Adapting and Updating: Patient Education, Clinical Protocols

Adapting and Updating: Clinical Protocols

Comprehensive Care for Joint Replacement Model

January 13, 2021

Audio available through device speakers OR by dialing (800) 832 - 0736

Conference Room:*2657582#


Comprehensive Care for Joint Replacement Model 2

Welcome

Alicia Goroski, MPH CJR Learning System Team

The Lewin Group

Laura Maynard, M.Div CJR Learning System Team

The Lewin Group


Webinar Agenda

• Welcome & Logistics

• Clinical Protocols in CJR Model Toolkit 2.1

• Margaret R. Pardee Memorial Hospital Presentation

• Reactions, Questions, & Discussion

• North Shore University Hospital Presentation

• Reactions, Questions & Discussion

• Announcements & Reminders


Logistics

• All telephone lines are muted • We encourage comments, questions, and reactions via Chat

throughout the webinar

Disclaimer: The Centers for Medicare & Medicaid Services (CMS), its employees, agents and staff assume no responsibility for any errors or omissions in the content of this webinar. CMS makes no guarantees of completeness, accuracy or reliability for any data contained or not contained herein. CMS shall not be held liable for any use of the information described and/or contained herein and assumes no responsibility for anyone's use of the information. CMS does not endorse any strategies, tactics, or vendors referred to in this webinar. The views and opinions expressed in this webinar are those of the participants and do not represent the official policy or position of CMS.


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• Please share in Chat now : – Organization – Location – One clinical protocol that your

hospital has adapted or updated recently

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Clinical Protocols in the CJR Model Toolkit 2.1


Clinical Protocols

Information on clinical protocols can be found primarily under the primary driver Right Care, Right Time


CJR Driver Diagram


Poll 1

Which clinical protocols have you adapted or updated over the course of CJR? [select all that apply]

– Infection Prevention – Ambulation – Pain Management – Physical Therapy – PE and DVT Prevention – Other (please type into chat)

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Margaret R. Pardee Memorial Hospital

Dan Hein MBA, CMPE Administrative Director of

Orthopedics and Sports Medicine

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U N

C H E A L T H C A R E S Y S T E M

Pardee UNC Health Care located in Western N.C.

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U N


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Pardee at a Glance

• 222 acute care beds

• 322 physicians representing 37 medical specialties and 127 allied health areas

• 188,896 visits to physician practices

• 29,763 visits to the emergency department

• 47,348 visits to Urgent Care facilities

• 19,547 visits to patient homes by home health professionals

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U N


Service Mix of Orthopedic Program

Orthopedic Wellness• Athletic Training• Performance Enhancement• Baseline Assessment• Senior Conditioning• One Call Access• Osteoporosis Clinic*

Facilities Capabilities• Fracture Center*• Inpatient-dedicated Units• Laparoscopic capabilities • Rehabilitation• Spine center• Orthopedic urgent/walk-in care

Physician Complement Fellowship Trained

Ortho• Spine• Joint• Sports Med• Foot/Ankle• Oncology• Hand

Rehab• Joint Camp• Physical Therapy• Occupational Therapy• Inpatient/Outpatient at

distributed locations

Community Presence• Education• Prevention• Distributed Locations• Business and Industry

Support• Care Management• Home Care• SNF/AL/Post Acute• Support Groups• Workers Comp• Nutrition and Weight

Management

Comprehensive Orthopedics Program• Pardee offers• Partners offer

Diagnostics• Advanced Imaging• Magnetic Resonance Imaging • Computed Tomography• Bone Density

Other• Physiatry• Rheumatology• FP/Sports Med• Pain Management• Radiology/ Imaging• Neurosurgery*

Alternative Med• Pain management

* Planning to offer service per strategic plan

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CJR Episodes Over Time

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CJR Quality is a Journey and Not a Destination

“How we track progress using data and dashboards”…

Year One:

Almost no direct line - of - sight into specific data points and quality elements

Year Two:

Sheer “force of will” to address cost side of equation, post - acute spend, specific program elements such as LoS , SNF utilization

Year Three:

Use of specific protocols, checklists, and multidimensional dashboards to manage and generate line - of - site data for providers and multi - disciplinary team

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Checklists and ProtocolsInfection Prevention: Yes No Notes·

If MRSA screen + on day of surgery, isolation precautions upon admission until

MRSA screen and decolonization for + resultso

decolonization complete

· Antimicrobial shower evening before and morning of surgery.

