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![Page 1: Achieving Optimization and Functional Outcomes for the ... · PDF fileFunctional Outcomes for the Orthopedic Patient Chris Vannello, Director of Quality Improvement, Rothman Institute](https://reader031.vdocuments.us/reader031/viewer/2022030508/5ab7320d7f8b9ac10d8b7694/html5/thumbnails/1.jpg)
Achieving Optimization and Functional Outcomes for the
Orthopedic Patient
Chris Vannello, Director of Quality Improvement, Rothman Institute
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Goals
• Provide high quality care
• Improve clinical and functional outcomes
• Reduce avoidable complications and readmissions
• Eliminate waste and be more efficient
• Outcome based demand matching level of care
• Cost reduction
• Data driven decisions
• Improve safety
• Integrated care experience
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Issues
• Payers are encouraging patients to make value driven choices
• Payers are selecting surgeons that they consider high value, low cost providers based on their outcomes
• Payment incentives focus on quality over quantity
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Copyright 2007, Health Grades, Inc. All Rights Reserved.
Nursing Home Quality Initiative
CMS Updates Hospitals on HCAHPS
New Multi-Million Dollar Initiative to Reward Doctors and Hospitals for Higher Quality Care
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The Rothman Institute Overview
*
BUNDLED PAYMENT: RI VISION – DEMAND MATCHING*
Bundle to
Rothman Institute
(“Own the Bundle”)
ASC Specialty Hospital
Community Hospital
University
Hospital PT
Home
Health
Rehab Facility
Low High
Operative Facilities Post-Op Care (Rehab)
Low High
Low High
Cost Structure
Rehab Requirements
Cost Structure
Pre-OP
Acuity Level
Low High
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Care Pathways
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Patient Care Pathways
• Develop High Level Processes
• Reduce Waste
• Avoid Common Pitfalls
• Metrics should be patient centered and process focused
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Patient Care Pathways
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Standardized Patient Care Pathways and Protocols
Pre-op
• Labs
• H & P
• Pre-op Rehab
• EKG
• CXR
• Medical Clearance
OR
• Prep- Patient/Surgeon Scrub
• Positioning
• Equipment
• Implants
• Tourniquet Use and Times
Post-op
• Orthotics
• X-rays
• Rehab
• Follow up- Functional Score/Pain Management
• Post Discharge Disposition
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Completed Pathways 31 Completed
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Perioperative Clinics
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“Clearances”
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Perioperative Medicine Clinic
This new model coordinates the patient experience through the Surgical Continuum with numerous value-added enhancements to workflow, quality, safety, and cost.
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The Cost of Quality…An Orthopedic Case Study
• 57 year old male, presents for total knee replacement
• Appears healthy, but actually has ETOH history
• Surgery goes fine but 24 hours post-op:
• Develops DT’s
• Aspiration pneumonia
• PE
• Stroke
• 22 days in ICU
• Survived, and went to LTAC CHARGES- what the hospital billed
$497,000
HOSPITAL ACTUAL COSTS
$312,000 (give or take)
HOSPITAL WAS PAID- under current rules
$71,000
What you’ll be paid under Bundled Payments
$13,211
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15
Pre-Op Risk Screening Tool • 14 pages
• Evidence-Based
• Covers Cardiac, Pulmonary, Renal, Pain History, Anesthesia History, Patient Meds, GI, Delirium Risk, Skin Risk, Urinary Retention Risk, etc.
REDESIGNED PREOPERATIVE PROCESS
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16
Preoperative Assessment Process for Very Good Ortho Hospital
PST Testing
Dept.
NP All
TKR/THR
Patients
- Hospital
- Physicians’ Offices
- External Facilities
1st Level Screening-
using the
“Screening Form”
Patient Info (and
the Patient?) to
Pre-Op Physician
for Final Review
Labs, tests and
consults ordered Results
Patient
Risks trigger
changes in
Care
Patient
information
put into the
“Summary
Form”
REDESIGNED PREOPERATIVE PROCESS
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Post-Op Care
Focus on:
Pain Management
VTE prophylaxis
Wound management
Education, education, education!!!
