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Posted April 24, 2017

Managing Bundled Payments with Care Transition Calls

By Lisa Reich, RN

Partially fueled by the Affordable Care Act, hospitals must increasingly focus on managing risk while delivering better quality healthcare. Current projections call for a $310 billion decrease in Medicare reimbursements by 2022. To reduce medical costs, the Centers for Medicaid and Medicare Services (CMS) created alternative payment models, such as bundled payments, that shift quality and financial risks to hospitals. The bundled payment model is one tool that CMS is using to meet its goal of moving 50 percent of Medicare expenditures to alternative payment models. In these payment models, hospitals that provide quality care at a lower cost are eligible for a bonus, and those who provide lower quality care will be subject to a penalty. This financial impact is an incentive for hospitals, physicians, and post-acute care providers to work together to streamline processes and coordinate patient care.

In April 2016, CMS implemented the Comprehensive Care and Joint Replacement (CJR) model, a bundled payment program. The CJR model, which covers Medicare reimbursement for knee and hip replacements, is mandatory in 67 metropolitan service areas – close to 800 hospitals.

In the CJR bundled payment model, CMS reimburses the hospital a lump sum for a patient’s entire episode of care, which includes hospitalization and 90 days after discharge. During this 90-day period, hospitals deduct the cost of any medical care related to the procedure from the agreed upon bundled payment amount.

Managing Discharge Care under CJR

Bundled payments change how a hospital cares for a patient after discharge. Traditionally, a hospital is not financially responsible once a patient is released. When a Medicare patient receives care from home health or rehab, that agency must handle reimbursement from CMS. However, under the CJR bundled payment model, hospitals are responsible for a patient's quality and cost of care for 90 days after discharge.

With this emphasis on post-discharge care, hospitals must identify solutions that help them maintain contact and provide care to a patient during the 90-day recovery period. Organizations should consider four essential categories when coordinating care: cost and margin management, patient care process, provider alignment strategies, and patient engagement. Care transition calls assist caregivers in the patient care process and patient engagement categories.

Many hospitals have already implemented pre-visit and post-visit phone calls. By asking specific questions and changing the frequency of calls, providers can also use these two powerful tactics to extend care to their patients.

Pre-Visit Calls

Preparing a patient for discharge should begin before the patient enters the hospital. Many organizations hold intensive patient education classes where the patient learns what to expect before, during, and after their procedure. A pre-visit call should complement and reinforce what patients learn in these classes (or if classes are not offered, the call should cover critical information a patient may not otherwise receive). Discussing relevant information during the pre-call helps the organization address potential barriers to a patient’s recovery. The call also establishes trust between the patient and the hospital, which can reduce the patient’s anxiety and reassure the patient that the hospital will help them recover. Consider adding the questions below to your pre-visit calls:

Sample pre-visit call questions:

  • Do you have someone at home to help you after you leave the hospital?
  • Have you ensured that your living area will be comfortable to move around in after you come home?
  • Have you scheduled your physical therapy appointments?
  • Do you have a list of your prescriptions for after the procedure?

Post-Visit Calls

Many hospitals are currently making post-visit calls to help prevent readmissions, avoid medical complications, improve the patient experience and increase patient engagement. Post-visit calls also enable the hospital to provide support to patients by maintaining a connection during the 90-day recovery period required by CJR.

Hospitals can use post-visit calls to ensure patients have what they need to commit to their discharge plans and recover successfully at home. Calls help detect barriers that prevent patients from following their discharge care plan. For example, providers can verify that the patient has filled their prescriptions, has scheduled a follow-up appointment and has someone at home to help them.

Regularly reaching out to patients during the 90-days following discharge builds a relationship that helps patients to engage in their recovery. As the calls progress, trust grows, so the patient feels more comfortable discussing their care. Patients are more likely to ask questions and self-report any complications, instead of returning to the emergency room or visiting another healthcare facility with non-emergent issues. Under these circumstances, the originating hospital would be financially responsible for both incidents since they occur in the 90-day window.

Post-visit CJR calls should regularly be made to check on the patient and ensure they are recovering well at home. Knowing when to expect the next call reassures the patient that they are not alone in their recovery and that the hospital is involved and concerned.

Questions should be designed carefully to check for complications and encourage discussion between the provider and the patient. Well-crafted questions will allow the caller to explore what the patient is experiencing, detect any possible problems and initiate a conversation that engages the patient in their care. Below are some questions Studer Group partner hospitals have used when conducting post-visit calls for CJR.

Sample questions to ask after discharge:

  • Can you tell me how you should care for yourself now that you are home?
  • Did you have your first post-op appointment with your surgeon?
  • Are you able to manage your discomfort levels?
  • Are you satisfied with your progress so far?
  • How is your mood? Are you experiencing any anxiety or depression?
  • Have you been to the ER or in a facility as a patient in the past 30 days? If so, for what reason?
  • Have you been given permission to return to work?

Studer Group’s Patient Call Manager™ (PCM) helps organizations manage the additional accountability that the bundled payment model demands. Pre- and post-visit calls, accelerated with the technology of PCM, can help hospitals provide quality care to patients and succeed in the era of bundled payments. For example, hospitals can use PCM’s recurring call feature to schedule ongoing calls with a patient, which takes manual planning out of the process and hardwires the important frequency component of post-visit calls. PCM also features colored borders as patient identifiers, which can help hospitals classify patients who are participating in bundled payment programs.

The landscape of healthcare reimbursement is changing, and those organizations that adapt their processes and implement proven tactics will excel.

To deepen your knowledge on this topic, we recommend the following resources from our colleagues at Huron:

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