· Dental clearance

· Oral antiseptic rinse BID preoperative and postoperative.

· Antibiotic prophylaxis is weight-based.

· Cefazolin given within 60 min of incision (no beta lactam allergy)

· Vancomycin within 120 min of incision with beta lactam allergy and/or known MRSA colonization or high-risk for MRSA infection

· With tourniquet use for TKA, antibiotic completely infused prior to tourniquet inflation

· Intra-op re-dosing if procedure exceeds half-life or with blood loss > 2 liters

§ Half-life cefazolin = 1.8 hours § Half-life vancomycin = 4-6 hours

· Intraoperative skin prep with antiseptic containing alcohol

· Glucose maintained ≤180 mg/dL throughout stay?

· Postoperative incisional dressing used:

· What guidance was provided to the patient for wound care at home?

Blood Conservation - Bleeding Prevention: Yes No Notes

· Preoperative optimization of hemoglobin. o Preoperative Hgb/Hct closest to time of

surgery.

· Cessation of anticoagulation, antiplatelet medications within guideline recommended timeline.

· Intraoperative control of BP (<140 SBP)

· Use of tranexamic acid.

· Use of tourniquet (if yes, release prior to closing)

· Transfusion trigger (Hgb/Hct at time of transfusion, symptoms)

· Autologous transfusion (cell saver)?o Amount transfused

· Nonautologous transfusion?

· If nonautologous, 1 unit transfused at a time with recheck of labs?

· Timing of transfusion (DOS or postoperative day)

· Was patient receiving anticoagulation therapy? o If yes, what medication(s)?

· Was patient receiving antiplatelet therapy?o If yes, what medication(s)?

· Was patient started on FeSo4 therapy?

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Formalized Action Plans

Quality Review:5. Ensure the Facility Quality Improvement Program includes monitoring of structural, process, and outcomes measures for the orthopedic patient population:

· Ensure regular orthopedic quality meetings occur no less than quarterly.

· Quality staff to attend orthopedic meetings.

· Identify metrics to monitor and report at quarterly orthopedic service line meeting.

o Review Monitoring Suggestions to Ensure Optimal Outcomes for Patients undergoing TJA. o Work with Quality to monitor Orthopedic Service Line metrics.

o Include metrics for patient outcomes and process measures, including those used for public reporting.

o Leverage Quality staff experience to mentor orthopedic service line on chart review. Track and trend findings.

o Track and trend findings.

· Report quarterly quality summary up to MEC · Address barriers

o Develop mediation plan to resolve conflict. · Validate process improvement

o Audit compliance, remove barriers and celebrate success.

Care Delivery and Standardization:6. Ensure Consistent Pre-operative Screening/Testing, Optimization, and Preparation for the Orthopedic Patient Population:

· Review and implement the following pre-admission tools.

o Preoperative evaluation protocol for patients undergoing total joint arthroplasty.

o Patient agreement form for undergoing total joint arthroplasty.

o Optimal preoperative assessment and management of the geriatric orthopedic patient.

● Engage key stakeholders in the change process.○ Work with physicians to come to a consensus.

● Establish implementation plan · Address barriers

o Develop mediation plan to resolve conflict. · Validate process improvement

o Audit compliance, remove barriers and celebrate success.

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Recommendations and Initiatives Going Forward

• Improve pre - op optimization, timing and scope

• More clearly define anesthesia guidelines

• Adopt ERAS for the TJA population

• Standardize blood utilization across physicians

• Streamline order sets

• Chart reviews and engage intradisciplinary Quality Dept.

• Development of Coordinator role and implementation

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Overlapping Programs and Initiatives Lead to Complexity

• CJR program and metrics run in parallel with other programs

• External rating platforms

• Commercial insurance metrics

• Internal metrics (within hospital and system)

• Triangulating all measures across once comprehensive dashboard for complete visibility

U N


U N


Questions / Comments Thank YOU!!!


