1. Bundle Payment Care Initiative Advanced Update
Heather Peiritsch MSN, RN Bundle Payment Program Manager
Abington Jefferson Health

2. Affordable Care Act (ACA)
Accountable Care Organizations (ACO
Hospital Readmissions Reduction Program
Bundled Payment Care Improvement (BPCI)
Bundled Payment Care Improvement Advanced (BPCI-A)
2012
2012
2012
2018
Provider led organization, takes on full responsibility for the overall cost and quality of care delivered to a defined patient population
Risk adjusted readmissions within 30 days of discharge:
AMI, CABG, COPD, Elective THA/TKA, HF, PN
Payments linked for multiple services beneficiaries receive during an episode of care.
Include financial and performance accountability
New iteration of bundled payments, align incentives for reducing expenditures and improving quality of care. Qualifies as an APM.
Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished. Research has shown that bundled payments can align incentives for providers – hospitals, post-acute care providers, physicians, and other practitioners – allowing them to work closely together across all specialties and settings.
2012: Accountable Care Organizations (ACO)
Integrated health systems
Linking payment to quality outcomes – shift healthcare payments away from fee-for-service toward value-based reimbursement
2012: Hospital Readmissions Reduction Program
Risk-adjusted readmissions within 30 days of discharge
Initially AMI, HF, PN, now expanded to include others
2014: Bundled Payment Care Improvement (BPCI)
Episodes of care bundled together – financial and performance accountability
example: Acute care admission plus 30/90 days post discharge
Focus on high-cost episodes
Precursor was HMO (1980’s) – unpopular; incentivized providers to limit services
According to CMS - BPCI models lead to higher quality and more coordinated care at a lower cost to Medicare – yep, that’s true – but higher cost to discharging organizations

3. Jefferson Hospitals Heart Failure and Sepsis
Abington ONLY—Stroke
Best Practice Protocols/Policies
Streamlining Education
Analytics
Preferred Providers
Nurse Navigation

4. The IHI Triple Aim Improve the health of the population
Reduce or control the per capita cost of care
Enhance the personal experience –quality, access and reliability
. In the current healthcare landscape, no one is held accountable for all three dimensions of the IHI Triple Aim. To optimize the health of a population, all three Triple Aim dimensions need to be addressed at the same time.

5. Navigation Program Goals
Cost
Readmission Reduction
SNF placement and SNF LOS
Patients will go to the safest, lowest level of care as soon as medically stable
Quality
Care Redesign
Patient satisfaction and Engagement
Patients will have a great hospital experience
Coordination
Acute and post-acute provider alignment
Patients will have excellent care coordination

6. Post Acute Partners

7. Benefits of a Post Acute Network
Patient-centered care
Development of new relationships amongst healthcare providers, homecare agencies and facilities
Decreased variation in care practices
Decreased 30 and 90-day readmission rates
Increased education and quality of care
ENHANCED COMMUNICATION
Application 2015

8. Networking a Pathway to Quality
Physician Practice
Patient
Coordination of Care
Zone Management Education
Specialized teams
Goals of Care
Readmission Review
Tele-monitoring
Practice Care Managers
Pharmacist
Behavioral Health Specialist
Health Coach
Social Work
Same day sick appointments
Advanced Care Planning
Monthly leadership meetings
Best Practice Guidelines
Weekly patient updates
Home Care
Inpatient Facilities

9. Advanced Care Planning

10. Quality Metrics for BPCI-A Heart Failure, Sepsis and Stroke
BPCIA Quality metric: Advance care planning
Quality Metrics for BPCI-A Heart Failure, Sepsis and Stroke
CMS has selected seven quality measures for the BPCI Advanced Model.
Two of them will be required for all Clinical Episodes.
The other five quality measures will only apply to select Clinical Episodes.
The two measures that apply to our Bundles are:
All-cause Hospital Readmission Measure (NQF #1789)
Advanced Care Plan* (NQF #0326) (QPP #47)

11. Advanced Care Plan (NQF #0326): Care Plan- Communication and Care Coordination Domain
Rationale: The patient’s wishes regarding medical treatment need to be established prior to incapacity.
Performance period: is 1 year- beginning 9 months prior to the initiating anchor stay/ hospitalization and ending day 90 of the bundled payment episode
Appropriate use: ALL healthcare settings (e.g., inpatient, nursing home, ambulatory) except the Emergency Department.
Physicians (MDs and DOs), nurse practitioners (NPs),and
physician assistants (PAs)
Provider can use these codes if they perform an initial service and a non-billing team member (e.g., registered nurse, social worker) helps deliver part of the service, with ongoing direct supervision and involvement of the billing provider.

12. Coding Summary CODE TYPE Measure Description 99497 CPT
BPCIA Quality metric: Advance care planning
CODE
TYPE
Measure
Description
99497
CPT
Advance Care Directive
Advance care planning including explanation and discussion of advance directives such as standard forms (with completion of such forms) when performed by the physician or other qualifying health care professional; first 30 minutes, face to face with the patient, family member(s), and/or surrogate. This services carries an eligible charge, and also a co-payment for the patient unless performed as part of the Annual Wellness Visit.
99498
Each additional 30 minutes (list separately in addition to code for primary procedure)
1123F
CPT II
Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record
1124F
Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

13. Readmissions

14. Providing Warm Handoffs
Nurse Navigator to Care Practice Manager
Nurse Navigator to Home Care Nurse
Facility Nurse to Nurse Navigator
Hospital Physician to Facility Physician
Hospital Nurse to Facility Nurse

15. Jefferson Health Educational Sessions (adopted from MLH thru the DVACO)
Goal: Implement a set of tools to optimize the care of residents with Heart Failure, COPD and Sepsis to improve outcomes and prevent hospital readmission.
Heart Failure/COPD Sepsis
HF/COPD Admission Order Sepsis Nurse and CNA education
HF/COPD Consent to treatment Stoplight tool education
HF/COPD nurse and CNA education SBAR tool for a change in condition
Stoplight tool education
SBAR tool for a change in condition

16. What YOU Can DO

19. BPCI Original October 2015-September 2018
Heart Failure
CMS Baseline: 57.6%
2016: 43.8%
2017: 43.8%
2018: 43.3%
Stroke
CMS Baseline: 31.5%
2016: 27.7%
2017: 28%
2018: 26.7%

20. Abington Residential Care (ARC) Group
Affiliated with Jefferson Medical Group
Team of Nurse Practitioners and Physicians delivering care to patients in their own home environment
Visit in the patient’s home
Lab work and Xray’s
Arrangement for Home Care services
Timely medication refills
Prevention of Readmissions