Business Balance
7th Aug

On July 9th, CMS proposed The Comprehensive Care for Joint Replacement payment model to hold hospitals accountable for the quality of care they deliver to Medicare fee-for-service beneficiaries for hip and knee replacements from surgery through recovery. These bundled payments for joint replacement surgeries would build upon successful demonstration programs already underway in Medicare. This model is also consistent with the private sector, where major employers and leading providers and care systems are moving towards bundled payments for orthopedic services.

Depending on the hospital’s quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs. As a result, hospitals would have an incentive to work with physicians, home health agencies, and nursing facilities to make sure beneficiaries get the coordinated care they need, with the goal of reducing avoidable hospitalizations and complications. Hospitals would receive tools – such as spending and utilization data and sharing of best practices – to improve the effectiveness of care coordination. 

If providers are to survive — and prosper — they will need to make some changes. First, they need to understand the new reimbursement system that is coming but also prepare themselves to deliver quality care at a lower cost.

Most will agree that lower cost means shortened lengths of stay and decreased hospital readmission rates. But how is quality care being measured? The challenge for the skilled nursing facility is to balance the cost reduction expectations related to a shortened length of stay with quality care outcomes particularly in an initiative where the three-day hospital stay requirement is being waived. 

The “Provider of Choice” will be the one with the most success related to coordination of skilled nursing and skilled rehabilitation. services. One hospital in one of our client markets has indicated that they are going to want to transfer orthopedic services to the skilled nursing facility on day one of the inpatient stay and that the expectation is a 10-11 day length of stay and then discharge with no outpatient therapy required. While that may be an extreme example I believe several care areas need to be evaluated for a skilled nursing facility to partner with providers in a bundled payment initiative.

First, rehabilitation will need to be aggressive and begin on day one of admission and may need to be done in twice a day sessions.  Therapy will need to work closely with the interdisciplinary team to carefully set discharge goals on day one of the patient stay and then set goals for discharge outcomes that correlate to the discharge setting and additional services that the resident may receive. So it may not be realistic that a patient can leave the skilled nursing facility in 10 days and be totally independent if they are going to be discharged with home health and outpatient therapy. Unrealistic setting of therapy outcome goals could give the appearance of not meeting discharge goal outcomes.

Secondly, nursing staff must prepare for receiving the patient in the skilled nursing facility setting most likely on the second day after surgery. Nurses will need to demonstrate competency in pain management and dealing with the side effects of the pain medications delivered. They will also need to be well versed in post-operative complications and be able to identify warning signals as well as have processes in place to deal with complications in the skilled nursing facility unless the complication is emergent in nature. There will also need to be a plan in place to deal with nutritional needs of the post-op patient.

Finally, care coordination will be the key to success. It is becoming more and more a “norm” to see that skilled nursing facilities are creating positions and hiring case/care managers or nurse navigators. There needs to be a “watchdog” that not only monitors and ensures financial efficiencies of the episode of care but also ensures that the resident quality and care outcomes are not overlooked in this evolution of care delivery that is quickly descending upon us.

Sheila Capitosti

VP of Clinical and Compliance Services


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