CMS’ Care Model for Joint Replacement Takes Effect April 1

GREAT NECK, NY -- To promote a higher quality of care with lower overall cost, the US Centers for Medicare & Medicaid Services (CMS) finalized its Comprehensive Care for Joint Replacement (CJR) model, which will begin in all New York area hospitals this Friday, April 1.  Under this approach, 14 Northwell Health hospitals that perform total joint replacement surgery and other facilities involved in patients’ care become responsible for both the cost and overall quality of care delivered to Medicare patients for 90 days after their procedures.  The national CJR program is scheduled to last five years and is mandatory for every hospital in 67 metropolitan statistical areas, which includes almost 800 hospitals.

According to CMS, Medicare beneficiaries received more than 400,000 knee and hip replacement surgeries in 2014.  While joint replacement surgeries enjoy massive appeal because of their ability to improve overall quality of life, the complication rate and costs vary significantly from hospital to hospital and surgeon to surgeon. 

The overarching goal of the CJR program and others like it is to achieve best-in-class clinical outcomes, while reducing costs, and improving patient experience. The payment model upon which CJR is based, known as “Bundled Payments for Care Improvement” (BPCI), is a voluntary program introduced by CMS in 2013.  In a departure from the so-called “fee-for-service” model of care, in which providers are paid whenever they treat a patient,  the bundled payment system holds hospitals accountable for all costs incurred during  the entire episode of a patient’s care -- from admission, to surgery, inpatient hospital stay, rehabilitation and other care delivered after the patient leaves the hospital.  

“Low readmission rates link both to overall patient experience and overall cost of care,” said Zenobia Brown, MD, MPH, medical director at Northwell Health Solutions (Northwell’s care management organization), which works with the health system’s hospitals and outpatient programs to manage patients’ care.  “It’s also a good indicator of how healthy we keep patients in the community.”

Dr. Brown cited early successes with bundled payment pilot projects at two Northwell Hospitals.  At Huntington Hospital, where BPCI has been in place since 2013, there has been a 20 percent reduction in readmissions. Lenox Hill Hospital in Manhattan, which entered into a bundle arrangement with CMS in 2015, has seen a 40 percent reduction in its 30 day readmission rate -- to three percent in 2015. 

“The discharge from the hospital is not the end of the medical journey for the patient but marks the beginning of the next phase of recovery,” Dr. Brown said.  “Ensuring that each phase starts at the right location and intensity of care is critical to the best outcomes for patients -- and often that location is home.”  Since the program’s inception, Huntington Hospital has nearly tripled discharge rates to home, while Lenox Hill leads all Northwell Health hospitals with 60 percent of all cases being discharged to home in its first year of bundle payment participation.”

Northwell has employed multiple innovative approaches to achieving these clinical outcomes and improving the overall patient experience.  Northwell Health Solutions’ Patient Navigation Model starts the patient’s journey with a pre-operative “health coaching” phone call completed by a licensed clinical social worker.   During this call the patient has a motivational-style interview to address fears, concerns, questions and decision-making around discharge planning.  This becomes a touch point with the patient to promote a patient-centered engagement with Northwell Health providers.  While hospitalized, the patient is then introduced to the program and the care navigator, who assists patients once they leave the hospital, with the aim of supporting and helping them achieve and maintain healthcare goals.  Patients are given a cell phone number so they can directly reach the navigator, eliminating any potential barriers to communication.  The navigators work closely with the patients’ surgeons, primary care physicians, specialists, home care and rehabilitation facilities to ensure a fully integrated continuum.   The goal is to deploy this model, which has been successful in BPCI pilots, across all of the Northwell hospitals now participating in CJR.

“Ultimately the success of a bundled payment program lies in the alignment of the entire health care network around the multiple and varied needs of the patients we serve. This model works to meet those needs,” said Nicholas Sgaglione, MD, chair of orthopedics at Northwell Health.

Northwell Health’s Rehabilitation Service Line and Post Acute Network have developed a comprehensive care model for total joint replacement patients, contributing to the success of the pilot projects and the start of bundle payment programs throughout the health system.  All patient needs are addressed during entire continuum of care to support the highest quality of care.  Specialized joint replacement rehabilitation programs at Northwell hospitals, inpatient rehabilitation centers, homecare and outpatient rehabilitation sites such as STARS (Sports Therapy and Rehabilitation Services) have been created to ensure patients maximize their recovery. 

In CJR, the total volume of total joint replacements that are part of a bundled payment arrangement will expand from approximately 800 cases per year to 2,800 total cases across 14 Northwell Health hospitals.  In total, Northwell Health physicians perform over 5,000 total joint replacements per year, making the network of providers a regional leader.

“Leadership at the hospital level, orthopedic service line and Northwell Health Solutions are aligning to design and deploy a world-class program for patients at every critical point throughout their surgical experience,” Dr. Sgaglione said. “By leveraging best practice standards, technology innovation and a fully engaged healthcare provider community, Northwell aims to keep patient interactions at the center of all activities.”

About Northwell Health
Northwell Health (formerly North Shore-LIJ Health System) is New York State’s largest health care provider and private employer. With 21 hospitals and nearly 450 outpatient practices, we serve more than 1.8 million people annually in the metro New York area and beyond. Our 61,000 employees work to change health care for the better. We’re making breakthroughs in medicine at the Feinstein Institute. We're training the next generation of medical professionals at the visionary Hofstra Northwell School of Medicine and the School of Graduate Nursing and Physician Assistant Studies. And we offer health insurance through CareConnect. For information on our services in more than 100 medical specialties, visit Northwell.edu

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