09 Mar Adopting — and Adapting — to the CJR Payment Model, Part I:
Before the Inpatient Stay
Sarika Aggarwal, MD, MHCM, Chief Medical Officer, SVP, Population Health, xG Health Solutions, March 4, 2016
Effective April 1, 2016, all hospitals paid under the inpatient prospective payment system (IPPS) for lower extremity joint replacement procedures (including hip and knee replacements) will be accountable for total cost and quality of care provided to Medicare fee-for-service beneficiaries. Of course, improved efficiencies, outcomes and patient experiences have long been a primary goal for hospitals. What’s different now?
Under the Centers for Medicare & Medicaid Services’ (CMS) final rule for the Comprehensive Care for Joint Replacement (CJR) payment model, hospitals will be held accountable for the costs and quality of care provided during the inpatient hospital stay — and for 90 days after discharge from the hospital (including a patient’s stay at a rehabilitation center or skilled nursing facility (SNF), and while recovering and rehabilitating at home). This window of accountability can be divided into four distinct periods:
- Pre-admission (or the ambulatory period)
- Surgical procedure and inpatient stay
- Post-acute care in a rehab center or SNF
- Home care and rehabilitation
For Hospitals, this final rule means that their responsibility for and financial risks related to patient care and cost-containment have increased exponentially, into areas that were not typically under their sphere of influence. Under former CMS payment models, hospitals were held accountable only for services provided during the pre-operative, operative and post-operative inpatient stay; today, the hospital must exercise greater control over the services provided by rehab facilities, visiting nurses, physical therapists and others.
Over several xGPulse blog posts, we will explore some of the issues facing hospitals, and identify tools and solutions that can help them achieve the goals of the CJR program. In Part 1, we will take a look at the pre-admission experience.
Before a candidate for joint replacement enters the hospital, a number of pre-existing factors, many of them longstanding, lifestyle-related issues, can affect the success of his or her joint-replacement procedure. These include:
- Smoking history
- Pre-existing and/or chronic medical conditions
- Cognitive and physical functional status
- Post-surgery quality of life goals and expectations
With this in mind, and in order for hospitals to succeed under CJR, they must take a broader view of population health. They must work closely with primary care physicians, orthopedic surgeons and other specialists long before the patient enters the hospital for the joint-replacement procedure. Together with the broader healthcare community, hospitals can improve overall population health and better identify those patients who are good candidates for joint replacement surgery. For those who are high-risk candidates, the hospital can work with physicians and other medical professionals to address and ameliorate pre-existing conditions so that the patient is better prepared for a procedure at some point in the future.
Drawing on more than 20 years of proven, Geisinger-developed solutions, xG Health offers a number of products, including ProvenCare, ProvenHealth Navigator and other tools, that have a demonstrated, positive impact on population health and can help your organization succeed under the CJR model.
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