Nuts and Bolts of Implementing a CJR Program – Panel Presentation and Discussion

Jennifer Blaha, MBACedars-Sinai

Nuts and Bolts of Implementing a CJR Program

Jennifer Blaha, MBAExecutive Director of Surgery & Orthopaedics

Cedars-Sinai Health SystemOctober 25, 2016

3

Current State Building a Team

Actions Taken The Future

Agenda

4

Cedars-Sinai: Leading the Quest

Established in 1902, Cedars‐Sinai is one of the largest not‐for‐profit medical centers in the western United States with 886 licensed beds

Major Training Center ‐More than 500 residents and fellows in graduate medical programs, with fellowships in 80 specialties and subspecialties

Translational Research leader ‐ Ranks among the nation’s top independent hospitals in National Institutes of Health (NIH) funding.   More than 1,180 active sponsored research projects and 1,900 research papers appear annually in peer‐reviewed journals  

One of the few hospitals nationwide awarded the Magnet Excellence in Nursing designationfour consecutive times by the American Nurses Credentialing Center

Health System ‐ Cedars‐Sinai Medical Group repeatedly ranked one of California’s top performing physician organizations for highest overall quality by the Integrated Healthcare Association

Understanding Current State

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Current State – Patient Volume Trends

826

839

885

775

800

825

850

875

900

FY13 FY14 FY15Ann (May)

Volume

Medicare LEJR Volumes FY13 ‐ FY15 Annualized (May)

MS‐DRG 469 & 470; VOLUMES EXCLUDE MEDICARE MANAGED CARE PATIENTS

7

Current State – Volume by Physician

MS‐DRG 469 & 470; Excludes Medicare Managed Care

948

341

218192

148 135 124

370

0

100

200

300

400

500

600

700

800

900

1000

LEJR Volume by Physician FY13 ‐ FYTD15 (May)

38%

14%9%

8%

6%

5%

5%

15%

LEJR Volume Percentage by PhysicianFY13 – FYTD15 (May)

Surgeon 1

Surgeon 2

Surgeon 3

Surgeon 4

Surgeon 5

Surgeon 6

Surgeon 7

All Others

Surgeon 1

All Others

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Current State – Patients’ Destination Post-Surgery

0.4%

5.4%

56.9%

2.2%

0.6%

34.1%

0.3%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

EXPIRED

HOME

HOME WITH HOME HEALTH

INPATIENT REHAB ‐ CSMC

INPATIENT REHAB ‐ OTHER FACILITY

MEDICARE CERTIFIED NURSING FACILITY (SNF)

OTHER

Discharge Disposition Percentage of LEJR Medicare Patients(FY13‐FYTD15 May)

MS‐DRG 469 & 470; Excludes Medicare Managed Care

Current State – Skilled Nursing Facility Usage

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0

50

100

150

200

1. to<= 7.8

7.8 to<=14.7

14.7to <=21.5

21.5to <=28.4

28.4to <=35.2

35.2to <=42.1

42.1to <=48.9

48.9to <=55.8

55.8to <=62.6

62.6to <=69.5

69.5to <=76.3

76.3to <=83.2

83.2to <=90.

# Observatio

ns

Days in SNF

HistogramSNF ALL CJR Episodes

2012‐2014

Normal Distribution Mean = 23.81Std Dev = 17.127KS Test p‐value = .0000

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Current State – Workflows

Multiple people read and understood the intricacies of the rule Mapped out the current workflow for our top three volume surgeons Audited the coding of 469 versus 470

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Current State – Our Conclusion

Surgery  Inpatient stay

ProcedurePre‐Procedure Inpatient Stay Post‐Acute Care

SNF

Outpatient Rehab

Costs not included in bundle

Fixed 90‐day global 

payment

Fixed payment that can be impacted mainly by ensuring appropriateness of 

DRG This is the variable expense.

Need to focus our efforts here.

Home Care

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Current State – Lessons Learned

Understand your current process before trying to 

change it

Use data to drive your plan

Building a Team

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Building a Team

Weekly team meeting Bi‐Monthly Steering Committee

Project Management

Project Management

PhysiciansPhysicians

ClinicsClinics

NursingNursing

RehabRehab

AdministrationAdministration

Care Management

Care Management

ITIT

AnesthesiaAnesthesia

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Change required hiring Care Managers

Your team must expand outside of 

the hospital

Building a Team – Lessons Learned

Leveraging Population Health Infrastructure

• Program designed to provide individualized help to coordinate quality care and ensure safe, seamless transitions between services and care settings

• Care managers, composed of nurses (RNs or LVNs) and social workers, work collaboratively with patients and providers to develop patient goals

