EXECUTIVE SUMMARY

Recognizing that bundled payments were likely to be one way healthcare is reimbursed in the future, Sentara Healthcare in Norfolk, VA, began numerous bundled payment arrangements under the Bundled Payments for Care Improvement initiative so they could gain experience for the future.

  • An executive-level steering committee looked for opportunities for improvement and determined that the biggest gaps occur when patients transition from acute to post-acute care.
  • The health system contracted with an outside firm to manage its bundled payment program and to provide telephonic follow-up and case management during the post-acute period, and developed a systemwide steering committee to make sure the programs are in alignment with work flows, compliant with regulatory requirements, and to provide feedback on what is working and what isn’t.
  • Sentara started building relationships with post-acute providers four years ago by organizing the Sentara Hampton Roads Long-Term Care Council, which includes representatives from the hospital’s integrated care management department and post-acute providers in the Hampton Roads area, including those not affiliated with Sentara.

When CMS announced the Bundled Payments for Care Improvement initiative, Sentara Healthcare chose to participate in a big way and now has implemented bundled payments across 12 hospitals, covering 180-plus DRGs.

Sentara decided to take part in the initial voluntary bundled payment program to gain the experience and efficiency necessary to succeed in the future when bundled payments would become mandatory, says Teresa Gonzalvo, RN, BSN, MPH, CPHQ, ACM, vice president for care coordination for Sentara Healthcare, headquartered in Norfolk, VA.

“We wanted to stay ahead of the game. We know that eventually these programs won’t be voluntary and we wanted to start learning and identifying opportunities before that happened,” she says. (CMS began a mandatory bundled payment initiative for total joint replacement in 67 markets in April of this year.)

The health system started its program by creating an executive-level steering committee of key stakeholders including physician representatives, the vice president of integrated care management, and representatives from ancillary services, finance, long-term care, and home health.

When the committee analyzed data, it concluded that post-acute care had the greatest opportunity for care redesign and the biggest potential for savings. The committee determined that the biggest gaps occur when patients transition from acute to post-acute care. “Patients need to get their prescriptions filled, have their durable medical equipment delivered, and see their primary care provider for a follow-up visit. These need to be bundled together so all the things that are supposed to be done get done,” Gonzalvo says. The goal is for Sentara’s pharmacy program, durable medical equipment vendor, home care program, and other post-acute services to work together to provide a seamless transition for the patient.

The team looked at the volume and cost of DRGs and the opportunities for improvement to prioritize the DRGs for the bundled payment. Among the conditions they chose were total joint replacement, spinal surgery, congestive heart failure, acute myocardial infarction, sepsis, pneumonia, gastrointestinal bleed, and esophagitic obstruction.

“We looked at the opportunities within our system, beginning with the acute care stay as well as home care and other post-acute options. We looked at it from a cost savings standpoint, but we also looked at care across the continuum and how to increase quality of care and patient safety. Bundled payments are not just about the cost containment and payment; our goal is to improve care and outcomes for our patients,” Gonzalvo says.

The initiative focuses on care management and how to optimize the function of care managers to best manage the stay of patients.

The health system partnered with an outside firm to manage its bundled payment program and to provide telephonic follow-up and case management during the post-acute period. A systemwide steering committee works with the firm to make sure the programs are in alignment with work flows, compliant with regulatory requirements, and to provide feedback on what is working and what isn’t.

When the care managers conduct the initial assessment after admission, they inform the patient and family members that they have been identified as a patient in the bundle. Care managers educate them about the program and alert them to expect follow-up calls from a care coordinator at the outside firm who will follow them for 90 days, provide education, answer questions or concerns, and collect the data needed to assess performance closer to real time instead of waiting for lagging claims data from CMS.

To make the program more efficient for case managers who are already busy, the health system added a component to its case management software that creates an additional column on the care managers’ work list that identifies patients covered by the bundle. Every morning, the analyst from the vendor sends the administrative assistant in each hospital in the system a list of patients in the bundled payment program. The assistant tags them manually in the system.

During daily multidisciplinary rounds, the care manager identifies the patients in the bundled payment program and works with the team to determine the next level of care. “By having this discussion take place during rounds, we make sure everybody is on board,” Gonzalvo says.

If the discharge plan calls for a skilled nursing admission, the goal is for patients who are covered by a bundled payment program to go to a “partnering” facility that can meet their needs, and has a good quality and patient safety record and the commitment to work with the hospitals to achieve program goals, Gonzalvo says.

Sentara’s involvement with patients continues after they are transitioned from acute care, Gonzalvo says.

Representatives from Sentara participate in multidisciplinary rounds at skilled nursing facilities and home health providers owned by the company. The manager of care management at one hospital talks daily to the director of nursing at one of Sentara’s Life Care facilities. “They have a conference call about patients who have been readmitted and what could have been done differently to prevent an unnecessary readmission. We have a pilot to replicate some of their suggestions to determine what is ideal for patients if they are readmitted, starting with our own facilities,” Gonzalvo says.

There is another team working on a plan to have providers from the hospital on site at the skilled nursing facility every day and seeing patients on the day of admission. “Depending on the patient’s clinical needs, we plan to have a mid-level provider or physician rounding daily at the skilled nursing facility for the first week. Data has shown that the first 72 hours at a skilled nursing facility is a critical time. We want to closely manage the patients and make sure the transition is successful,” she says.

Sentara started building relationships with post-acute providers by organizing the Sentara Hampton Roads Long-Term Care Council four years ago. The council includes representatives from the hospital’s integrated care management department and post-acute providers including skilled nursing facilities and long-term acute care hospitals in the Hampton Roads area, including those not affiliated with Sentara. The council has about 40 members and meets every other month for educational updates and to brainstorm ways to facilitate smooth transitions.

The purpose of the council is to facilitate the transition of patients from Sentara acute care to long-term care facilities and back to acute care when appropriate and to effectively communicate clinical information as patients transition, Gonzalvo says.

The Long-Term Care Council has a readmissions subgroup, chaired by Sarah Clark, RN-BC, MHA/INF, BSN, CCM, manager of integrated care management education, that includes facilities that are interested in sharing data. The group created a regional dashboard that will be used to share information on readmissions and how facilities handle potential readmissions. The team also analyzes specific patient readmissions, root causes, lessons learned, and opportunities for improvement.