CJR McLeod Regional Medical Center

1. CJR McLeod Regional Medical Center

3. “For the hospital CEO or CFO out there who says, ‘I’m doing really well in fee-for-service so I’m just going to stick with it and it’s going to be OK,’ eventually it will not be OK, and I actually predict it will not be OK in a much shorter time frame than they might imagine.” Patrick Conway, MD, Deputy Admin. and Leader of CMMI- CMS

5. 67 MSAs

6. What is CJR – Patient Inclusion? Episodes are triggered by hospitalizations of eligible Medicare FFS beneficiaries discharged with diagnoses: • MS-DRG 469: Major joint replacement or reattachment of lower extremity with major complications or comorbidities • MS-DRG 470: Major joint replacement or reattachment of lower extremity without major complications or comorbidities Episodes include: • Not a Single Payment Methodology • Hospitalization • 90 days post-discharge • All Part A and Part B services, with the exception of certain excluded services that are clinically unrelated to the episode • 4 Target Prices (470/470F/469/469F)

7. Start By Understanding Our Data • CMS Provided Data on Continuumpayments. CY 2012 & 2013 • CY 2014 released in April • Separate files by service (acute/SNF/HH/etc….)BKD Consultants • Reconciliation is Quarterly butepisode is 90 days. Challenge

8. Based on 2013/2014 Medicare claims data, McLeod would have been responsible for 390 lower extremity joint replacement episodes. DRG 470 374 episodes DRG 469 16 episodes

10. First Discharge Location is KEY to final Payment DRG 470

14. 12% 79% 9% 13% 18% 36%

15. Leakage? • The movement of a patient from the 1st Discharge to a higher (Unanticipated) level of care • DRG 470 = 18% Leakage • DRG 469 = 31% Leakage

19. AGE

20. What Are We Doing To Bend The Curve?

22. Decision Making Pre-Operation Acute Care Post-Acute

23. Orthopedic & Spine Specialists Decision Making Pre-Admission Joint Academy • The patient has an appointment with an Orthopedic Surgeon • After all other options have been exhausted, the surgeon informs the patient that surgery may be an option. • The surgeon discusses the indications for surgery and tells the patient he/she may be a candidate. • Before a date for surgery is scheduled, the patient must attend a class titled “The Joint Academy”.

24. Orthopedic & Spine Specialists Decision Making Power Point Presentation for patients considering surgery • The presentation gives patients information to help them have realistic expectations to enable them to plan accordingly. • The Clinic covers: • Going home from hospital • Having someone, a Coach, to care for them at discharge • Participating willingly with both Occupational and Physical Therapy • Preparing their house for return home • Attending pre-op testing including “One Medical Passport” • Obtaining medical clearance • Attending the Total Joint Class

25. Orthopedic & Spine Specialists Decision Making RAPT Process

26. Orthopedic & Spine Specialists - Results of the RAPT tool are sent to the surgeon. - RAPT tool offers recommendations for the Surgeon to consider so the patient has the best surgical outcome.

27. Orthopedic & Spine Specialists Pre-Operation - Pre-op Education - Pre-Admission Testing - Medical Clearance - PreHab

28. Orthopedic & Spine Specialists Pre-Op Requirements • When patient is deemed ready for surgery, the surgeon’s office schedules the patient for surgery. Patient is given instructions about: • Phone interview which includes “One Medical Passport” • Pre-Admission testing visit which includes: • Pre-op labs • Pre-op x-rays • Physician consultation for Medical Clearance • Total Joint Class

29. Orthopedic & Spine Specialists Pre-Operation Class Attendance • Reconciling Surgery Schedule 1 week ahead to verify ALL patients have attendedTotal Joint Class • Patients who have not attended are contacted and given a choice of available classes prior to their surgery date • Feedback given to Surgeon on patients that do not attend • Any patient who does NOT attend class, receives a DVD and Patient Guide • Surgeons have recommended a no exception policy stating if a patient does not attend the Pre-op Joint Class, their surgery will be re-scheduled.

30. Orthopedic & Spine Specialists Acute Care • - Standardized Order Sets • - Discharge Planning • - Multi- Disciplinary Rounds • -Discharge Instruction

31. Orthopedic & Spine Specialists

32. Orthopedic & Spine Specialists Certification Performance Measure 2 Length Of Stay < 2.5 Days

33. Orthopedic & Spine Specialists Performance Measure Inpatient Satisfaction (PRC)

34. Orthopedic & Spine Specialists Performance Measure Inpatient Satisfaction (PRC)

35. Orthopedic & Spine Specialists Post-op Pain Trends by Milestone Day Continuum

36. Orthopedic & Spine Specialists Post-Acute • - Home With Home Health • - Outpatient Rehabilitation • - SNF Report Card • - Follow-up with Surgeon • Joint Coordinator • Telehealth

37. Orthopedic & Spine Specialists Post Acute Provider Improvement Skilled Nursing Facilities • Post-Acute Provider Score Card Developed • Held Post-Acute Provider Summit • 31 People • 19 Facilities • Visited Facilities where surveys were returned • Identify Potential Preferred Providers

38. Orthopedic & Spine Specialists Skilled Nursing Provider Report Card

39. Orthopedic & Spine Specialists Skilled Nursing Provider Report Card

40. CMS Payment Estimator

41. Questions?