around waiting for the one to two hours of therapy they receive. Why not sit at home and come in for outpatient therapy daily instead? Dr. Riordan: Clearly outpatient joint replacements are trending upward. Our experience, as well as that of other facilities in our region, is that an exciting increase in patient and surgeon demand for this service is occurring. ASCs are ideally positioned to lead this movement that lowers costs, controls complication rates, improves satisfaction and is preferred by patients. Source: http://www.optimhealth.com/what-will-it-take-for-total-joints-to-succeed-at-ascs 4

SURGEONS DOING OJR Q: Are insurance companies coming onboard with outpatient joint replacements? Dr. Scioli: The insurance companies will be more inclined to endorse these procedures being performed as an outpatient once adequate data exists to support the practice as being safe and effective. Medicare and Medicaid should allow for certain criteria to exist such that special cases could be done as an outpatient. In time, outpatient joint replacement will gain the traction it needs to become routine. Dr. Riordan: Insurers were initially cautiously supportive or sitting on the sidelines as interested observers. Lately, insurers have contacted us regarding our outpatient joint program, requesting data, asking to gain an understanding and even promoting our model in their other markets. Dr. Burgoyne: Medicare has acknowledged this trend and is revisiting their policies in regards to payment for outpatient joint replacements. Once they allow for outpatient arthroplasties, it is likely other insurance companies will follow suit. With rising costs and the large volume of procedures to be performed in the coming years, I think this shift to outpatient care is crucial to maintaining access to these vital procedures. Source: http://www.optimhealth.com/what-will-it-take-for-total-joints-to-succeed-at-ascs SURGEONS DOING OJR There are some roadblocks to outpatient arthroplasty, as described by Dr. Lombardi: Patient Fear/Anxiety Patients are afraid of the unknown, not knowing what is going to happen Patients are afraid of the pain associated with the procedure Risk Factors Patient co-morbidities Medical complications as a result of the treatment Side Effects of the Treatment Narcotics/anesthesia Blood loss Surgical trauma Source: http://icjr.net/report_137_outpatient_arthroplasty.htm HOW DO WE SUCCESSFULLY TRANSITION? SERVICE LINE APPROACH THE PATIENT EXPERIENCE People Alignment/Structure System of Care Patient Focused Culture Management from Metrics Enabling Systems Tools and Materials 5

OUTPATIENT JOINT REPLACEMENT Program Components Infrastructure Clinical Program Management Service Line Leaders Outpatient Clinical Pathway Outcomes Physician Participation Standardized Plan of Care Marketing Patient Selection Patient Education Program Sustainability Facilities & Equipment Service Providers/Partners Surgery Scheduling Staff Training: OR & Postop Payer Contracts Emergency Protocols OUTPATIENT JOINT REPLACEMENT Program Components Clinical Program Outpatient Clinical Pathway Standardized Plan of Care Patient Education Service Providers/Partners Staff Training: OR & Post-op Emergency Protocols Home Health/SNF Procedure Training/Competency Room and Procedure Set-up Clinical Care Path Discharge Plan Selection Criteria Post-op Discharge Criteria 4 week pre-op process Plan A: Plan A/B: Pre-op discharge planning o The preferred plan; requires o VSS, alert, pain <5, appropriate caregiver (24/7 x wound/dressing intact, able Admit ASC DOS 1 st wk.) and have minimal to void, tolerates oral Discharge plans: steps or able to live on one intake o Plan A: Home with level o No EKG changes Outpatient PT o Outpatient PT start date o PT clears patient on bed to Discharge to home confirmed prior to admission chair transfer, ambulates 4-6 hours post-op Plan B: 100 ft. with walker, able to if discharge criteria o Option for overnight stay is go up/down 4 steps Alternate D/C plans initiated surgeon decision; can be o Medical clearance by by Surgeon based on specific based on clinical or functional anesthesia/surgeon patient needs; these plans will need required if the above not be presented as options o Outpatient PT start date to be discharge criteria not met; for patient choice confirmed preop *see list below for o Plan B: (overnight) Plan C: indications to call which Discharge to home o Option for Hospital/SNF is a provider (Outpatient) in the true back up plan for o Patient and family am unplanned situations that safety/d/c teaching o Plan C:3 variations present during the postop o Plan B discharge is 2359 Hospital admit period. Plan C: 4-6 hrs p/o Note: Discharge to SNF that o VSS, alert, pain <5, SNF transfer 4- involves pain control issues should wound/dressing intact, able 6 hrs p/o not occur, but if it does, it will be to void, tolerates oral SNF transfer monitored and trended as this may intake after 2359 mean there is an issue with the o Surgeon completes Post-op Follow-up: anesthesia/pain/block protocol. transfer summary o Physician phone o If any of the above call discharge criteria are not o ASC CC phone met, medical clearance by call anesthesia/surgeon o Anesthesia phone required before proceeding call with transfer; *see list o Post-op office visit below for indications to call Post-op Follow Up and Key Time Frames Physician phone call: o POD 1 ASC CC phone call: o POD 1 Anesthesia phone call: o POD 2 ASC patient satisfaction survey o 2 weeks postop Post-op office visit with surgeon: o 2 weeks ASC CC phone call: o 30 days postop Reunion Luncheon event o Every two months STANDARDIZED PROTOCOLS Mobility Checklist 6

