Keys to Successful Management of MSK Value-Based Care Programs: Part 1 – Acute Care Setting


Written by Dr. David Ben-Aviv & DeLyle Manwaring

The recent buzz in orthopedic care has been around ‘value-based care’ and ‘population health’.  But, most conversations are only scratching the surface of the opportunities that exist in properly managing risk in order to have long-lasting and successful programs.  Providers, hospitals and Skilled Nursing Facilities (SNF’s) have specific tracks or processes for patients that may not be suited for today’s value-based care programs.  In order for an orthopedic practice, SNF’s and hospitals to be successful in a risk sharing program, such as BPCI-A and capitation, they must fundamentally change the regular order, take control of the process, and alter provider culture and practice patterns.

Reconfiguring Workflows: Regardless of whether the hospital system is participating directly in the value-based care program, one of the most difficult problems to solve (but one that is required for success) is identifying patient risk factors from the outset and then appropriately cascading this information to all staff that have the potential of impacting resource allocation.  While this information is important as soon as possible to help guide discharge decision making, it is often not until a potential authorization question is being presented that staff is aware of the payor.  Even then, recognizing a patient takes a level of awareness of the providers and diagnoses that are included in the program that may not be commonly known among hospital staff. To avoid missing patients who fall within the program, and therefore forfeiting the opportunity to affect their care path, it is imperative to set up a process for identifying and flagging patients as soon within the hospital stay as possible.  All case managers and social workers (even temporary ones) should be intimately aware of the details that determine whether or not a patient may fall within a specific program and be on the lookout for potential patients that have not yet been flagged.   In addition, during all discharge and interdisciplinary rounds, the team should identify patients so they may use this information as part of the decision-making process.  These rounds can be a golden opportunity to identify patients that may not have been identified earlier in the hospital stay.

 Optimizing Touchpoints:  In the scenario where a hospital system allows efficient recognition of the patient, it is still difficult to align staff to offer recommendations that would lead to a high quality, resource efficient discharge plan.  While seemingly common sense for hospital systems to let therapists guide the intensity needed for functional recovery, not all care providers are aware of the goals of the program.  In addition, typical acute care therapy culture can lead to a recommendation of the highest resource allowed, which does not always align with the most appropriate site of service.  However, in the hospital setting, it is not only the discharge planners and therapists who may not be aligned in the program.  Nurses, nursing aids, therapy aids, transporters, radiology technicians and other hospital staff may provide their own recommendations for a discharge plan to the patient and/or family and can influence the ultimate decision.  In addition to the confusion this may cause the patient and family, the recommendations from the hospital staff come from a varied level of experience and understanding of population health and bundle payment systems.  Counteracting an acute care culture that is not aligned with the goals of a program is heavily reliant on education of all patient-facing staff about not just the program, but also about population health and appropriate resource management.  In addition to lectures as a program commences, intermittent education sessions are also necessary to maintain staff attention to the program and due to the impact of staff turnover.  A hospital-branded marketing campaign with educational flyers and posters may also be of use to alert staff that may not be typically involved in formal education sessions. Ultimately, data is king and you need data to see practice patterns by therapist, nurse, case manager and physician to truly move the needle.

 Opposing Financial Priorities: One barrier to a successful bundle is trying to curb the high volume of unnecessary inpatient rehabilitation and skilled nursing admissions.  While this issue is multi-factorial, hospital systems allowing the highest percentage of inpatient rehabilitation admissions typically are those that have a financial interest in the receiving rehab facility and those that exclusively rely on the recommendations of the therapists.  In order to better control the negative impact that these financial interests may have on a program, it is helpful to set up regular meetings to discuss resource management and to create a roadmap of clinical parameters to help determine the most appropriate post-acute care location.   In addition to the potential for opposing financial priorities to undermine the success of a program, inpatient rehab, skilled nursing admission teams and marketers often assist with paperwork and transportation details, which helps alleviate the workload of the hospital discharge planner. This is an attractive incentive to a hospital discharge planner due to time restraints and the hospital’s emphasis on throughput.  Since the need for efficient throughput does not appear to be waning, hospitals must implement a discharge process that allows an efficient discharge that is site agnostic and support the discharge planners in any means necessary to allow discharge to the most appropriate level of care.

Without the buy-in of everyone interacting with the patient within the hospital setting and the right data, a bundle, or any other value-based care initiative, it will be impossible to manage successfully.  In addition to early recognition of the patient, cascading the goals of the program and developing processes that allow these goals to be distributed to all pertinent hospital staff is paramount to success.   If the process in the hospital setting is not set up to overcome barriers at the outset, it then becomes much more difficult to achieve success for the remainder of the risk period. Creating a solid foundation in the hospital setting cannot be underestimated since, after the patient leaves the hospital, there are many more barriers to overcome.

Overcoming These Barriers: HOPCo has decades of experience in overcoming each of these barriers.  This experience, coupled with our proprietary tools, clinical pathways and evidence-based protocols has led to HOPCo becoming the leading provider of musculoskeletal value-based health outcomes management, service line management and practice management.

Contact us today to see how we can help your organization avoid these pitfalls.