Bundled Payment Succe$$: Setting Expectations for Episode Alignment

Posted by Signature Care Management Team on Friday, July 29, 2016 in Blog

There is no silver bullet strategy to be successful in bundled payments. Signature Medical Group's (SMG) previous articles have discussed high level strategy encompassing preparation for bundled payments, the importance of data analytics, and more. Our insights are built on our experience as an Awardee Convener for nearly 60 orthopedic physician groups across the country for the Centers for Medicare and Medicaid Services (CMS) Bundled Payment for Care Improvement (BPCI) initiative. Jason McCormick is the Manager of Process Improvement at Campbell Clinic Orthopaedics in Germantown, TN, which is one of the orthopedic groups we work with directly as a Convener. Below he discusses Campbell's experience in BPCI and specifically addresses how they have managed expectations and the impact they have realized in their bundled payment initiative. Jason McCormick explains:

1. Setting Patient Expectations

Campbell Clinic decided to address patient expectations from the first moment a patient was a candidate for surgery, which was usually the first office visit. In Campbell's experience, when a patient goes into the hospital knowing the surgeon has already planned a 2-day inpatient stay, followed by a discharge home with outpatient physical therapy, the patient is less likely to use postoperative facilities the day after surgery. We found we could help prepare patients for surgery and reduce postoperative anxiety by setting the expectation for what would occur once they were discharged. To facilitate postoperative preparation, we required patients to participate in a pre-habilitation therapy session that educated patients on postoperative exercises that would help restore their range of motion and functionality. We also began setting expectations by asking patients to identify environmental needs they may have upon discharge, such as stairs or other obstacles that may prove problematic the first several days after surgery. The greatest expectation we addressed early with patients was the need for someone to be with the patient upon discharge. We communicated to patients the fact that socio-economic issues were not suitable reasons for a patient to utilize a post-acute care facility, so we needed to begin planning to have other options available. Once patients were aware of the expectation, they were more likely to have something in place weeks before surgery, such as a friend from church or their community that may be able to check in on them once a day.

2. Setting Physician Expectations

Campbell Clinic has five outpatient offices each in unique regions of a large urban city. When we originally began identifying ways to standardize the process for handling bundled payment patients, we quickly learned each physician had different expectations of how their patients would respond to their postoperative care plans. We also learned each physician's level of comfort in addressing patient expectations varied greatly. As most medical practice managers are aware, prior to BPCI, physicians had never been completely involved with patient care after the 3-day inpatient stay was over. In order to increase physician engagement in patient postoperative discharge plans, we utilized data reports to connect cost savings to the use of preferred post-acute care facilities. SMG provided a comprehensive review of our data and we discovered certain post-acute care facilities had high service utilization rates that were not medically necessary and inflated the overall cost of care. As a result, we set the expectation that physicians needed to be more involved in post-acute care decisions.

3. Setting Post-Acute Care Partner Expectations

Campbell Clinic sets expectations for post-acute care provider partners who care for our bundled payment patients. During our initial meetings with partners, we discuss our expectations, protocols, and required services. One of the most important expectations of post-acute care partners, regardless of service line, is the expectation for communication between the post-acute care provider and the Campbell Clinic case manager on a daily, weekly, and as-needed basis. If a provider was unwilling to agree to these expectations, our physicians identified different facility partners willing to meet our expectations and we subsequently suggested those facilities to our patients. Post-acute care facilities are expected to implement postoperative protocols established by Campbell Clinic surgeons. Our most successful strategies to ensure postoperative providers work with our expectations is we do not set rigid length-of-stay guidelines and we expect communication regarding patient progress. A rigid length of stay is not in the patient's best interest, and our experience has shown it is a barrier to having a successful relationship with post-acute care providers. Physicians set an initial estimated length of stay on a case-by-case basis. Then the post-acute care provider is expected to communicate with Campbell Clinic's case manager if the patient has not reached the desired functional level prior to discharge. Thank you Jason for your insights.

Communication Communication Communication

After 700 BPCI cases, Jason attributes the majority of Campbell's success to managing expectations. Everyone involved in an episode, including the patient, knows what to expect prior to a patient having the surgery. As a Convener for bundled payments, we agree on the importance of managing expectations and we worked in tandem with Campbell Clinic to identify key strategies to align providers and reduce costs. Setting and meeting expectations is an important strategy for bundled payment success whether in BPCI, the Comprehensive Care for Joint Replacement (CJR) model, or other bundled payment models. By the Signature Bundled Payment team and Jason McCormick, Manager of Process Improvement, Campbell Clinic Contact Signature at SignatureCareManagement.com for more information or assistance in working with bundled payments. Contact Jason at jmccormick@campbellclinic.com or connect with him on LinkedIn.

About the Author

For more information or assistance in working with bundled payments and value-based care, visit SignatureCareManagement.com.