Bundling Pilot Programs to Redefine Care in an Episodic Manner

The CMS Innovation Center Pilot programs are slated to begin in early 2014, and will reinvent care as we have known it under the PPS model. Looking back, it is evident that the installation of the Prospective Payment System (PPS), altering how care was managed from the previous fee-for-service approach, that defined the care continuum of today. By introducing Diagnosis Related Groupings (DRGs), acute hospital care became focused and efficient, and inpatient length of stay statistics were reduced up to 77%. 1996 marked the introduction of PPS to the sub-acute Skilled Nursing Facility care Providers, as Resource Utilization Groups (RUGs) redefined how nursing and therapy were managed via clinical acuity. In 1999, Home Health received the Interim Payment System (IPS), as a precursor to the PPS installation of the Home Health Resource Group (HHRG) mechanism we all work under today.

The result of these reforms was to produce new levels of care efficiency that matched the clinical advances and insight realized since the start of Medicare in the mid-60s. Care advances include developments in care delivery, and ongoing change in these areas is the hallmark of an evolved healthcare system. But problems can arise as we constantly reinvent care in the era of rapid healthcare and technological advances. The silo element of the care continuum, whereas each Provider views and treats the patient in traditional manners, produces patient care that addresses the needs of the care profile in terms of the specific Provider type involved. That is, hospitals attempt to resolve care concerns primarily in terms of DRG management; what happens after patient discharge is a second level concern for the Hospital Provider. SNF Providers often focus on what portion of the Part A 100 days their sub-acute patients can be programmed for; longer length of stays means larger billing totals. Home Health Providers, until recently, described levels of recertification rates as a sign of agency health, reflecting a volume-based motivation towards patient care. These Provider-centric approaches combine to create the siloed care continuum currently in operation, where the concerns of the Provider’s business challenges are the primary force in care production and delivery.

The Affordable Care Act addresses the silo concern as it outlines the episodic approach of the future; re-casting the current care continuum in terms of integrated health system management of acute and chronic patient episodes. By eliminating the traditional care transition obstacles that exist between care sites, the patient can receive a more efficient, streamlined care experience. Ponder some of the standard issues relating to this concept; difficulties in obtaining orders, medications, equipment, and general communication related to patient transfers. According to the healthcare reform laws, ALL Medicare patient programs will be managed according to a Bundled, episodic approach by 2018.

In January, the CMS Innovation Center announced specific healthcare organizations to participate in the Bundled Payment for Care Improvement (BPCI) Initiative. Under the BPCI initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. These models are expected to lead to higher quality, more coordinated care at a lower cost to Medicare. The changes that will be produced will reinvent the care experience in a manner similar to the extent that DRGs redefined hospital programming.

The author’s recent collaboration with the Detroit Medical Center (DMC), a CMS Pioneer Awardee, led to the award of a BPCI Pilot program for MS DRG 469/470 – Lower Extremity Joint Replacements. Slated to launch in January of 2014, the pilot will run for three years; similar pilot programs addressing other DRGs will run simultaneously. The DMC pilot, titled the J.U.M.P. program, is an acronym for Joint Utilization Management Program. In preparation, post-acute vendors (SNF & Home Health) were vetted for quality results, care costs, outcomes, and clinical management. Care protocols were created to focus post-acute care volumes on the specific drivers of care for each diagnosis; focused care derives desired outcomes from decreased utilization, and that is the goal of the pilot program.

Many opportunities exist to reinvent the care experience along the lines of a Bundled approach; the basic goal is to elicit more efficient results based on savings derived from new care programming. Frequency/Duration orders will be connected to clinical profiles subdivided by objective specifics for each patient, care site placements will be tracked for movement to the next Provider level as progress occurs, care navigators will manage the patient throughout the hospital stay and throughout the entire 30-day post-acute Bundle. Orders, meds, and equipment will be managed without traditional silo care site issues. Even the issues of post-surgical Range of Motion concerns can be addressed via help from the latest care developments.

The Measuring Every Day (M.E.D.) device provides a post-surgical knee replacement patient the ability to measure their own range of motion (www.measuringeveryday.com). This allows for the patient to record range absent a separate pair of hands (often belonging to a PT or PTA), and allows for the care navigator to focus on the terminal range as a cornerstone of post knee replacement progress. Of course therapists offer much more than range measurements during homecare visits, but the Bundling pilots seek opportunities to replicate current outcomes under decreased utilization. The M.E.D. device offers a new approach to an old problem; these type solutions will be crucial elements as we develop the Bundled care episodes of the future.

So take stock of how you approach clinical issues in your agency or clinical practice; MD orders will not be a primary factor in the care volumes of the future. Assess the objective clinical findings of your SOC or professional assessments, identify the flexibility of your clinical delivery staff, determine the willingness of your clinicians to be managed to new care vehicles, and prepare your care for the challenges of tomorrow.

Arnie Cisneros, P.T., President of Home Health Strategic Management, is the most progressive speaker in homecare today. He provides coaching and consulting services to providers on a national basis (see www.homehealthstrategicmanagement.com) regarding S.U.R.C.H. and other clinical management protocols for quality outcomes.