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Patient Navigator
Manages the entire episode of care 30 days pre-op to 90 days post-op
Patient Navigator Multidisciplinary
Team
Consistent contact point
Medication self management Surgeon follow up
Nutrition Home Safety
Awareness of red flags Lack of transportation Technology knowledge
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The Rothman Institute Overview
*
BUNDLED PAYMENT: RI VISION – DEMAND MATCHING*
Bundle to
Rothman Institute
(“Own the Bundle”)
ASC Specialty Hospital
Community Hospital
University
Hospital PT
Home
Health
Rehab Facility
Low High
Operative Facilities Post-Op Care (Rehab)
Low High
Low High
Cost Structure
Rehab Requirements
Cost Structure
Pre-OP
Acuity Level
Low High
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Post Discharge- Next Steps
Based on Patient’s: • Pre-op/post-op functional status
• Home Safety/Social Disposition
• Health/Co-Morbidities
Rothman Resources only (follow-up call, Force
Therapeutics, postop visit in 2 wks)
Home PT only 1-4 visits Home Nursing & Home
PT Inpatient Rehab Facility Skilled Nursing Facility
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Outcome Measurement
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OBERD
• Outcomes Based Electronic Research Database
– Outcomes-based
– Interactive with patients
– Integrates with electronic medical record system
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OBERD
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Rothman Institute of Orthopaedics at
Thomas Jefferson University
Quality Outcome Instruments
Generic
VR 12
SF 12 Version 1
SF 36 Version 1
EQ-5D
MFA and SMFA
Shoulder/Elbow
ASES
Constant
DASH
Penn
Rowe
SST
UCLA
Foot/Ankle
AOFAS
FAAM
SMFA
Hand/Wrist
DASH
PRWE
Quick DASH
Joints
Harris Hip Score
HOOS
Knee Society Score
KOOS
Lysholm
Oxford Hip Score
• Spine - Back Pain Index - Modified ODI - Neck Disability Index - Oswestry Disability Index - SRS 22
•Sport Medicine
–Cincinnati
–IKDC
–KJOC
–Kujala
–Marx
–Tegner-Lysholm
–WOSI
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Healthgrades Engagement
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Healthgrades
• We needed
– To quantify our outcomes
– Data from all payers
– Data from all sites
• Data integrity is paramount
• Cannot go back and fix must look forward
• Be a part of the process defining outcomes
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TJUH
Orthopedics Risk-adjusted Complications Ratios
0.58
0.32
0.48
0.22
1.05 1.04
1.59
1.00 1.02
0.78
0.0
0.5
1.0
1.5
2.0
10/10-9/11
10/11 -9/12
10/10-9/11
10/11 -9/12
10/10-9/11
10/11 -9/12
10/10-9/11
10/11 -9/12
10/10-9/11
10/11 -9/12
A/P
RA
TIO
Total Knee Replaceme
nt
Total Hip Replaceme
nt
Hip Fracture
Treatment
Back and Neck
Surgery (w/o Spinal
Fusion)
Back and Neck Surgery
(w/ Spinal Fusion)
= Benchmark
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5.99%
3.08% 3.17% 2.58%
8.73%
11.72%
15.75% 16.66%
3.98%
7.68%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
Q4 2011 Q1 2012 Q2 2012 Q3 2012
Actual Predicted
5 - Star Actual 5 - Star Predicted
0.69
0.26 0.20
0.15
0.52
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
Q4 2011 Q1 2012 Q2 2012 Q3 2012
A/P A/P 5 Star
Volume Complications
Q4 2011 217 Q4 2011 13
Q1 2012 227 Q1 2012 7
Q2 2012 252 Q2 2012 8
Q3 2012 194 Q3 2012 5
TKR – TJUH
Actual vs. Predicted Complication Trends & Comparison – All Payer Data
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Total
Knees
(N=194) Renal 2 Acute Renal Failure
Delirium 1
Genitourinary 1 UTI
GI 1 C. Diff
Pulmonary 1 Pneumonia
Total Knee Replacement- Complication Summary (July 2012 - Sept 2012)
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Hospital Comparison
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Atlanticare TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 5 3 5 3 3
2012 3 3 5 3 1
Bryn Mawr Hospital TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 3 3 3 3 3
2012 5 3 3 3 3
Kennedy Hospital TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 3 3 5
2012 3 3 3
Lankenau Medical Center TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 3 3 3 3 3
2012 3 3 3 3 3
Nazareth Hospital TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 3 5 3 3 3
2012 3 3 3 3 3
Riddle Hospital TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 5 3 1 1 3
2012 3 3 3 1 3
RSH TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 5 5
2012
TJUH TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 5 5 1 3 1
2012 5 5 1 5 1
Paoli TKR THR Hip Fracture
Spine with
fusion
Spine without
fusion
2013 1 1 1 3 3
2012 3 3 3 3 3
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“Dashboard”
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What did we discover?
