Bundled Payments: Rigorous Focus on Quality and Patient Safety Will Improve Patient Outcomes and Ensure Financial Success

 Bundles / Financing 
 Team 

Agency
Penn Home Care & Hospice Services, Bala Cynwyd, Pennsylvania.

Agency Description:
Penn Home Care & Hospice Services consist of Penn Care at Home and Caring Way, both Medicare-certified and Joint Commission-accredited home health care agencies. The agencies offer the full range of home care services including skilled nursing, physical therapy, occupational therapy, speech therapy, social work services, and home health aides. Included in this entity is Wissahickon Hospice, a Medicare certified and Joint Commission-accredited hospice agency. Wissahickon Hospice also operates Penn Hospice at Rittenhouse, a 20-bed hospice inpatient unit used for short term symptom management and respite care.

Population Impacted:
Patients receiving a joint replacement at Penn Presbyterian Medical Center that are being discharged directly from the acute care setting to Penn Home Care & Hospice.

Project Description:
Home care plays a vital role in the orthopedic care pathway in reducing hospital length of stay, reducing readmissions, and improving health and function for patients that have undergone joint replacement surgery. This orthopedic care pathway was developed in response to the bundle payment initiative. This session will summarize the operations and clinical care associated with the orthopedic care pathway as well as the financial and quality metrics used to gauge its success.

Penn Medicine Orthopedics is regionally/nationally recognized for being highly skilled and highly specialized. The implementation of the lower major joint bundled payment initiative, prompted the orthopedic team at Penn Presbyterian and Penn Care at Home to strategically redesign our methods of care delivery across the care continuum. The goal for the project was to focus on improving the value of the care we provide by improving quality and patient safety, while reducing costs.

The project focused on all patients receiving a lower major joint replacement at Penn Presbyterian hospital. The project team set out to discharge more patients to home care services than to in-patient rehab. The research literature supports that an early return home, following a joint replacement, while the patient is supported by home care services, has a positive impact on patient satisfaction and improved patient outcomes. In order to do this, operational processes were put in place at Penn Presbyterian and Penn Home Care. These processes included preoperative discharge planning, a pre-operative social work assessment, referral placed to Penn Home Care & Hospice (for skilled nursing and therapies), and the scheduling of the first home care visit taking place prior to surgery.

Results:
The metrics used to track success were:
  • Number of patients discharged to home vs. inpatient rehab
  • Therapy and nursing response times
  • Knee ROM
  • Timed Up and Go Measurements (TUG)
  • Boston Activity Measure for Post-Acute Care (AM-PAC) measurements taken by PT and OT at evaluation, discharge.
  • Readmission rate
  • Number of home care visits by discipline
  • Net Revenue
  • MI
Outcome Measures:
The project started in November 2014 and is ongoing. More than 80 percent of the patients were seen in less than 24 hours (from the day of hospital discharge) by both the home care nurse and physical therapist. Improvements were seen in knee range of motion and TUG scores. Readmission rates were lower than the historical average for orthopedics at Penn Presbyterian. The cost of care was lower than the historical average for patients receiving a new joint at Penn Presbyterian. This project demonstrated how coordinating care across multiple entities can improve patient outcomes while reducing cost.
  • Home Care response times have improved so that more than 80 percent of the patients were seen in less than 24 hours, from the day of hospital discharge, by both the home care nurse and physical therapist.
  • TUG scores went from 41 seconds to 13 seconds
  • AMPAC scores
  • Basic: 46.45 - limited indoor mobility to 53.80 - moving around indoors
  • Daily activity:  52 - daily tasks a struggle to 64.09- getting  things done
  • Readmissions Reductions - Readmissions went from four percent to two percent resulting in estimated savings for the readmission reduction is $57,000, based upon the average cost per readmission of $15,000.
  • Utilization of Skilled Nursing Facility and Inpatient Rehabilitation Facility Usage
Barriers to Implementation:
  • Number of patients discharged to home vs. inpatient rehab
  • Therapy and nursing response times
  • Knee ROM
  • Timed Up and Go Measurements (TUG)
  • Boston Activity Measure for Post-Acute Care (AM-PAC) measurements taken by PT and OT at evaluation, discharge.
  • Readmission rate
  • Number of home care visits by discipline
  • Net Revenue
  • CMI