Q&A

• Use the Chat pod to submit any questions

• Please use “@” if your question is directed to a specific presenter

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North Shore University Hospital

Michael Langino , MPT, MBA Assistant Vice President

Orthopedic Surgery Northwell Health

Macsood Khalilullah , MS Director Operations

Transitional Care Management Northwell Health

Alanna Carcich Director Operations Orthopedic Surgery

Northwell Health

§ 756 Licensed Beds

§ 1,950 + Nurses

§ 6,100 + Employee

§ 4,000 + Physicians

§ Quintenary Care Hospital

§ 86,000 Emergency Visits

✶ ACS Verified Level 1

Trauma Center

✶ Sandra Atlas Bass Heart

Hospital

✶ Katz Woman's Hospital

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We are Northwell Health

§ 23 Hospital Health System

§ 2M + patients treated annually

§ 303,729 Hospital Discharges

§ 5.5 Million Patient Encounters

§ 865,260 Emergency Visits

45%

42%

8%

2% 2% 1% 0% Nassau

Queens

Suffolk

Kings

Other

New York

Bronx

30%

18%15%

13%

10%

6%5%

3%0% MedicineCardiac ServicesOB/GYNNewbornGeneral SurgeryNeurosciencesOrthopedicsSpinalTransplants

41%

39%

15%

3% 2%Medicare

Commercial/HMO

Medicaid

Employee

Self & Other

13%

24%

22%

41%

0-17

18-44

45-64

65+

28%

72%

Transfers fromNon-NorthwellHospitals

Transfers fromNorthwellHospitals

1. English 2. Spanish 3. Mandarin 4. Korean 5. Russian 6. Haitian Creole 7. Cantonese 8. Bengali 9. Farsi 10. Punjabi 11. Italian 12. Greek 13. Polish 14. Hindi 15. Arabic

NSUH | Serving the Community

FY 2018

Inpatient Origin Discharges by Product Line Patient Transfers to NSUH

Payer Mix Age Distribution

Department of Orthopedics | Team Approach!

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Orthopaedic ACP’s 10 PA’s

Nicholas Sgaglione, MD & Thomas Mauri, MD Chair & Vice Chair, Orthopedic Service Line

Alanna Carcich Director, Joints & Spine

Orthopaedic Service Line

Orthopaedic Residency Program 55 Residents

(rotations of 10 quarterly)

Michael Langino AVP, Orthopaedic Service Line

Nicole Brown Administrative Manager

Orthopaedics NSUH

Aida Ocasio Medical Secretary

Orthopaedics NSUH

Joints Ortho Spine

Trauma Hand & Wrist

Shoulder Foot & Ankle

Sports Pediatrics

Ortho Oncology

Interdisciplinary Team

Anesthesia Partners

Perioperative Services

Nursing (PACU & 7 Tower)

Rehabilitation PT, OT

Case Mgmt. & Social Work

Office Practice Staff

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Volume & Programmatic Snapshot

Spine Surgery

Trauma

Musculoskeletal Oncology

Joints Replacements

ü Primaries

ü Fractures

ü Revisions

Hand & Wrist

Shoulder

Foot & Ankle

Sports Medicine

‘650’ cases Total Joint Arthroplasty

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Access

Outreach

Pre - Op Screening

Hospital Program

Post Acute

Research

Education

• Physician Partners referrals • External referral sources • Other Program feeders

• Regional Community Lectures • Local event participation • Patient direct outreach

• Outcomes collection • Registry Participation • Clinical and basic science

studies• Professional Education Series • Post Graduate Trainee series • Standardized patient education

• Northwell Health at Home • STARS • SNF relationships

• Risk Stratification Care Pathways • Pre-surgical Clearances

Ambulatory Program

• Centers of Excellence • Standardized protocols • Inpatient process improvement

• Patient Selection Criteria • Uniformed Medication

Protocols

Joint Preservation and Restoration | Playbook

Joint Replacement System CollaborationCollaboration between Health Solutions and North Shore University Hospital

Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.

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Northwell Health Solutions

Provides system-wide assistance to each hospital through administrative

support, data analytics, and care navigation for all CJR patients. Works alongside surgeons and hospitals to

ensure 90 day follow-up in the community.

