Earlier this week we published our experience implementing a bundled payment program for total hip replacement (1). We worked with an independent group of orthopedic surgeons, an acute care hospital, a home health agency, and a small group of skilled nursing facilities on the program for patients in a regional commercial health plan. Two of the most notable findings were that quality of care improved while more patients were discharged home. The latter finding was associated with lower post-hospital costs. Here I’d like to describe some of the major factors in achieving these results. In future posts, I’ll discuss other features of the program and talk about some challenges that remain.
Physician leadership and coordinated messaging with case management
Two surgeons were model physician champions, taking full ownership for the program’s success, ensuring that expectations for a home discharge were conveyed to patients, and seeing to it that quality of care for the full episode was maintained. Another facet of physician leadership was that they coordinated the key messages for patients in the program with the hospital case managers, who echoed physician expectations for a home discharge whenever possible.
A clearly articulated model of care throughout the episode
The clinical team designing the care episode, led by an orthopedic surgeon with substantial input from nursing, physical therapy, a joint replacement program coordinator, and the finance department, developed a clear model of care interventions for the episode. The pathway encompassed pre-operative assessment and preparation, in hospital care, and type, duration and frequency of post-hospital services. For example, for patients discharged home after a 2 day hospital stay, the care model called for 8 home physical therapy visits; for a 3 day hospital stay, 6 home physical therapy visits. If patients went to a skilled nursing facility, a 6 day length of stay with functional goals for mobility was prescribed; if further therapy was needed to achieve prior level of function, 3-4 home physicial therapy visits were delivered. The goal of a home discharge was stated and reinforced from the initial preoperative assessment through the time of hospital discharge.
A small group of aligned skilled nursing facilities
The program worked with only three SNFs, and of these, a single facility cared for most patients who needed SNF care. There was an engaged SNF physical therapy leader, who ensured 7 day a week services and expedited discharge home when patients met their functional goals.