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.
- 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.
Please contact Abeer Yassine at email@example.com or Deb Evans at firstname.lastname@example.org for more information and if you have any questions.
Dr. Recchia is Chief of Cardiology at Munson Medical Center
Some goals of the MVC Hospital Engagement team are to help hospitals reduce Heart Failure (HF) readmission rates along with improving patient care and quality in order to have Michigan become a leader in this domain. The Hospital Engagement team has been locating and speaking to hospitals nationwide with the lowest HF-related readmissions. One hospital, Munson Medical Center, falls in the top 1% of hospital readmissions and is located right in Michigan. Munson is on the forefront of using coordination of care to reduce readmissions. The Hospital Engagement team had the opportunity to speak to Dr. Recchia, Sheila Falk, and Anne Bacon about the HF Clinic at Munson Medical Center, which has helped better manage patients and improve readmission outcomes among their sickest patients.
The clinic was the shared vision of Dr. Recchia and Sheila Falk who began planning the program in 2010. They identified gaps in the care of many heart failure patients which was resulting in high rates of readmissions and sub-optimal quality of life. They also saw the growing role of LVADs in the management of end stage heart failure which presented difficulties for LVAD patients in northern Michigan who lived many hours away from an LVAD center. A similar situation existed for patients with pulmonary hypertension. They approached the Munson Foundation with a plan to establish a multidisciplinary heart failure program to address the needs of this difficult patient population. With seed monies from the Foundation, the Munson Heart Failure Clinic was established in 2011.
The clinic has grown dramatically over the last 5 years now involving a heart failure cardiologist, special heart failure nurse practitioner, 3 dedicated nurses, and 2 support staff. 90% of the referrals to the program come from Dr. Recchia’s partners and involve cases that are too complex to manage in a general cardiology practice. Once the patient is referred, care is taken over completely by the Heart Failure clinic with no co-managing between cardiologists. Patients referred to the HF Clinic begin care management the day they are discharged. Inpatients are seen and educated by the nurse prior to discharge as the team found that the time between discharge and their first HF Clinic appointment is a very vulnerable time. The Munson team has also developed a “shared care” approach for patients with LVADs allowing these patients to be co-managed with their implanting LVAD centers downstate greatly reducing the frequency with which patients and their families have to drive long distances for a routine LVAD follow up appointment. The same approach is used for co-managing patients with pulmonary hypertension seen in those same institutions. Another unique feature of the HF Clinic at Munson Medical Center is the phone call strategy they employ. Instead of suggesting patients call the HF Clinic if something is wrong after a change in their treatment regimen is made, the HF Clinic team arranges a “phone call appointment” at a specific date and time to follow-up on the response to the treatment and facilitating further decision making. These patient management methods at the Munson Medical Center HF Clinic help better coordinate care and consequently improves patient experience and outcomes. Patients reap such benefits from being in the program that they often want to stay in the program even after they have improved enough to no longer need this level of care. Munson has also had great success integrating hospice care in to their program for those patients that have no further care options resulting in over 60% of the deaths in the program occurring in a hospice setting.
Outcomes and Measurement of Success
Readmission rates can be used as a measurement of success of a program geared towards improving patient care and costs. Munson took less than 2 years to measure the positive outcomes the clinic had on patient care and on readmission rates. Munson’s overall hospital readmission rate for heart failure is 18.6% down from 23% before the HF program was established. The national average for this metric is 22%. The patients followed by the HF Clinic are the most difficult heart failure cases with a predicted readmission rate based on clinical parameters of over 25% yet this subgroup had an overall readmission rate of only 12% which is a further testament to the success of the program. Moreover, Munson has used patient testimonials and resource usage to measure the downstream impact of the HF Clinic and shown benefactors the benefit of investing in a HF clinic.
Advice to Hospitals
Munson was able to provide great advice for hospitals seeking to begin a HF Clinic program. First and foremost, there has to be complete buy-in from the cardiologists where the specialty clinic takes over care for the patient so there is no confusion. Hospitals should structure a multi-disciplinary clinic where each member works to the full potential of their credentials. This ensures coordination of care among services and makes patients feel secure in their decision to use the HF Clinic services. This team is critical to ensuring that patients are receiving timely and quality care.
Dr. Recchia and the HF Clinic team are happy to talk to anyone interested in finding out more about the clinic at Munson. Please contact Deb Evans (email@example.com), Abeer Yassine (firstname.lastname@example.org), or Dr. Recchia (email@example.com) for more information.