HVHC selected nine conditions or treatments for initial study: total knee replacement, hip replacement, diabetes, heart failure, asthma, bariatric surgery, perinatal care, spine surgery and depression. These conditions represent a combination of discreet episodes of care and the management of chronic conditions. Costs for the care of these conditions is anticipated to accelerate rapidly in the future, as a result of increasing incidence and prevalence of the underlying condition and increasing costs of providing treatment. The conditions span primary and specialty care, present varying potential lengths and definitions of what constitutes an episode of care, and undoubtedly present opportunities for evaluation of the effectiveness of some aspects of care such as shared decision making, care management and coordination, telemedicine and care pathway adherence that are not included in traditional reimbursement models but are essential elements of high-value care.
HVHC conducted a pilot study on a cohort of patients who had undergone total knee replacement in 2008-2009. The findings of that treatment-specific retrospective analysis were published in Health Affairs in June 2012. The study showed substantial variations across the participating health care organizations in surgery times, hospital lengths-of-stay, discharge dispositions, and in-hospital complication rates. The study also revealed that higher surgeon caseloads were associated with shorter lengths-of-stay and operating time, as well as fewer in-hospital complications. These findings led the Collaborative to test more coordinated management for medically complex patients, more use of dedicated operating room teams, and a process to improve management of patients’ expectations around length-of-stay.
Center for Medicare and Medicaid Innovation Funding
In June of 2012, HVHC was awarded a $26 million CMMI Innovation Award, the second highest among 107 Innovation Award recipients. The award has a goal of $64M in savings to Medicare over the three-year period achieved through improvements in six clinical areas: congestive heart failure, diabetes, arthritis of the hip, knee and lumbar spine, and sepsis.
Goals of HVHC’s CMMI award:
- Improve quality, outcomes, and cost of care by advancing best practice care models for patients considering hip, knee or spine surgery, and patients with diabetes, congestive heart failure or sepsis.
- Improve patient experience and reduce utilization and total cost by implementing:
- Shared decision making (SDM) interventions for preference-based decisions (hip, knee, spine).
- Patient engagement interventions (e.g., decision tools, motivational interviewing, patient management) for complex patients with diabetes or CHF.
CMMI Improvement Targets:
- Improve care:
- >50% eligible patients referred to SDM and >50% of referred patients/families participate in SDM intervention.
- Improve optimal adherence to sepsis bundled care by 5% (relative rate) over three years.
- Improve health:
- Improve health status measures (function, pain) for > 50% of patients considering hip, knee, and spine surgery at one year.
- Reduce the burden of chronic morbidity from sepsis-associated chronic organ dysfunction.
- Reduce cost:
- Reduce rates of surgeries (hip, knee, spine) and episode utilization resulting in 5% total cost reduction.
- Reduce ED visits and hospitalizations by 10% and reduce cost of annual episodes by 2% for complex patients with diabetes or CHF.
- Reduce number of patients with sepsis requiring long term acute care or sub-acute nursing care by 5%.
- Total $64M reduction in Medicare reimbursements over the three years.
For the CMMI award, HVHC implemented projects in over 150 member clinics:
HVHC Care Model Projects
Hip & Knee projects:
- Shared Decision Making for Preference Sensitive Care to offer patients decision aid videos describing the risks and benefits of hip or knee surgery versus non-surgical treatments and assess the patients preferences, values, and knowledge about their decision through web-based questionnaires.
- Length of Stay (LOS) Expectation Management to provide education and consistent messaging from all members of the care team that healthy patients (defined as have < 2 co-conditions) will be discharged from the hospital 2-3 days after their surgery.
- Multidisciplinary Pre-operative Clinic to provide patient education, discharge planning, and risk assessment prior to surgery.
- Consistent Operating Room Teams matching surgeons with the same scrub techs and other members of the OR team for most surgeries they conduct.
- Discharge Disposition to Self-Care to provide healthy patients with the expectation and training to go home and care for themselves after surgery (as opposed to home with home health visits or physical therapy visits).
- Complex patient management to provide care coordination, care planning, patient education, shared decision making, and motivational interviewing for diabetic patients with multiple comorbidities.
- Remote patient management to monitor patients with uncontrolled diabetes and proactively contact them by phone or email to manage their care.
- Depression screening to systematically screen diabetic patients for depression and take appropriate actions to ensure treatment for those who trigger a threshold depression score.
- Optimizing the treatment of septicemia and sepsis through implementation of bundled care interventions with improvement strategies.
- Shared Decision Making for Preference Sensitive Care to offer patients coaching and decision aid videos that explore the risks and benefits of spine surgery versus non-surgical treatments and assess the patients’ preferences, values, and knowledge about their decision through web-based questionnaires.
- Shared Decision Making describing the risks and benefits of Implantable Cardioverter Defibrillators (ICD) to patients with heart failure who meet the criteria for ICD placement for primary prevention according to the 2013 American College of Cardiology Foundation/ American heart Association (ACCF/AHA) Guideline for the Management of Heart Failure.
Final Reports to CMMI