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.
- 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.
- 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.
- 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.
- 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.
- 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.