• Documentation errors
– Failure to document pre-existing conditions
– Failure to explain abnormal labs
– Careless documentation
– Coding inaccuracy
Actual opportunities for improving care!
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MUST HAVE
• Perioperative Clinic
• Perioperative Physician
• Comprehensive Pre-op assessment
• Coders on the orthopedic units
• Orthopedic Service Line Coordinators
• Clinical Definitions and protocols
• Complication Review
• Complication Review Committee
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Quality Initiatives
Pre-Operative Medical Evaluation
Pre-Operative Patient Education (Ortho Camp)
Medical Co-Management- Peri-Op B-Blockers, Glucose Management, Etc.
Pain Protocols
Discharge Planning
Delirium Prevention
Renal/Urinary/Catheter Management
DVT/PE Prophylaxis
Anesthetic Technique
Pulmonary/Respiratory Optimization/O2 Therapy
Cardiac Monitoring
Antibiotic Usage/Infection Control
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Identify Problem Areas
Inconsistent (or incomplete) Pre Op Evaluations
Poor Communication Between Providers, Anesthesia and Surgeons
Lack of Patient Education/Expectations
No Standard Process to Identify/Prevent Recurrent Complications
Coding Language
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Establish Mandatory Process
Surgeon Participation
Centralized Medical Evaluation Facility
Dedicated Sub-Specialty Groups
System Based Guidelines (i.e. abnormal labs/studies)
Standardized Patient Education
Joint Class
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Patient/Disease Specific Protocols
“Trigger Form”: Identifiers to Guide Pre-Op Care
Specialist Guided Recommendations • i.e. Fluids for renal patients and specialized induction
for delirium risk patient
Specific Post Op Order Sets: Initiated in Recovery Room through Hospital Course
• I.e. Telemetry for OSA patient and meds/Foley management for retention risk patient
Educate Staff
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Self Evaluation
Complication Log • Provides “real time” assessment
Quarterly Team Review • Discuss every complication and readmission
“Tweak”/ Create Triggers / Make Changes
Reinforce/ Re-educate
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We need a unified and consistent approach to determining quality initiatives and data review
• Specialty dashboards
• 100% complication review
• Discussion of quality initiatives
Orthopedic Quality Teams
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Total Hip Replacement Risk Adjusted Major Complications
0.89
0.53 0.53
0.37 0.48
0
0.5
1
Q3 2011 Q4 2011 Q1 2012 Q2 2012
A/P Ratio National Benchmark
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Co-Management Agreements
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Conclusions
• Changes are going to be made
• Policy makers will dictate changes based on measures they see as important
• We can help guide change based on measures that physicians and patients see as important
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Conclusions
• Do not focus only on cutting costs—not great for patient
• Do not focus only on improving quality—too expensive, spending to improve quality can be limitless
• Focus on getting highest quality for least cost over time
– Changes should be patient-centered
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Conclusions
• Measure those outcomes that are
most important to the patient
– Pain
– Function
– Return to work or previous
activity
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Conclusions
• Requires
– Comparative effectiveness research • Determine which procedures work/have value
• Minimize influence of industry/bias
– Transparency • Who is doing what?
• How are the patients doing?
• Reporting results/complications
• Quality and cost data available to all stakeholders, including patients
– Leadership to implement changes
![Page 52: Achieving Optimization and Functional Outcomes for the ... · PDF fileFunctional Outcomes for the Orthopedic Patient Chris Vannello, Director of Quality Improvement, Rothman Institute](https://reader031.vdocuments.us/reader031/viewer/2022030508/5ab7320d7f8b9ac10d8b7694/html5/thumbnails/52.jpg)
Leading? Following?
Do You Want To Be…