By Amanda Connoyer, MSHI, MSN, APRN, FNP-C Regional Clinical Diretor, Fusion5 Shawna Zabkiewicz, RN, BSN, CCM Director, Value Based Care and Case Management, OrthoIllinois Introduction Targeting the optimization of patients’ health before surgery to improve patients’ post-surgical outcomes, reduce or prevent possible perioperative complications, decrease readmissions, and reduce recovery times is a worthwhile endeavor to increase success in the Bundled Payment for Care Improvement Advanced (BPCI-A) program. Physicians participating in Advanced Payment Model (APM) programs, such as BPCI-A, are focused on optimizing patients with the intention of not only improving the post-surgical outcomes for the patient but also because improving outcomes for patients leads to lower cost of care which maximizes the financial incentives offered through these programs. According to Lee (2013), providers are incentivized for various reasons with the new quality improvement programs available in the healthcare system, which include participants of BPCI. Fusion5 has implemented pre-surgical optimization protocols in partnership with several of our orthopedic practices to evaluate the effects on patient outcomes and readmission rates, which will benefit patients, and physicians nationwide. Methodology With the substantial evidence showing the positive correlation between pre-surgical optimization and patient outcomes, Fusion5 was able to determine which optimizations would be most beneficial for our higher risk orthopedic BPCI patient population. In a study conducted by Duke University, an optimization program was implemented for patients over the age of 65 years with at least one medical condition. During this study, by optimizing patients prior to surgical intervention, they were able to see a decrease in readmissions from 18.3% to 7.8% within 30 days of discharge and significantly lower patient complications during the perioperative period (Duke Health, 2018). Fusion5’s goal was to evaluate the correlation of optimization thresholds for our patient population with improved surgical outcomes and decreased readmission rates. There are many differing thoughts about which optimizations should be implemented pre-surgically for patients. Fusion5 will be using the example of the successful implementation of pre-surgical optimization at OrthoIllinois (OI), a multi-specialty orthopedic group in Northern, IL and the significant improvement in their patient outcomes and success in the BPCI-A program. Results OrthoIllinois (OI) began BPCI Classic on January 1, 2015, with DRG’s 469/470 Major Joint Replacement of the Lower Extremity with and without complications. While initially OrthoIllinois was focused on post-acute utilization, setting up preferred providers, and case management services to manage post-op recovery, it quickly became apparent that there was a strong need to focus on the pre-op phase of a patient’s clinical episode as well. OI established the use of a pre-operative risk assessment with a biopsychosocial approach to comprehensively understand the needs of their patients pre-operatively. This holistic patient view allowed them to design the patient’s care plan for each patient’s specific needs and identify other comorbid conditions that might affect the patient’s outcome. Through a systematic approach and nurse case management model, identifying specific clinical indicators such as BMI, HbgA1c, smoking status, cardiac, mental health diagnoses and more, OI was able to work with the patient, their family members, primary care physician and other members of the healthcare team to improve modifiable risk factors, thus improving the patients’ outcome. The surgical team was empowered with the knowledge of the complete picture of health, allowing a more open and honest communication with patients about the importance of improving clinical risk factors and proceeding with surgery. Coordinating the care of the patients’ optimization empowers patients to engage with their Care Team, take charge of their health and have a vested interest in the outcome of their surgery. One shining example is a total knee joint replacement patient who when educated about the impact of a high BMI and undergoing surgery went on to lose 30 lbs. Her report back to her Care Team after her successful recovery was “I never had a physician so invested in my overall health.” She felt cared for, empowered and is now pain-free and within a healthy BMI range. The use of pre-surgical risk assessments and patient optimization is a valuable tool for any BPCI-A participant to utilize to improve outcomes and maximize financial incentives. The program has been enhanced with the use of the tools in Table 1 and as evidenced by the data represented in Figure 2. Conclusion With the success Fusion5 has seen with OI and other clients nationwide, we will continue to develop and recommend evidence-based optimization protocols for our quality improvement programs. We will continue to work closely with our partners to implement these protocols into their every day at their practices and monitor for improved patient care and outcomes. For further questions, please contact Amanda Connoyer at Amanda.Connoyer @fusion5.us. To download a printable, PDF version of this White Paper, click here. Citations 1. Duke Health. (2018, January 4). Cross-Disciplinary Program Improves Surgical Outcomes for Older Patients: Assessing risk and intervening before surgery leads to shorter hospital stays. https://corporate.dukehealth.org/news-listing/cross-disciplinary-program-improves-surgical-outcomes-older-patients?h=nl 2. Lee, M. J. (2013). Optimizing the Safety of Surgery, Before Surgery. Clinical Orthopaedics and Related Research, 472(3), 809-811. doi:10.1007/s11999-013-3406-8

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