5/26/2015 Outpatient Joint Replacement in the ASC; Service Line … Friday/Track G/5_Fri... · 2015-06-25 · Outpatient Joint Replacement in the ASC; Service Line Approach ... Are

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© 2014 Stryker Performance Solutions. Reproduction or distribution prohibited without the express written consent of Stryker Performance Solutions.

Outpatient Joint Replacement in the ASC; Service Line Approach

Richard Conn, MD, Associate Medical Director, SPSMarita Parks, RN, BS, MHA, Project Manager, SPS


TODAY’S AGENDA

Outpatient Joint Replacement (OJR)

• Historical Progression of TJA Procedures

• Industry Demand for Change

• Marshall Steele Approach

• Results


1. http://www.aaos.org/news/aaosnow/may09/clinical4.asp

2. Comparative Safety and Resource Utilization of Total Knee Arthroplasty in Inpatient and Outpatient Settings; Scott D. Schoifet, MD; Journal of Managed Care Medicine, Vol. 14, No. 3

OUTPATIENT JOINT REPLACEMENT: 5 FACTS!

1. The percentage of the M|S joint database that represents outpatient joint replacements has doubled each year over the last 3 years (still less than 2 percent).

2. Outpatient joint replacement requires everything be “perfectly executed”!1

3. Controlling overall cost of the continuum of care for a specific disease state is important when looking at reimbursement and payment reform changes.

4. Direct Costs for an outpatient versus inpatient joint replacement in a hospital can be 25% less. 2

5. Patient requirements of an improved experience, lower cost, reduced risk of infection, and efficient throughput may translate into the ultimate demand for an outpatient joint program.

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SAFETY - PATIENT SELECTION

• Patient less than 65 y/o unless a uni-knee candidate (Medicare) with definitive diagnosis and who has been pre-assessed by medical consultant

• Fully informed/educated patient/family regards surgical care process and discharge expectations

• No co-morbid medical conditions that might lead to hospitalization

• Motivated patient willing to aggressively pursue rehabilitation on an outpatient level

• Family support system for maintenance of home care

• Suitable for straight forward primary joint replacement


• Staff adequately trained in the surgical care of a joint replacement patient

• Orthopedic implants and equipment suitable for joint replacement with backup

• Anesthesia protocols allowing same day or 23 hour discharge

• Pain management protocols

• Blood management protocols (pre, peri-op, and post-op)

• Transfer agreements with local hospital ( ASC)

• 23 hour permit for patient care with staff/facility to manage patient/family (ASC)

• Follow-up appointments confirmed prior to discharge

SAFETY – FACILITY REQUIREMENTS


TJR TIMELINE FROM A SURGEON PERSPECTIVE

• 1983: Mayo Clinic Fellowship: THA/TKA 5-7 days

• 1984: Return home: Total Hip Patients in bed 10 days in slings

• 1991: TVC program initiated: TKA stay reduced from 5 to 3 days

• 2002: Out-patient (23 hour stay) Uni-Knees performed in ASC

• 2011: In patient stay for THA/TKA average 2.4 days

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WHY MOVE TJR TO OUTPATIENT SETTING?

• Improve Quality/Patient Safety

• Greater Surgeon Control

• Cost Savings

• Increased Revenue

• Outpace the Competition

• Patients are Asking – New Option for Joint Replacement

• Anticipating the Future Direction of Healthcare (i.e. bundled payments)

• Other


• Superior Clinical Outcomes

• Cost Savings For Insurance Companies and Patients

• Profitability For Surgeons/ASCS

• Extraordinary Patient Experience

• Positive Word of Mouth Marketing

• As Good or Better than Inpatient TJR

• Will Out-patient Joint Replacement in

ASC Become Standard?...

WHAT IS NEEDED TO ACHIEVE SUCCESS?


ENGAGING SURGEONS – WIIFM?

• Patient Satisfaction

• Staff Satisfaction

• Reduced Complication Risk By Having Patients Return Home ASAP

• In ASC, Surgeon Control of Entire Care Process Including Time Management

• In ASC, Potential Financial Benefit Depending on ASC Ownership Structure and Payor Regulations

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9

1

3

Do You Believe Outpatient Joint Replacement is Here to Stay?

Yes

No

Not Sure

1

8

4

Are You Currently Performing Outpatient Joint Replacement?

