The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Author: Deby Evans (page 1 of 7)

Using Clinical Pillars to enhance value in a Joint Replacement Bundled Payment Program

Deby Evans

Deb Evans is the MVC Site Engagement Manager

An article published in the Journal of Arthroplasty in June 2017 discussed 5 clinical pillars that one hospital in New York identified for enhancing value in their joint replacement practices through the bundled payment program.

  1. Optimizing patient selection and comorbidities: The hospital identified common comorbidities within their Total Joint Arthroplasty (TJA) patient population. The most frequent were found to be musculoskeletal comorbidities, hypertension, hyperlipidemia, tobacco use and diabetes. Each of these comorbidities is associated with an increased risk for readmission. By incorporating the use of a readmission risk assessment tool (RRAT) into the Perioperative Orthopedic Surgical Home (POSH) initiative, the hospital identifies patients that are at high risk for readmission and delays surgery in favor of working to optimize the patient’s modifiable risk factors. By getting the patient in optimal condition for surgery, the risk of an unplanned readmission can be reduced, saving the hospital the associated costs.
  2. Optimizing care coordination, patient education, shared decision-making and patient expectations: Multiple studies have shown that splintered care pathways, unnecessary services and a lack of patient-centered care negatively impact clinical outcomes. Characteristics of programs that displayed improved patient outcomes were synchronized management among the patient’s care team and managing the expectations of the patient and family. The goal for this hospital was to institute a streamlined pathway for the duration of the episode of care that focused on collaborative decision making and standardized pathway criteria.
  3. Multimodal analgesia: An increased length of stay not only affects cost but also increases the risk of readmission. One of the factors known to influence length of stay is pain management. This facility reviewed their pain management protocol and made changes with the intention of decreasing opioid use while maintaining pain relief as well as facilitating early ambulation and rehabilitation and decreasing falls. These principles help to reduce length of stay by expediting discharge and decreasing the use of post-acute care facilities.
  4. Risk-stratified Venous Thromboembolic disease (VTED) prophylaxis: Use of an aggressive mode of VTED prophylaxis may be effective in preventing venous thrombosis, but has also shown to increase the risk of major complications. The institution performed a study to analyze their adapted risk-stratification algorithm with positive results. The use of this algorithm to identify which VTED prophylaxis trajectory was most appropriate helped the hospital optimize care and reduce costs.
  5. Minimize Post-acute care facility and resource utilization: Increased costs have been shown to be related to the use of post-acute care facilities and the associated resource utilization. In an effort to help control post-acute care costs, this institution worked on identifying selected post-acute care partners. Once identified the hospital and the partnering skilled nursing facility increased communication and collaboration through meetings and performance and resource utilization monitoring. By establishing these partnerships post-acute care length of stay was reduced with associated cost savings.

Through focusing on these five clinical pillars, this New York hospital was able to identify areas of improvement and subsequently implement initiatives targeted towards care and cost improvement. If your hospital is interested in identifying five clinical pillars of focus, the MVC Coordinating Center can help  identify common readmission diagnoses, along with post- acute care SNF utilization and length of stay information.

Moreover, the MVC Coordinating Center, in conjunction with MARCQI and MOPEN, is also holding workgroups on November 30th and December 7th to discuss pre- and post- surgical pain management. If you are interested in joining either of the workgroups, please register here.

Please contact Abeer Yassine at abeery@med.umich.edu or Deb Evans at debevans@med.umich.edu  for more information and if you have any questions.

Transitions of Care Enhanced by I-MPACT, a BCBSM CQI

Pam James

Pam James, MS is the I-MPACT Program Manager

The Integrated Michigan Patient Centered Alliance in Care Transitions Collaborative (I-MPACT) is a Blue Cross Blue Shield Value Partnership collaborative quality initiative (CQI) which was established in 2015 and formally launched with an inaugural kick-off for cohort one in April 2016. This CQI has several aspects that make its approach to quality improvement unique. Hospitals and physician organizations (PO) are required to partner with each other to better coordinate care and ultimately improve patient outcomes and experiences; that partnership is called a “cluster”. Another unique feature of I-MPACT is the incorporation of patient or caregiver advisors on each cluster team. These patient advisors are an integral part of the team and, to encourage continued participation and ensure the patient’s voice is heard, the clusters have to provide information to I-MPACT how the patients are integrated into and utilized on any projects or initiatives. Lastly, each cluster is evaluated as one entity for the Pay for Performance Index (P4P) to encourage collaboration, equity and inclusion between them. The entire cluster, both hospitals and POs, can earn additional dollars based on their cluster’s score on the P4P.

The ultimate goal for I-MPACT is to help improve care transitions for patients. I-MPACT strives to accomplish this goal by focusing on three key areas:

  1. Increasing the frequency with which patients are seen by a provider within 7 days of discharge,
  2. Working on reducing readmissions,
  3. Working on reducing Emergency Department visits.

I-MPACT currently has 20 hospital and PO clusters which are divided into 4 groups or cohorts. Data extraction centers around key documents in the care transition process including the discharge summary, patient summary/after visit summary and the admitting history and physical. The goal is to understand more about processes and communication during the care transition and gain a better understanding of where gaps and challenges are occurring.

I-MPACT focuses on five specific patient populations which were strategically chosen to align with other collaboratives and Center for Medicare & Medicaid Services (CMS) initiatives. The five conditions are:

  1. Acute Myocardial Infarction (AMI),
  2. Congestive Heart Failure (CHF),
  3. Pneumonia,
  4. Chronic Obstructive Pulmonary Disease (COPD),
  5. Patients transitioning from hospital to a skilled nursing facility (SNF).

I-MPACT helps their members understand the care transition process, especially from a patient perspective by performing an on-site observation of a patient’s discharge process and mapping the data gathered in a document called “the patient journey”.

Upon joining I-MPACT each new cluster, along with their patient advisors, attend a day long kick off where they work through mapping out a transition process, identifying gaps and challenges in their organizations’ care transitions and brain storming interventions aimed at addressing those gaps and challenges.

If you would like more information about I-MPACT check out their website at http://www.impactcqi.org/, contact Pamela James,  the Project Manager at  I-MPACTCC@med.umich.edu or contact the MVC Coordinating Center through Abeer Yassine (abeery@med.umich.edu ) or Deb Evans (debevans@med.umich.edu)

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