North Shore University Hospital

Collaborates with Health Solutions to ensure patients have a seamless

experience from pre-operative optimization and classes to surgery and discharge into the community with follow up for 90 days post op.

CJR Programmatic Goals

Pre-CJR Performance

q Improve Preoperative Patient Education rate

q Enhance POD - 0 Rehabilitation

q Reduce Hospital Length of Stay

q Increase Discharge to Home Rate

q Prevent Avoidable Readmissions

Patient Education 80%

Ambulation Day Zero 30%

LOS 4 days

Discharge to Home Rate 20%

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Challenges We Faced

{ Pre - operative patient optimization

- Home safety assessment

- Medical management

{ Early mobilization with rehabilitation services team

{ Historical reliance on SNF utilization

- Need to change patient expectations and staff culture

{ Frequency and compliance of home care visits

- Partnership with Northwell Health at Home

34

Joint Replacement System CollaborationCollaboration between Health Solutions and North Shore University Hospital – CJR Claims Data Dashboard

Confidential: Education Law 6527: Public Health Law 2805, J., K., L., M.

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Key Program Elements

{ Engaged physician leadership

{ Focus on the entire continuum: Preoperative through post discharge

{ Effective pre - operative education

{ Standardized clinical care pathways

{ Enhanced rehabilitation services

{ Patient experience focus

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Performance Improvement Measures Advanced Total Hip and Knee Program

{ Preoperative Functional Assessment Tool – Patient Reported Outcomes (PRO) – Adapting technology partners – FORCE Therapeutics – HOOS and KOOS Jr distribution at TJR education class – electronically tabulated via REDCap

{ % Regional Anesthesia – JPAR System - Wide workgroup – Accelerated Arthroplasty Recovery Protocol “AARP” (PACU length of stay project)

{ Early Ambulation / Day of Surgery – AARP project supports early transition to 7 tower – Expansion of PT/OT hours of operation (from 8am - 7pm to 7am - 9pm) – Nursing Staff mobilization training by rehab team – orientation

{ Discharge to Home – Enhanced preoperative education to set proper expectations – Interdisciplinary bedside rounding – Northwell Health @ Home partnership – FORCE Therapeutics – Rehabilitation technology partnership

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Goals Achieved

ü Preoperative Patient Education >

90%

ü Ambulation Day Zero > 90%

ü Overall Length of Stay Goal < 2 days

ü Discharge to Home Rate > 85%

ü Current Readmission Rate – 9.8%

Ongoing Initiative:

§ PACU Length of Stay < 2 hours

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Questions

39


Q&A

• Use the Chat pod to submit any questions

• Please use “@” if your question is directed to a specific presenter


Discussion: Updating Clinical Protocols

• What indicates a need to update a protocol? • How do you implement an updated protocol

and roll it out to clinical staff and physicians? • Has the recent public health emergency

created a need for changes to any protocols?


Poll 2

Which of the risk assessment and optimization strategies below has your organization updated or adapted recently? [select all that apply]

– Changing , improving, or standardizing beneficiary preoperative assessment

– Assessing beneficiary’s financial and social risk factors that may impact health outcomes (e.g., support system, transportation, ability to afford medication or supplies)

– Stratifying beneficiaries based on risk assessment – Optimizing beneficiary’s health prior to surgery – Using prehabilitation to improve post - surgical outcomes – Conducting home visits in the post - acute care period for high - risk

patients – Other (please tell us more in chat)


Poll 3

What are the top priorities for your CJR program over the next 6 months? [open text]


Leaving in Action

Please type into chat: What have you learned today that you think you can use at your hospital?


Notice

Disclaimer: The Centers for Medicare & Medicaid Services (CMS), its employees, agents and staff assume no responsibility for any errors or omissions in the content of this webinar. CMS makes no guarantees of completeness, accuracy or reliability for any data contained or not contained herein. CMS shall not be held liable for any use of the information described and/or contained herein and assumes no responsibility for anyone's use of the information. CMS does not endorse any strategies, tactics, or vendors referred to in this webinar. The views and opinions expressed in this webinar are those of the participants and do not represent the official policy or position of CMS.

46


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Adapting and Updating: Patient Education, Clinical Protocols

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