Yes

No

Would Like To

Survey Taken: May 2014 Stryker Annual AMC Summit –Outpatient Joint Replacement

What Colleagues are Saying

SURVEY


WHAT SURGEONS PERFORMING OJR ARE SAYING…

Q: To successfully bring total joints to an outpatient setting, what procedures and protocols must be in place? Chad Burgoyne, MD, The Spine & Orthopedic Surgery Center (Santa Barbara, CA):

• The most important factors in performing a joint replacement as an outpatient procedure are the coordination and protocols that allow the surgical team to provide streamlined service.

• The surgical team needs to be consistent and well trained in joint replacements; the shorter the surgical time, the less pain and subsequent anesthesia is required, and the more the patient is able to participate immediately in therapy comfortably. Second is the anesthesia team. With a combination of spinal, regional and local anesthesia, we are now able to have postoperative patients that need little to no pain medication in the first days after surgery.

• The nursing staff must also shift their focus to enable the efficient discharge of patients. Their role is as much coach as caregiver. They must care for, educate, facilitate and encourage all in one breath. All the resources and steps must be in place so they can focus on the task at hand. Finally, there is the therapy team. The therapists must organize their days around the operating room schedule to minimize down time. A patient cannot be allowed to sit in bed and simply “recover.” The therapists must be available to start ambulation within the first hour after surgery is complete.

Source: http://www.optimhealth.com/what-will-it-take-for-total-joints-to-succeed-at-ascs/


Source: http://www.optimhealth.com/what-will-it-take-for-total-joints-to-succeed-at-ascs

SURGEONS DOING OJR…

Q: Are total joints trending outpatient or inpatient, and why?

• Dr. Burgoyne: Joint replacements are most definitely trending towards an outpatient model. At the most basic level, long inpatient stays are simply not necessary. Often my patients are bored, requesting discharge by the second day after surgery. The reality is that there is not much we do for patients during their two- to three-day hospital stay. If their pain is well controlled with the regional anesthesia, they are usually sitting around waiting for the one to two hours of therapy they receive. Why not sit at home and come in for outpatient therapy daily instead?

• Dr. Riordan: Clearly outpatient joint replacements are trending upward. Our experience, as well as that of other facilities in our region, is that an exciting increase in patient and surgeon demand for this service is occurring. ASCs are ideally positioned to lead this movement that lowers costs, controls complication rates, improves satisfaction and is preferred by patients.

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Source: http://www.optimhealth.com/what-will-it-take-for-total-joints-to-succeed-at-ascs


Q: Are insurance companies coming onboard with outpatient joint replacements?

• Dr. Scioli: The insurance companies will be more inclined to endorse these procedures being performed as an outpatient once adequate data exists to support the practice as being safe and effective. Medicare and Medicaid should allow for certain criteria to exist such that special cases could be done as an outpatient. In time, outpatient joint replacement will gain the traction it needs to become routine.

• Dr. Riordan: Insurers were initially cautiously supportive or sitting on the sidelines as interested observers. Lately, insurers have contacted us regarding our outpatient joint program, requesting data, asking to gain an understanding and even promoting our model in their other markets.

• Dr. Burgoyne: Medicare has acknowledged this trend and is revisiting their policies in regards to payment for outpatient joint replacements. Once they allow for outpatient arthroplasties, it is likely other insurance companies will follow suit. With rising costs and the large volume of procedures to be performed in the coming years, I think this shift to outpatient care is crucial to maintaining access to these vital procedures.



There are some roadblocks to outpatient arthroplasty, as described by Dr. Lombardi:

• Patient Fear/Anxiety

– Patients are afraid of the unknown, not knowing what is going to happen

– Patients are afraid of the pain associated with the procedure

• Risk Factors

– Patient co-morbidities

– Medical complications as a result of the treatment

• Side Effects of the Treatment

– Narcotics/anesthesia

– Blood loss

– Surgical trauma

Source: http://icjr.net/report_137_outpatient_arthroplasty.htm


PeopleAlignment/Structure

System of Care Patient Focused

Managementfrom Metrics

Enabling SystemsTools and Materials

Culture

HOW DO WE SUCCESSFULLY TRANSITION?SERVICE LINE APPROACH – THE PATIENT EXPERIENCE

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Infrastructure Clinical Program Management

Service Line Leaders Outpatient Clinical Pathway Outcomes

Physician Participation Standardized Plan of Care Marketing

Patient Selection Patient Education Program Sustainability

Facilities & Equipment Service Providers/Partners

Surgery Scheduling Staff Training: OR & Postop

Payer Contracts Emergency Protocols

OUTPATIENT JOINT REPLACEMENT

Program Components


Clinical Program

Outpatient Clinical Pathway

Standardized Plan of Care

Patient Education

Service Providers/Partners

Staff Training: OR & Post-op

Emergency Protocols

Clinical Care Path Discharge Plan Selection Criteria Post-op Discharge Criteria Post-op Follow Up –and Key Time Frames

