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Navigate Effectively through Medicare’s New CJR Program (Part 2)

November 16, 2016
by Debra Mathias, consultant, Freed Associates
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Freed Associates' Debra Mathias discusses the value of reviewing CJR data and metrics
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This is part two of a two-part series on successfully navigating through the new Comprehensive Care for Joint Replacement (CJR) model. In part one, which was published November 10th, Debra Mathias, a consultant with Freed Associates, discussed internal steps for hospitals to take. In part two, Mathias explores the role of post-acute care (PAC) networks in the new CJR model, and the value of reviewing CJR data and metrics.

Determine PAC Networks

Hospitals, either independently or using an external consultant, need to develop a high-quality preferred post-acute care (PAC) network to which they can discharge high-risk CJR patients. The PAC must, per CMS, have a minimum 3-star rating or reimbursement will be negatively impacted.

By developing a PAC preferred provider network based on objective criteria and supported by collaborative agreements, hospitals can more readily create effective two-way communication between their care coordinators and PAC teams. Two-way communication is critical to managing post-acute care problems rapidly and efficiently. Keep in mind that patient participation in CJR is voluntary, and fee-for-service (FFS) Medicare patients can select a PAC provider that is not on the acute providers’ preferred list. The challenge is when patients want to select a PAC organization with less than a 3-star rating.

Debra Mathias

 

Recommendations to successfully maximize PAC network relationships include:

  1. Develop multidisciplinary work groups, including physicians, to create aligned preoperative (pre-habilitation, joint camp support or a similar program), acute stay and discharge care guidelines. The acute care facility’s existing lower extremity joint replacement (LEJR) guidelines should include documentation of a functional assessment score, identification of high-risk patients, and hand-off and/or post-discharge care management policies for patients who are discharged to a PAC.
  2. Identify senior leader and medical staff champions to lead the bundled payment initiatives (CJR, cardiac, etc.). These leaders are responsible for the overall success of the shift toward managing care in the acute and post-acute care environments, as well as for communicating regularly with staff, providers and clinical leaders.
  3. Create standard protocols for educating and communicating with CJR patients, prior to surgery and while they are an inpatient, as well as upon discharge, in order to gain better patient cooperation and compliance.
  4. Utilize evidence-based practices, such as functional assessments, to support first PAC placement recommendations (as these have a significant impact on episode costs).
  5. Assess the hospital’s ability to manage patients in the PAC environment, including electronic, such as shared electronic medical record (EMR), etc., telephonic or on-site oversight, to ensure adherence to care plans.
  6. Develop a meaningful PAC scorecard that includes outcome and process measures. The scorecard should allow both the acute and post-acute provider to measure their performance against stated metrics.
  7. Use objective criteria to select preferred PAC network providers (published quality scores, adverse events, utilization data, staffing ratios and safety scores, etc.) and conduct on-site tours of each preferred provider.
  8. Formulate preferred PAC networks that include high-quality PAC providers including SNFs [skilled nursing facilities], home health agencies, and other providers (IRFs [inpatient rehabilitation facilities], etc.). Invite post-acute providers to a kick-off meeting and review your organization’s PAC strategy including the development of a preferred PAC provider network.
  9. Form cooperative agreements with preferred PAC providers to delineate shared goals and ensure that goals and two-way communication tools are in place (exchanging protected health information (PHI) requires that PAC providers adhere to HIPAA [Health Insurance Portability and Accountability Act of 1996] requirements). Develop and agree upon a PAC scorecard.
  10. Ensure PAC adherence to post-acute care plans as part of the cooperative agreement, which includes the PAC reporting any variance from care plans to the acute provider.
  11. Develop PAC patient monitoring tools and processes, such as an integrated EMR tool that provides a concise discharge summary that can be sent to the PAC provider, a universal transfer form, and/or patient tracking software.

Acute care providers, except for those that have already been involved in CMS’ bundled payment programs or other risk-bearing arrangements, generally have not created internal competencies for managing patients throughout the 90-day post-discharge period. Under CJR, acute providers are responsible for the entire episode, including all PAC costs, quality outcomes and patient satisfaction results. Developing the skills, expertise, and care model takes time and adds complexity to the acute providers’ delivery model.

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