EXECUTIVE SUMMARY

Vanderbilt University Medical Center’s first bundled payment program for cardiac valve replacement and valve repair surgery patients was so successful that the medical center added total joint replacement and stroke to its bundles.

  • A multidisciplinary team, led by nursing, physician, and business leadership, looked for areas of opportunity and set up work groups for each component of the program.
  • The team designed a care coordination program and the hospital hired two care coordinators who follow the patients from the pre-surgical educational session through post-acute care.
  • To meet the goal of reducing overutilization of post-acute facilities, the team created “prehab,” a pre-surgical physical therapy program for patients who need it, and everyone who comes in contact with the patients educates them to expect a discharge to home.

After Vanderbilt University Medical Center began a bundled payment project for patients who had cardiac valve replacement or valve repair surgery, readmissions for those patients dropped by 20% and the cost of care decreased at the same time.

“We still struggle with long lengths of stay in some skilled nursing facilities. The medical center doesn’t own any skilled nursing facilities, but we are collaborating with the post-acute providers in the community to work on reducing the stays,” says Brittany Cunningham, MSN, RN, CSSBB, director of episodes of care for the 1,000-bed medical center in Nashville, TN.

Vanderbilt went live with its first bundled payment arrangement for cardiac valve replacement and repair surgery under the CMS Bundled Payments for Care Improvement model in 2014. After the success of that model, the health system added total joint replacement and stroke to its bundled payments arrangements. The health system was chosen to participate in Medicare’s oncology care model program announced by CMS in June. (For more on the oncology care model, see related article in this issue.)

The medical center is participating in a total of 11 programs that base payment on episodes of care. In addition to the CMS programs, Vanderbilt University Medical Center participates in Tennessee’s Medicaid program that determines payment by reconciling actual costs with a threshold and sharing the savings with providers. Tennessee Medicaid announced the program in 2013 for selected diagnoses and rolled it out in 2015.

The health system leadership chose cardiac valve replacement and repair as the first bundle in the Medicare Bundled Payments for Care Improvement because the department had a strong leadership team, which put them in a good position to test the bundled payment model, Cunningham says.

“The hospital leadership told us that they felt that CMS and other payers were moving toward alternative payment models and it was in our best interest to start testing the model early on,” she adds.

The cardiac center created a multidisciplinary team led by the nursing leadership, the physician leadership, and the business leadership in the department to choose a DRG and to design the program.

“When we looked at the data, we saw there wasn’t much variation between the patients having a valve replaced or those undergoing valve repair, and the opportunities for improvement were similar for all DRGs,” she says.

The team identified the areas for opportunities, such as reducing readmissions, improving patient education, and adding a care coordination component, and created work groups for each one made up of disciplines that are knowledgeable about, and would be affected by, the changes.

For instance, the work group responsible for creating and implementing a pathway for valve patients was made up of a nurse practitioner, physicians, nurses, and pharmacists.

The team outlined a new care coordination process for patients covered by the bundled payment arrangement and hired two new care coordinators to implement it.

Vanderbilt doesn’t have dedicated care coordinators in every area, Cunningham says. “We feel that care coordination can be done by everyone in the clinical team,” she says.

However, since the bundle covers an episode of care that lasts 90 days, the team felt that the program needed someone to follow the patients over a long period of time, she adds.

“Care coordination was the only new resource we put into place. When we looked at other components of the program, we determined that we just needed to change the way things were done,” she says.

For instance, the team added a mandatory patient education program so patients are prepared for the surgery and the recovery period. The class includes instructions on what to expect the day of surgery, during the hospital stay, and after discharge.

The care coordinators meet the patient for the first time when they attend the education session and complete a detailed assessment of the patient’s home situation, support system, and psychosocial needs at that time. “This allows us to start the discharge plan up front, before the patient comes in the door for surgery,” she says.

The care coordinator gives the patients a checklist of what they should do before surgery, at the time of discharge, and when they go home.

The care coordinators alert the inpatient team to any psychosocial issues and any barriers to being discharged to home so they will be aware of the problems early in the stay. They work with the social worker on the unit to create a discharge plan.

The care coordinators follow up with patients within 72 hours of discharge and call them a minimum of twice in the weeks following discharge. Most patients receive three or four follow-up calls, Cunningham says.

The team created a follow-up tool that includes questions the care coordinators should ask and allows them to track trends. For instance, if the care coordinator asks about the patient’s blood pressure, the electronic tool shows the previous blood pressure readings.

“If the care coordinators are concerned about anything, they work with the nurse practitioner to get the patient back to the clinic. They have had great success in keeping patients out of the emergency department and avoiding readmissions,” Cunningham says.

The team created a Stop Light tool that divides signs and symptoms patients may experience into “green,” “yellow,” and “red” categories and lists what steps the patient should take if his or her symptoms fall into one of the categories. Patients also are asked to wear a rubberized armband with a phone number they can call 24 hours a day if they have questions or concerns.

Following the success of the cardiac valve surgery program, the medical center replicated the process for the total joint replacement and stroke bundled payments arrangements and adapted the process to meet the needs of those patients, Cunningham says.

Before starting the total joint replacement program, a multidisciplinary team analyzed data from CMS and determined that to be successful, the hospital had to reduce overutilization of post-acute facilities for total joint replacement patients. “We had to make sure we were sending patients to the right place at the right time, and that meant we had to cut down on the practice of routinely sending patients to a skilled nursing facility for more rehabilitation and to set the right expectations for patients and family members about the discharge destination,” Cunningham says.

The care coordinators began informing patients that they should expect to be discharged to home during the presurgical education classes.

“Instead of discussing the possibility of a skilled nursing stay, we talk about a discharge home and educate them on what kind of care they will need when they get home,” she says.

Everyone who comes in contact with the patient talks about the discharge to home, she adds. “It hasn’t eliminate skilled nursing stays for every patient. We still have some who need to go to a post-acute facility, but we have dramatically increased the number of patients who are discharged to home,” she says.

Patients undergoing joint replacement surgery are required to attend an educational class led by the care coordinators before surgery. If they don’t attend the class, their surgery is postponed until the education is completed.

The joint team has started what they call “prehab,” a program in which appropriate patients have one or two outpatient physical therapy sessions before their surgery.

When patients see the surgeon for a preoperative consultation, the surgeon decides if the patient needs “prehab” or if the educational class will be sufficient.