Creating a bundled payments program is like building an airplane while it’s flying, reports Brittany Cunningham, MSN, RN, CSSBB, director of episodes of care for Vanderbilt Medical Center in Nashville, TN.

CMS has given providers only a short time frame in which to go live with their bundled payments programs — which makes it difficult for providers, adds Cunningham, who has spearheaded the medical center’s bundled payments initiatives. “To be successful with bundled payments requires a culture change. It takes at least 18 to 24 months to get everything in place, and that’s why it’s so hard,” she says.

Cunningham advises hospitals that have not yet begun bundled payment programs to prepare by creating initiatives to decrease variation and increase efficiency.

“This will serve hospitals well when they participate in bundled payments, and it’s what providers should be doing anyway to improve care for the patient and the bottom line,” she says.

The frontline staff, including physicians, should be involved in development of a bundled payment program. Get their input in creating the program, and make sure they buy into the changes, Cunningham says.

Succeeding under a bundled payment arrangement requires a change in culture, says Teresa Gonzalvo, RN, BSN, MPH, CPHQ, ACM, vice president for care coordination for Sentara Healthcare, with headquarters in Norfolk, VA. (For more on Sentara’s bundled payment initiatives, see related article in this issue.)

“Change is never easy. The entire healthcare team, including the physicians, care managers, and post-acute facilities, have to change the way we do things,” she says.

“Our primary focus is the continuum of care. The first step for providers is to drop the word ‘discharge’ from their vocabulary,” she says. “We should never ‘discharge’ patients because that indicates the end of care. We should transition them to the next level of care and make sure their care is consistent as they move from one level of care to another.”

Hospitals have a lot of work to do to succeed under bundled payments, says John W. Malone, MOD, vice president at Novia Strategies, a national healthcare consulting firm.

“They have to develop relationships and establish dialogue with providers in the community. They also have to develop metrics and measurement systems, come up with protocols for every step of the episode of care, and understand what drives costs across the continuum,” he says.

Case managers can prepare for future bundled payment programs by analyzing the variability in patient outcomes and cost of care and identifying opportunities for improvement. Work on building care pathways that extend to the post-acute environment, and on ways to coordinate care more effectively, adds Graham A. Brown, MPH, CRC, vice president and practice lead for population health and bundled payments for GE Healthcare Camden Group.

Case managers have gotten very good at triaging patients to any willing post-acute care provider and getting them out of the hospital as quickly as possible. Instead of looking at the cost of care, their emphasis has been on utilization review and discharge planning, says Donna Hopkins, MS, RN, CMAC, vice president at Novia Strategies. “Now, they have to shift to a totally different way of thinking and use their sphere of influence to assess the most appropriate and cost-effective setting for post-acute care,” she adds.

Hospitals need to develop a cost-accounting system and determine how the variability in treatment affects cost and outcomes, Brown adds.

Post-acute care is uncharted and where most of the opportunity for savings must occur. This means that in addition to getting patients in the right post-acute setting based on the agreements the hospital made with post-acute providers, case managers are going to have to evaluate the cost of each option and influence provider practice to order the most economical one, Hopkins says.

For instance, it may be more cost-effective to keep a patient in acute care a few extra days and discharge him or her to home with home health, rather than discharging to a post-acute facility. “Emerging navigator roles follow the patient’s plan of care into the post-acute setting until the episode has ended,” she says.

“Every patient has their own algebraic formula taking into account their conditions, their payer, their home environment, whether or not they have a caretaker, and other factors that could affect their transition post-discharge,” Hopkins says. She predicts that assessing the home environment and the availability of a caretaker will take on more importance as “why not home?” becomes the mantra of providers.

Hospitals need to initiate internal reviews to determine the opportunities to refine their processes, Brown says.

Break down the episode of care into key elements and determine where the variability lies. For instance, look at preparations in advance of the surgery. Is there an educational session so patients are prepared before surgery on what to expect during the recovery period? Does the case manager make sure patients have caregivers to help them after surgery? Do patients understand the purpose of therapy and rehabilitation?

“Hospitals need a standardized tool that incorporates best practices and leads to consistency across all surgeries,” Brown says. For instance, in the total joint bundled payments program, hospitals should work with the surgeons to standardize the types of implants used in joint replacement and use quick-recovery anesthesia so patients can be mobile soon after surgery, which leads to better clinical outcomes, he says.

Hospitals also need a tool to track patients throughout the entire episode of care, beginning with the day they are scheduled for surgery and until the 90-day episode is over, Brown says.

“Case managers in the acute care setting need to have the ability to manage care before surgery and at the point of admission and to coordinate with post-acute providers so they know what happens to the patient during the entire 90-day cycle,” he adds.

Once the patient has made the decision to have the surgery and the surgeon has set a date, case managers or navigators should begin to engage and prepare patients for what will happen prior to surgery, the day of surgery, each day of their stay, and their potential post-discharge destination, Hopkins says. “Personalized follow-up will need to occur, via a registry process and pathways into the continuum,” she adds.

A huge challenge is coordinating follow-up after an acute stay, Hopkins says. “Often, patients get post-discharge calls from the staff nurse, the transition case manager or navigator, the insurance case manager, or even a third-party transitions agency. There are too many people following up and it’s confusing to the patients,” she says.

“There is a lot of redundancy in healthcare and organizations need to reduce it. Decreasing fragmentation and improving handoffs at transitions is the essence and is fundamental to the goals of the bundled payments initiatives,” she says.