The bundled payment arrangement at Abington-Jefferson Health in Abington, PA has improved communication between all members of the treatment team and eliminated silos between the inpatient and outpatient sides of the hospital, says Elissa Della Monica, RN, MSN, NE/BC, vice president for post-acute and case management services.

“The bundle arrangement has been the catalyst for rethinking patient care. In the past, the inpatient and outpatient teams communicated, but it was disjointed. Now the team works together,” Della Monica says.

The Centers for Medicare & Medicaid Services (CMS) launched the Bundled Payments for Care Improvement, a three-year pilot project, in 2013 as part of the move to base reimbursement on quality.

Abington-Jefferson Health’s first bundled payment arrangement, focusing on joint replacement patients, went live on April 1, 2015. In the first three months, 115 patients were covered by the bundle.

The health system chose to pilot Model 2, which covers all Medicare Part A and B services during the initial inpatient stay, plus the post-acute services for 90 days. Participating providers continue to be paid on a fee-for-service basis. At the end of the pilot, total Medicare payments will be compared to the benchmark for the specific DRG. If total Medicare payments are less than the benchmark, the hospital will realize the savings, less a 2% CMS administrative fee.

The project was designed by two teams: a clinical team and a care coordination team.

The clinical team was charged with redesigning inpatient care, developing care paths, and improving clinical outcomes. The team included nurses, physicians, physical therapists, the physician assistant for orthopedics, case managers, and social workers.

“One of the main objectives was to standardize the medical care patients were getting by working with the physicians to develop order sets. The key to success was getting a diverse group of orthopedic surgeons on the same page and in agreement about what care should look like,” says Leslie McGrath, MS, director of care coordination management and social work services for Abington-Jefferson Health.

The care coordination team looked at what should happen during the 90 days after discharge. The team included case managers, social workers, representatives from the hospital’s public relations and marketing department, the billing department, finance department, a home health agency, and skilled nursing facilities.

Their goal was to develop care paths and flow charts to show what happens with patients once they are discharged from the hospital.

“We designed the flow chart to start while the patient is still in the hospital so the nurse navigator could interface with the inpatient team. The protocols focus on the 90 days after discharge but cross over into the inpatient stay to facilitate communication between the inpatient and outpatient team and to improve transitions in care,” Della Monica says.

The care coordination team continues to meet weekly to discuss any issues and patient problems, McGrath says. Members of the inpatient team join the conference by telephone as needed. “That weekly call allows us to have a SWAT team approach to correcting problems because the various team members can take care of issues within their expertise,” McGraths says.

Partnerships with post-acute providers are essential for success in the bundled payment project, Della Monica says. Before the program began, the hospital sent requests for proposals to skilled nursing facilities in the community.

The team chose four nursing facilities to partner with based on their proposals, their quality outcomes, reports on the CMS Nursing Home Compare website, the Medicare STAR rating, and their readmissions data.

“It was not an easy decision. We chose the four facilities with outstanding outcomes and where our patients were often opting to go,” McGrath says.

Abington Home Care, the health system’s own home health agency, also participates in the program.

The hospital created the position of nurse navigator, an RN who acts as project manager, for the bundled payment initiative. The nurse navigator meets with patients while they are in the hospital, follows them for 90 days after discharge, and communicates with the inpatient team, including the physician assistant for orthopedics, case managers, and social workers, as well as the primary care physician and other staff as needed, Della Monica says.

When patients are scheduled for joint replacement surgery, the nurse navigator calls them and makes sure they are progressing through the required preadmission testing. In addition, a physical therapist makes a pre-surgery visit, assesses the patient, and conducts a home assessment that is shared with the hospital case management department and nurse navigators. That way, the hospital case managers know the patient’s support system, the condition of the home, how many stairs the patient has to climb, contents of the cupboard and refrigerator, and other information they need to know to develop a discharge plan, she says.

“Having physical therapists see patients in their home environment helps us identify issues and deal with them ahead of time. We know what to expect and can deal with the entire continuum of care and start putting a safe and realistic discharge plan in place before the patient comes in,” McGrath says.

The therapist’s report goes to the navigator, the case management department, the orthopedic physician assistant, and the home care therapist. “If the physical therapists find major problems they send out an alert to everyone that this is a high-risk patient,” McGrath says.

The hospital case managers who will follow the patients while they are in the hospital meet with them during preadmission testing, educate them on what will happen during their hospital stay and after discharge, and discuss the anticipated discharge plans and what the patients will need to do after they get home.

“The goal is to discharge patients to home as much as possible. If that is not appropriate, the social worker helps them choose a post-discharge provider,” she says.

While patients are in the hospital, the nurse navigator makes daily phone calls to inpatient staff including nurses on the orthopedic unit, the physician assistant for orthopedics, case managers, and social workers. During the call, she discusses each patient on the unit, their discharge needs, and anticipated discharge date. The case managers and the nurse navigator collaborate on discharge plans to ensure a smooth hand-off, she says.

The orthopedic care plan calls for patients discharged to home to have a physical therapy visit within 24 hours of discharge and up to five home visits with a physical therapist in the first week, and the second week if needed, she says. Then patients typically are transitioned to outpatient therapy.

After patients are discharged, the nurse navigator calls them at least once a week, depending on their needs, for 90 days, she says. Patients who are stable and have gone back to work get bi-weekly phone calls. Some patients who need extra support may receive frequent calls until they stabilize.

If there is a problem, the nurse navigator contacts the physician and the clinical team in the hospital and alerts them to the issue. “She is constantly feeding information back to the inpatient side so we can rectify any problems,” Della Monica says.

Most problems occur within the first few weeks, she adds.

Among the problems the nurse navigator has uncovered is pain medicine was not ordered for patients in skilled nursing facilities, patients are on anticoagulants as prescribed by the surgeon and the nursing facility is also giving them nonsteroidal anti-inflammatory drugs, and patients have not ordered their compression stockings or can’t put them on.

“Medication issues sometimes are a problem. The nurse navigator conducts medication reconciliation, makes sure that patients understand their medication regimen, and that patients are on a bowel regime, especially if they are taking pain medications,” she says.

In one case, the patient reported excess draining from the incision and the nurse navigator was able to get him in to see a physician who changed the treatment plan and resolved the issue, she says.

When patients are transferred to a skilled nursing facility for rehabilitation, the nurse navigator coordinates the hand-off with the nursing facility staff and continues to follow the patients for 90 days, she says. A subcommittee of the care coordination team meets with the four providers on a weekly basis to discuss cases and resolve issues.

The bundled payment team is housed in Abington Home Care, making it easy for the nurse navigator to collaborate with home health providers, Della Monica says. She contacts other home care providers by telephone.

The team meets regularly to review data on patients in the bundle to track their progress and identify trends and opportunities for improvement, Della Monica says.

“We have created a template that we know what works and we can use it as we move into other bundles,” she adds.