• 4 week pre-op process

• Pre-op discharge planning

• Admit ASC DOS

• Discharge plans: o Plan A: Home with

Outpatient PT Discharge to home 4-6 hours post-op if discharge criteria

Alternate D/C plans initiated by Surgeon based on specific patient needs; these plans will not be presented as options for “patient choice”

o Plan B: (overnight) Discharge to home (Outpatient) in the am

o Plan C:3 variations

� Hospital admit

4-6 hrs p/o

� SNF transfer 4-

6 hrs p/o

� SNF transfer

after 2359

• Post-op Follow-up: o Physician phone

call o ASC CC phone

call o Anesthesia phone

call o Post-op office visit

• Plan A: o The preferred plan; requires

appropriate caregiver (24/7 x 1st wk.) and have minimal steps or able to live on one level

o Outpatient PT start date confirmed prior to admission

• Plan B: o Option for overnight stay is

surgeon decision; can be based on clinical or functional need

o Outpatient PT start date to be confirmed preop

• Plan C: o Option for Hospital/SNF is a

true back up plan for unplanned situations that present during the postop period.

Note: Discharge to SNF that involves pain control issues should not occur, but if it does, it will be monitored and trended as this may mean there is an issue with the anesthesia/pain/block protocol.

• Plan A/B: o VSS, alert, pain <5,

wound/dressing intact, able to void, tolerates oral intake

o No EKG changes o PT clears patient on bed to

chair transfer, ambulates 100 ft. with walker, able to go up/down 4 steps

o Medical clearance by anesthesia/surgeon required if the above discharge criteria not met; *see list below for indications to call which provider

o Patient and family safety/d/c teaching

o Plan B discharge is 2359 • Plan C:

o VSS, alert, pain <5, wound/dressing intact, able to void, tolerates oral intake

o Surgeon completes transfer summary

o If any of the above discharge criteria are not met, medical clearance by anesthesia/surgeon required before proceeding with transfer; *see list below for indications to call

• Physician phone call: o POD 1

• ASC CC phone call: o POD 1

• Anesthesia phone call:

o POD 2

• ASC patient satisfaction survey o 2 weeks postop

• Post-op office visit

with surgeon: o 2 weeks

• ASC CC phone call: o 30 days postop

• Reunion Luncheon event o Every two months

• Home Health/SNF• Procedure Training/Competency• Room and Procedure Set-up


Program Components


Mobility Checklist

STANDARDIZED PROTOCOLS

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Management

Outcomes

Marketing

Program Sustainability

• ASC Reported Outcomes• Patient Reported Outcomes

The Program improves the Metrics the Metrics improve the Program


Program Components


CLINICAL

Complications:

ASC

Complications:

30 Days Postop

- Cardiac - SSI

- Pulmonary - PE./DVT Rate

- Renal - UTI, Falls

- Hemodynamic - Blood Trans.

- Wound - Hematoma

- Pain/PONV - Pain/PONV

- Neurovascular Readmissions

- Alt.Mental Status Knee Flex/Ext

OPERATIONAL

Case Volume

Length of Stay – Hours

<6 hrs • <2359 • >2359

Discharge Disposition

- % Home

- % Home Health

- % Skilled Nursing Facility

Emergent Transfer w/Admission

Emergent Transfer w/o Admission

Cancellations

FINANCIAL

Direct Costs

Implant Costs

Reimbursement

- Payer Type

Contribution Margin

OPERATING ROOM

- Surgery Time

- Prep Time

- Exit Time

- Duration Accuracy

SATISFACTION

Overall Satisfaction

Likelihood to Recommend

FUNCTIONAL

SF - WOMAC

Knee Society

Harris Hip

ASC – JOINT PROGRAM METRICS


• Analyze Results by Procedure, Surgeon, Anesthesiologist

• Identify Trends/Comparisons

• Tease Out Strengths and Opportunities

• Develop Action Plans

• Manage Outliers

MONTHLY PERFORMANCE IMPROVEMENT MEETINGS

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• Did the Intervention Succeed?• Are the Patients Satisfied?