• Conduct comprehensive patient assessments, facilitate communication across the continuum to coordinate care, and act as an advocate

Ambulatory Care Managers

Enhanced Care Program

• Program designed to follow our patients when they leave the hospital to ensure safe transitions

• SNFologists and NPs embedded in five local SNFs where they work collaboratively with the SNF care team to provide the right care

•Home visit program in place for ACO patients and may be expanded to include CJR patients

Actions Taken

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Actions Taken – The Exceptional Patient Experience

The Traditional Model  The New Vision 

Patient scheduled for surgery Patient scheduled for surgery and immediately set up for coordinated system of care designed to meet them where they are

Patient attends class Patient participates in interactive education, gets help preparing their home and arranging support,  and begins their discharge plan

Discharge planning occurs during hospitalization

Discharge planning re‐affirmed during hospitalization

Surgeon, Anesthesiologist, Hospital,SNF, Home Health, and O/P PT all working relatively independent of each other

Surgeon, Anesthesiologist, Hospital, SNF, Home Health, O/P PT,  collaborating to coordinate care

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Actions Taken – EMR Registry

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Actions Taken – HealthLoop

•Automate routine care management to focus on exceptions

•Reinforce education between visits

•Monitor adherence and clinical status

• Identify at‐risk patients early to reduce readmissions

•Capture patient reported outcomes (PROs) 

HealthLoop is a patient engagement platform that guides patients throughout an episode of care to:

Actions Taken – HealthLoop

1,075 patients enrolled thus far

23 Cedars orthopedists have enrolled patients

77% of patients that are invited to participate

activate their HealthLoop account

63% patient engagement rate

95% of pts Extremely Likely to Recommend

83% PRO survey completion rate for pts that activate their HealthLoop account

339 PRO surveys have been completed in HealthLoop

Actions Taken – Regular Process Check-Ins

Identification

Assessment

EducationProcedure

SNF

Home Health

OP Rehab

Follow‐up

Opp

ortunitie

s

Reduce SNF LOS

Reduce SNF to HH

Reduce HH Use*

Eliminate SNF Visit ReadmissionsComplications

Implant/Supply Use

Delay High Risk Cases

Identify Social & Environmental Hurdles

Collect PROs

Doc & Coding team reviewing all cases for 469/470 accuracyInpatient rehab  and hospital case management helping with discharge planning

Interven

tions

Concerns

Do we have enough dedicated resources to impact the metrics?Are we proactively impacting the PAC decisions?

Many clerical duties upfront (identification, CMS letter, PRO collection).  Who should complete?

Care Managers meeting with/emailing  MD offices for lists1:1 meetings with high‐volume MDsAll Hands meeting Steering Committee

PAC dashboardsClinical Home VisitsECP Alignment with CJR goals

Care Managers or EIS initiate HealthLoopRAT tool created but not yet implementedPRO/RAT handed out by some MD officesTracking dashboardsNursing conducts weekly Joint ClassCare Managers doing discharge planning

Touching a small % todayHow do we assure that we are assessing all patients?How will we interpret RAT?How do we respond to concerning PRO/RAT answers?

We have a lot of data, but who is the air traffic control?Who is looking out for the overall process for each patient?

Weekly report

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Actions Taken

•Patients encouraged to take Joint Class‐ Updating video

•Multi‐disciplinary team reviews cases every Tuesday (pending surgeries, current inpatients, post‐acute, readmissions)

•Physical Therapy highly engaged in care plan‐ Developing a roster of outpatient therapy centers

•Progression of Care Rounds (POCR)•Standardized discharge pathways•Care Managers following patients in SNF and Home Health‐ Collaborating with Population Health team when appropriate‐ SNF and HH agencies sending monthly data on LOS and # visits

•Designed monthly dashboard to track progress

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Patient was afraid to go home because she had three steps. I was able to reduce her SNF stay from 21 days to 5 days by getting her a ramp.

- Jeff Alcala, LVN

Ambulatory Care Manager

Actions Taken – Share Your Wins

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Discharge expectations should be set early and 

reinforced

Building visibility in the EMR is difficult

Actions Taken – Lessons Learned

We are implementing changes for Medicare 

and beyond

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The Future

Challenges • Limited experience in managing post-discharge costs or partnering with

post-acute providers • Lack of current data to know how we are doing• No required downside risk for physicians or post-acute care providers

Next Steps • Strengthen PAC relationships. Consider gainsharing• Expand the Care Manager role• Connect CJR to MACRA

Questions?

Thank youJennifer Blaha, MBAExecutive Director of Surgery & OrthopaedicsCedars-Sinai Health Systemjennifer.blaha@cshs.org