1. CJR McLeod Regional Medical Center

3. “For the hospital CEO or CFO out there who says, ‘I’m doing really well in fee-for-service so I’m just going to stick with it and it’s going to be OK,’ eventually it will not be OK, and I actually predict it will not be OK in a much shorter time frame than they might imagine.”
Patrick Conway, MD,
Deputy Admin. and Leader of CMMI- CMS

5. 67
MSAs

6. What is CJR – Patient Inclusion?
Episodes are triggered by hospitalizations of eligible Medicare FFS beneficiaries discharged with diagnoses:
MS-DRG 469: Major joint replacement or reattachment of lower extremity with major complications or comorbidities
MS-DRG 470: Major joint replacement or reattachment of lower extremity without major complications or comorbidities
Episodes include:
Not a Single Payment Methodology
Hospitalization
90 days post-discharge
All Part A and Part B services, with
the exception of certain excluded
services that are clinically unrelated
to the episode
4 Target Prices (470/470F/469/469F)

7. Start By Understanding Our Data
CMS Provided Data on Continuum payments. CY 2012 & 2013
CY 2014 released in April
Separate files by service (acute/ SNF/HH/etc….)BKD Consultants
Reconciliation is Quarterly but episode is 90 days. Challenge

8. Based on 2013/2014 Medicare claims data, McLeod would have been responsible for 390 lower extremity joint replacement episodes.
DRG 470
374 episodes
DRG 469
16 episodes

10. First Discharge Location is KEY to final Payment
DRG 470

14. 79% 9%
12%
13%
18%
36%

15. Leakage?
The movement of a patient from the 1st Discharge to a higher (Unanticipated) level of care
DRG 470 = 18% Leakage
DRG 469 = 31% Leakage

19. AGE

20. What Are We Doing To Bend The Curve?

22. - Pre-Admission Testing - Medical Clearance - PreHab
Decision
Making
Pre-Operation
Acute Care
Post-Acute
- Community Education
- Contract
- Physician Guide
- Outcomes Guide
- Joint Academy
- RAPT Tool
- Pre-op Education
- Pre-Admission Testing
- Medical Clearance
- PreHab
- Standardized Order Sets
- Discharge Planning
- Multi- Disciplinary Rounds
- Discharge Instruction
- Home With Home Health
- Outpatient Rehabilitation
- SNF Report Card
- Follow-up with Surgeon
- Joint Reunion

23. Orthopedic & Spine Specialists
Decision Making
Pre-Admission Joint Academy
The patient has an appointment with an Orthopedic Surgeon
After all other options have been exhausted, the surgeon informs the patient that surgery may be an option.
The surgeon discusses the indications for surgery and tells the patient he/she may be a candidate.
Before a date for surgery is scheduled, the patient must attend a class titled “The Joint Academy”.

24. Orthopedic & Spine Specialists
Decision Making
Power Point Presentation for patients considering surgery
The presentation gives patients information to help them have realistic expectations to enable them to plan accordingly.
The Clinic covers:
Going home from hospital
Having someone, a Coach, to care for them at discharge
Participating willingly with both Occupational and Physical Therapy
Preparing their house for return home
Attending pre-op testing including “One Medical Passport”
Obtaining medical clearance
Attending the Total Joint Class

25. Orthopedic & Spine Specialists
Decision Making
RAPT Process

26. Orthopedic & Spine Specialists
- Results of the RAPT tool are sent to the surgeon.
- RAPT tool offers recommendations for the Surgeon to consider so the patient has the best surgical outcome.

27. Orthopedic & Spine Specialists
- Pre-op Education
- Pre-Admission Testing
- Medical Clearance
- PreHab
Pre-Operation

28. Orthopedic & Spine Specialists
Pre-Op Requirements
When patient is deemed ready for surgery, the surgeon’s office schedules the patient for surgery. Patient is given instructions about:
Phone interview which includes “One Medical Passport”
Pre-Admission testing visit which includes:
Pre-op labs
Pre-op x-rays
Physician consultation for Medical Clearance
Total Joint Class

29. Certification Performance Measure 1
Orthopedic & Spine Specialists
Certification Performance Measure 1
Pre-op Class Attendance (Goal 90%)

30. Pre-Operation Class Attendance
Orthopedic & Spine Specialists
Pre-Operation Class Attendance
Reconciling Surgery Schedule 1 week ahead to verify ALL patients have attended Total Joint Class
Patients who have not attended are contacted and given a choice of available classes prior to their surgery date
Feedback given to Surgeon on patients that do not attend
Any patient who does NOT attend class, receives a DVD and Patient Guide
Surgeons have recommended a no exception policy stating if a patient does not attend the Pre-op Joint Class, their surgery will be re-scheduled.

31. Orthopedic & Spine Specialists
Acute Care
- Standardized Order Sets
- Discharge Planning
- Multi- Disciplinary Rounds
-Discharge Instruction

32. Orthopedic & Spine Specialists

33. Certification Performance Measure 2
Orthopedic & Spine Specialists
Certification Performance Measure 2
Length Of Stay < 2.5 Days

34. Orthopedic & Spine Specialists
Performance Measure
Inpatient Satisfaction (PRC)

35. Orthopedic & Spine Specialists
Performance Measure
Inpatient Satisfaction (PRC)

36. Orthopedic & Spine Specialists
Performance Measure
Inpatient Satisfaction (PRC)

37. Post-op Pain Trends by Milestone Day
Orthopedic & Spine Specialists
Post-op Pain Trends by Milestone Day
Continuum

38. Orthopedic & Spine Specialists
Post-Acute
- Home With Home Health
- Outpatient Rehabilitation
- SNF Report Card
- Follow-up with Surgeon
Joint Coordinator
Telehealth

39. Post Acute Provider Improvement
Orthopedic & Spine Specialists
Post Acute Provider Improvement
Skilled Nursing Facilities
Post-Acute Provider Score Card Developed
Held Post-Acute Provider Summit
31 People
19 Facilities
Visited Facilities where surveys were returned
Identify Potential Preferred Providers

40. Skilled Nursing Provider Report Card
Orthopedic & Spine Specialists
Skilled Nursing Provider Report Card

41. Skilled Nursing Provider Report Card
Orthopedic & Spine Specialists
Skilled Nursing Provider Report Card

42. CMS Payment Estimator

43. Questions?