Surgery Post-op

Survey

Aggregate

Reports

Real-time6-12 Months

Annually

Patient

Results

Quarterly

0

5

10

15

20

25

30

35

40

45

50

Pre-op 6 week 3 mont hs 6 months 1 year 2 years

T

o

t

a

l

S

c

o

r

e

Reduced WOMAC Scores

0

5

10

15

20

25

30

35

40

45

50

Pre-op 6 week 3 mont hs 6 months 1 year 2 years

T

o

t

a

l

S

c

o

r

e

Reduced WOMAC Scores

Pre-op

Survey

Marketing

Materials

PATIENT REPORTED OUTCOMES


• Simple Data Collection, Analysis, Benchmarking Tool

• Survey at Pre-op and Post-op Intervals

• High Patient Compliance Rate

• Portable

• Secure

• Efficient: 15 To 25 Questions (< 6 Minutes)

• Customizable

Total Knee

Pain Intensity

I have no pain at the moment.

The pain is very mild at the moment.

The pain is moderate at the moment.

The pain is fairly severe at the moment.

The pain is very severe at the moment.

The pain is the worst imaginable at the moment.

PATIENT REPORTED OUTCOMES

IPad; Easy to Use for Patients and Staff


• Dashboard Report– Evaluate Progress

– Set Goals

– Benchmark: MS 1 day LOS:Your Own Performance

– Share Results with Key Stakeholders

• Program Sustainability

– Using Data to Help and Physician Leadership to

Effectively Manage the Service Line with

Comprehensive, Actionable and Relevant

Outcomes Data

PERFORMANCE IMPROVEMENT TEAM

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Program Display Board, Brochures, Patient Guidebook and Recovery Tracker, Website, Radio and TV

MULTIFACETED MARKETING PROGRAM


• Patient Recovery

• Improved Quality of Life

• Low Complication Rate

• Discharge Disposition/Plan of

Care

• Excellent Patient Experience

Share with Key Stakeholders – PCP – Surgeon – Payers - Community

OUTCOMES MARKETING


Metric Results: Q2 – Feb 2015

Surgeons 4 participating surgeons

Volume TKR: 13 THR: 18 Total case count YTD: 31Two patients returned for the second sideTotal of 4 cases have been done in one day

Discharge Home Health: 0 Outpatient PT: All

Average LOS/Hours 9.1 hours NO OVERNIGHT STAYS

Complications None

Readmissions None

Unplanned ED / Physician Visits

None

Avg. InsuranceContract Price

Around $25,000 – $27,000Almost 100% of payers on board

Average Contribution Margin

~ $11,000 – $16,000 depending on payer

Patient Satisfaction “I had surgery in the morning, went home on crutches four hours after the surgery and returned to work part time a week later. (Nick R.)”

SUMMARY: OUTPATIENT SURGERY CENTER, ANYWHERE USALAUNCH APRIL 17, 2014

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Stats: 12/1/14

Metric Results

Surgeons 15 participating surgeons thus far

TKR THR Uni TSR

Volume CompletedScheduled

207

123

133

1

Discharge Home Health: 45 Outpatient: 1

Average LOS / Hours 2359: 31>8 hrs.: 15

Complications None

Readmissions None

Unplanned ED / Physician Visits None

Avg. Insurance Contract Prices Pending

Avg. Contribution Margin Pending

Surgeon Satisfaction “It couldn’t have gone any smoother – I want to bring all my patients here.”

SUMMARY: OUTPATIENT SURGERY CENTER, ANYWHERE USALAUNCH OCTOBER 17, 2014


Physician Leadership/Staff Teamwork/Administrative Support

• Necessary for Effective Change and Sustainability

• A Program vs. Providing the Service

Care by Experts with Standardization and Best Practices

• Better, Faster, Less Costly, More Compassionate

• Predictable Outcomes, Reduced Complications

• Develop one day discharge standard in-patient before out-patient

• Consider initiating program with Uni-Knee patients

Reduced Variability Care Systems

• Shortens The Time To Expertise

• Efficiency-Surgeon skills in operating room (less than 2 hour cut to close time)

• Safety

• Cost Effective

Transparency with Data

• Leads To Continuous Improvements

• Creates Trust Between Surgeons, Staff and Administration

Create the “WOW” Factor

• Word of Mouth

LESSONS LEARNED


Thank You!

Contact InformationDerick ElliottVP Sales and Marketingderick.elliott@stryker.comwww.strykerperformancesolutions.com

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• DISCLAIMER: All services represented in this presentation will be presented as billable items at fair market value and are not offered free of charge to induce customer utilization of Stryker products.

• All service solutions can be utilized as standalone offerings or in conjunction with Stryker medical product purchases according to customer needs. In the event services are purchased along with Stryker products, charges for services and products will be separately itemized upon invoice.

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5/26/2015 Outpatient Joint Replacement in the ASC; Service Line … Friday/Track G/5_Fri... · 2015-06-25 · Outpatient Joint Replacement in the ASC; Service Line Approach ... Are