1. Medicare Comprehensive Care for Joint Replacement (CJR)
Program Years: April 1, CY 2020 1

2. Project Origination
Medicare
Health System
Care Site
Service Line

3. Summary
What? Bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery [90 days post discharge] (CMS 2015)
In Scope:
Major Joint Replacement (Hip/Knee/Ankle)with or without major complications
Payer: Traditional Medicare 3

4. Goals Meet or be below Episode target price
Patients readmitted and/or that go to Skilled Nursing Facility fall above target price
Cost per episode
Anticipated Target $
(Set by Medicare)
Other measures tied to amount of reimbursement or risk of penalty:
-complications -global health
-patient satisfaction -outcomes 4

5. Pre-operative During Hospital Stay Post-discharge Stakeholders
Patients/Families
Physicians
Registration
Schedulers
Dr. Office staff
Pre-admission testing
Physical therapy
Care Management
EMR Builders
Patients/Families
Physicians
Registration
Pre-op
Operating Room
Anesthesia RN
Recovery Room
Physical therapy
Care Management
Nurse Practitioner
Patients/Families
Physicians RN
Pharmacy
Home Health
Facilities (LTAC, SNF, rehab)
Navigator
Care Management
Nurse Practitioner

6. Post-Acute Management
Workflow impact
CCJR PHASE I
Preoperative
During Hospital Stay
Post-Acute Management
Beneficiary Notification at Registration
Therapy Work flow changes
Followup with patient within 48 hours regardless of discharge location
Process for collecting PRO
Communication plan for Plan of Care and high risk support
Work with SNF upon admit for medical necessity POC, 8-10 days
Prehab order sets for surgeons
Pain management resource and reinforcement
Virtual visits test
Preop risk Assessment
Outreach to PCP re: dc plan of care
Transition of Care Council-1st mtg with SNFs Feb 10th
Scheduling for Joint Camp and Preadmission testing
Establish community MD owner of 90 day orders
Transition of Care Council-1st mtg with HH (HOLD)
"Home First" one page in Surgeon's offices
DME Delivered prior to patient leaving the hospital
Hospital TOCs in March or April
"Home First" materials for Joint Class
Discharge checklist (f/u appt, pain, data collection)
SNF Quality Measure Dashboards
Pt developed home prep action plan
Establish and communicate "Plan B" on patient trying home first
SNF Readmission and Delays in Care Dashboards
Outreach to patients that don't attend Joint Camp to message home first and do risk assessment
Discharge criteria used by CM, therapy, Physicians
Overall Program Dashboard (system)
Preadmission testing communication pathway for "high risk" findings (no PCP, chronic medication)
Manage SNF & HH network on transfers
Set up PCP appointment for 7-10 days after expected DC
Risk stratify after DC and re-eval POC
Set up Plan B at SNF discharge
Readmission management

7. How did we get there?
Basic Lean Tools -SIPOC -Process Mapping -Waste identification -Value-added/Non-value Added/Non-value added but necessary -LOTs of Fishbone Diagrams -Visual Aides and tracking mechanisms -Key* Voice of the Customer

8. Implementation- Results
Met or below Target for the Year 1 implementation
Quality Metric requirements
Increased patient satisfaction
Workflows that enable flexibility when people are out of the office
Stronger relationships with whole Care Team

9. Lessons Learned Stakeholder Identification Voice of the Customer
Subject Matter Experts
Workflow that isn’t person-specific
Strong communication plans
Continuous improvement along the way
Build a foundation for additional work