By Jason McCormick Vice President, Partner Services at Fusion5 As we continue our series on the critical elements of a successful bundled payment program, we begin to focus on the normal day-in and day-out processes that can prevent any case from becoming a “bundle-buster.” The first few elements of a successful bundled payment program helped you choose the services you would offer in your bundled program and the post-acute providers that offer services on your behalf. The fourth critical element of crushing bundled payment programs is the ability to identify your surgical candidate as far ahead of surgery as possible. A successful bundled payment program depends on your ability to properly utilize the resources needed and to control any variance that may be a result of the treatment. One of the most successful ways of controlling variance is to identify issues that may not have surfaced until after the surgery. Factors such as in-home support after surgery, access to transportation to attend outpatient follow-up or therapy appointments, and environmental constraints that may exist in the patient’s home have contributed to inappropriate admissions and a greater expenditure on non-bundled services. In order to identify and plan for previously unknown factors, providers need to have different conversations with patients—and have them much sooner. The majority of services targeted in the BPCI program are elective surgeries that are scheduled weeks—if not months—prior to the date of service. Providers need to begin asking questions about socio-economic factors and addressing potential hurdles long before the patient is admitted to the hospital for surgery. Patients need to know that they should arrange for a family member to be present for the first few days after discharge from the hospital, and physicians should know if a patient is not going to have access to transportation to make it to their outpatient physical therapy appointments that are scheduled a few days post-op. Having crucial conversations earlier in the process of determining if a patient is a surgical candidate removes many of the “unknown” issues that show up a day or two after surgery. The fear of the unknown should also be addressed. Patients need to be reminded constantly of what is normal and expected after surgery, so that unexpected emergency room trips are removed from the post-op period. Addressing patients’ fears by simply reassuring them that you and/or your staff are available to answer questions as they arise can prevent anxiety about going home after surgery. After all, isn’t fear of the unknown the first thought that creeps into our heads when we don’t have someone available to be our sounding board? By preparing for the unknown, providers can ensure that the groundwork is laid for successful outcomes and the number of failures, and overall expenditures, is reduced. In addition to the mental and physical preparation for the surgical event and discharge, the ability to identify the patient ahead of time allows for the patient to receive “pre-hab” education and therapy. During “pre-hab”, the patient is informed on the different exercises that will help to regain functionality and mobility in the area once surgery is complete. Patients that receive prehab therapy have been shown to recover more quickly than those who don’t. This is also true for patients that are only identified once they show up in ER departments and need immediate surgery. The lack of pre-surgical identification makes it impossible to train them on post-surgical exercises or to troubleshoot any of the barriers to discharge that will need to be addressed with a quick turnaround. Barriers to discharge usually result in the need for non-bundled expenses, such as inpatient post-acute facilities or potential for reoccurrences or readmissions. If given plenty of time and opportunity to work through problems prior to the patient’s admission to the hospital, or the procedure date if done in the ambulatory setting, many risks can be mitigated to control overall cost. A clear treatment plan can be the recipe to bundled payment success, and it begins with ensuring your patients have what they need to be successful once they are out of your control. The next element that plays a big part in the success of bundled payment programs, especially BPCI-A and CJR, is the physical therapy services that the patient receives pre- and post-surgery. This department can be a huge factor in making sure you crush bundled payments. If you are currently experiencing difficulty with your bundled payment program, or are not achieving the results you hoped for, please feel free to reach out. Each type of bundled service can contain different elements. It is imperative to have a complete understanding of the type of program and the services that would be included. If you are interested in having a discussion regarding the program you have, or are trying to create, please feel free to email me at email@example.com.