OUTPATIENT JOINT REPLACEMENT Program Components Management Outcomes Marketing Program Sustainability ASC Reported Outcomes Patient Reported Outcomes The Program improves the Metrics the Metrics improve the Program ASC JOINT PROGRAM METRICS Complications: ASC -Cardiac CLINICAL Complications: 30 Days Postop -SSI - Pulmonary - PE./DVT Rate - Renal - UTI, Falls - Hemodynamic - Blood Trans. -Wound -Hematoma - Pain/PONV - Pain/PONV - Neurovascular Readmissions - Alt.Mental Status Knee Flex/Ext OPERATIONAL Case Volume Length of Stay Hours <6 hrs <2359 >2359 DischargeDisposition -% Home -% Home Health -% Skilled Nursing Facility Emergent Transfer w/admission Emergent Transfer w/o Admission Cancellations FINANCIAL Direct Costs Implant Costs Reimbursement -Payer Type Contribution Margin OPERATING ROOM - Surgery Time -Prep Time -Exit Time - Duration Accuracy SF- WOMAC Knee Society Harris Hip FUNCTIONAL SATISFACTION Overall Satisfaction Likelihood to Recommend MONTHLY PERFORMANCE IMPROVEMENT MEETINGS Analyze Results by Procedure, Surgeon, Anesthesiologist Identify Trends/Comparisons Tease Out Strengths and Opportunities Develop Action Plans Manage Outliers 7

50 45 T o 40 t 35 a l 30 25 S 20 c o 15 r 10 e 5 0 Pre-op 6 week 3 months 6 months 1 year 2 years 5/26/2015 PATIENT REPORTED OUTCOMES Did the Intervention Succeed? Are the Patients Satisfied? Pre-op Survey Surgery Post-op Survey Patient Results Aggregate Reports Marketing Materials 6-12 Months Real-time Quarterly Annually Reduced WOMAC Scores PATIENT REPORTED OUTCOMES IPad; Easy to Use for Patients and Staff Simple Data Collection, Analysis, Benchmarking Tool Survey at Pre-op and Post-op Intervals High Patient Compliance Rate Portable Secure Efficient: 15 To 25 Questions (< 6 Minutes) Total Knee Pain Intensity I have no pain at the moment. The pain is very mild at the moment. The pain is moderate at the moment. The pain is fairly severe at the moment. The pain is very severe at the moment. The pain is the worst imaginable at the moment. Customizable PERFORMANCE IMPROVEMENT TEAM Dashboard Report Evaluate Progress Set Goals Benchmark: MS 1 day LOS: Your Own Performance Share Results with Key Stakeholders Program Sustainability Using Data to Help and Physician Leadership to Effectively Manage the Service Line with Comprehensive, Actionable and Relevant Outcomes Data 8

MULTIFACETED MARKETING PROGRAM Program Display Board, Brochures, Patient Guidebook and Recovery Tracker, Website, Radio and TV OUTCOMES MARKETING Share with Key Stakeholders PCP Surgeon Payers - Community Patient Recovery Improved Quality of Life Low Complication Rate Discharge Disposition/Plan of Care Excellent Patient Experience SUMMARY: OUTPATIENT SURGERY CENTER, ANYWHERE USA LAUNCH APRIL 17, 2014 Metric Results: Q2 Feb 2015 Surgeons 4 participating surgeons Volume TKR: 13 THR: 18 Total case count YTD: 31 Two patients returned for the second side Total of 4 cases have been done in one day Discharge Home Health: 0 Outpatient PT: All Average LOS/Hours 9.1 hours NO OVERNIGHT STAYS Complications Readmissions Unplanned ED / Physician Visits Avg. Insurance Contract Price Average Contribution Margin Patient Satisfaction Around $25,000 $27,000 Almost 100% of payers on board ~ $11,000 $16,000 depending on payer I had surgery in the morning, went home on crutches four hours after the surgery and returned to work part time a week later. (Nick R.) 9

SUMMARY: OUTPATIENT SURGERY CENTER, ANYWHERE USA LAUNCH OCTOBER 17, 2014 Metric Results Surgeons Volume 15 participating surgeons thus far Completed Scheduled TKR THR Uni TSR Discharge Home Health: 45 Outpatient: 1 Average LOS / Hours 2359: 31 >8 hrs.: 15 Complications Readmissions Unplanned ED / Physician Visits 20 7 12 3 13 3 1 Avg. Insurance Contract Prices Avg. Contribution Margin Surgeon Satisfaction Pending Pending It couldn t have gone any smoother I want to bring all my patients here. Stats: 12/1/14 LESSONS LEARNED Physician Leadership/Staff Teamwork/Administrative Support Necessary for Effective Change and Sustainability A Program vs. Providing the Service Care by Experts with Standardization and Best Practices Better, Faster, Less Costly, More Compassionate Predictable Outcomes, Reduced Complications Develop one day discharge standard in-patient before out-patient Consider initiating program with Uni-Knee patients Reduced Variability Care Systems Shortens The Time To Expertise Efficiency-Surgeon skills in operating room (less than 2 hour cut to close time) Safety Cost Effective Transparency with Data Leads To Continuous Improvements Creates Trust Between Surgeons, Staff and Administration Create the WOW Factor Word of Mouth Thank You! Contact Information Derick Elliott VP Sales and Marketing derick.elliott@stryker.com www.strykerperformancesolutions.com 10

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