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Presentation• August 15, 2014
Hospital Based Same Day
Joint Program
Donna Howell, AVP Surgical Services
Gregory Bernardo, MD Perioperative Medicine
Kim Allen, Clinical Director
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AtlantiCare At a Glance
90+ Locations
5,500 Employees971 Providers / 300+ Employed
37,325 ACO Covered Lives
29,675 Discharges
337,000 APGOutpatient Visits
Baldrige Performance Excellence Program
Bond Rating
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SOUTHERNOCEANCOUNTY
CUMBERLANDCOUNTY
Buena Boro
BUENA VISTA
Folsom
Boro
Hammonton
MULLICA
HAMILTON
WEYMOUTH
ESTELL
MANOR
Corbin City
Egg
Harbor
City
Port Republic
Absecon
EGG
HARBOR
Northfield
PleasantvilleBrigantine
Atlantic City
Ventnor
Margate
Longport
Linwood
Somers Point
BURLINGTON
COUNTY
STAFFORD
LITTLE
EGG
HARBOR
EAGLESWOOD
TuckertonLittle
Egg
Harbor
Harvey
Cedars
Surf City
Ship Bottom
LONG
BEACH
Beach Haven
UPPER
Marmora Ocean
CityWoodbine
Boro
DENNIS
MIDDLE
CAPE
MAY
COUNTY
Sea Isle
City
Avalon
Stone Harbor
North Wildwood
Wildwood
Wildwood Crest
Cape May
LOWER
Cape May
Point
West Cape May
Mount Laurel
Cross Keys
Special Care Centers
Service Area Network
Urgent Care Centers
AtlantiCare Physician Group – Specialty Practices
AtlantiCare Affiliated Primary Care Practices
AtlantiCare Physician Group – Primary Care
AtlantiCare Regional Medical Center Mainland (Pomona)
AtlantiCare Regional Medical Center (Atlantic City)AtlantiCare Health Plex
AtlantiCare Hammonton Ambulatory Campus
RSA Market AreaPSA Market Area
AtlantiCare Health Park AtlantiCare Surgery Center – Egg Harbor Township
AtlantiCare Cape May Court House Ambulatory CampusAtlantiCare Surgery Center – Cape May Court House
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6 AtlantiCare Manahawkin Ambulatory CampusAtlantiCare Surgery Center – Ocean County
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History of Joint Replacement at AtlantiCare
• Began to formalize the program late 90’s
• Volume approximately 150 cases per year in 1999
• Current volume approximately 2500 cases per year
• Began analyzing publicly reported outcomes in 2008
• Designed multidisciplinary process to optimize patients
• Created the Center for Perioperative Medicine incorporating internal medicine practitioners and nurse navigators into the process in 2012
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Atlanticare- State Rankings 2010
QualityRank in New
Jersey
Joints 34/45
Spine 19/20
Overall 18/30
VolumeRank in New
Jersey
TKR 3/42
THR 3/42
Hip Fx 10/42
Spine 27/27
Spine Fusion 21/21
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2010 Star Report
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Released to the Public: October 14, 2009
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Why Such Low Ratings?
Preventable medical complications:
– Acute Renal Failure
– Heart Attack
– Pneumonia
– Delirium
– GI problems
– Urinary Retention
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Center for Perioperative Medicine (CPM)
• Focused on quality patient care and reducing complications for the elective surgical patient
• Medical model, Patient centered
• Standardized assessment/Algorithm
• Risk stratification process
• “Optimization” of patients vs. “Clearance”
• Reduced complications
• Reduced LOS
• Reduced same day cancellations
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Center for Perioperative Medicine (CPM) Staffing
3 Hospitalist (internal medicine) physicians
2 APN/PA providers
6 RN concierge (including one TL) 40 phone calls daily (8-10 calls per RN)
3 Medical Assistants
1 Registration person
3 Administrative associates
1 Clinical Manager
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Center for Perioperative Medicine (CPM) Overview
• RN Concierge calls patient shortly after surgery scheduled
• Phone interview/assessment, “Trigger Form”
• “Quick Pass” visit vs. “Comprehensive” visit scheduled
• PA/APN and/or Physician assessment
• Labs and studies reviewed
• Communication to surgeon and PCP/specialists (phone and via EMR)
• Completed chart, including summary form and “At Risk” guidelines , is sent to Same Day Surgery (SDS)
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Trigger Form
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“At Risk” Guidelines
• Guidelines help drive the care at each stage;
• Color Coded
• Evidence based
• Alert for providers
• Risk stratified order sets post op
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Outcomes• Reduced complications
• Decreased length of stay
• Increased reimbursements
• Increase quality of care
• Patient satisfaction
“We are not cancelling surgery………..We are cancelling complications by postponing surgeries”
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Total Knee Replacement - AtlantiCare Regional Medical Center - Atlantic CityActual vs. Predicted Complication Trends & Comparison - Annual
2014 Q2 - 2017 Q1 Client – All Payer
1.44%1.67% 1.52%
6.50%
7.17% 7.06%
2.54%
5.73%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
Q2 '14 - Q1 '15 Q2 '15 - Q1 '16 Q2 '16 - Q1 '17
Actual Predicted Top Perf Actual Top Perf Predicted
0.22 0.23 0.21
0.44
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Q2 '14 - Q1 '15 Q2 '15 - Q1 '16 Q2 '16 - Q1 '17
A/P A/P Top Perf
Year Volume Complications
Q2 '14 - Q1 '15 1181 17
Q2 '15 - Q1 '16 1255 21
Q2 '16 - Q1 '17 1318 20
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Total Hip Replacement - AtlantiCare Regional Medical Center - Atlantic CityActual vs. Predicted Complication Trends & Comparison - Annual
2014 Q2 - 2017 Q1 Client – All Payer
1.73%1.52%
2.47%
3.83%
6.17%
6.50%
1.90%
4.35%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
Q2 '14 - Q1 '15 Q2 '15 - Q1 '16 Q2 '16 - Q1 '17
Actual Predicted Top Perf Actual Top Perf Predicted
0.45
0.25
0.38
0.44
0.00
0.20
0.40
0.60
0.80
1.00
1.20
Q2 '14 - Q1 '15 Q2 '15 - Q1 '16 Q2 '16 - Q1 '17
A/P A/P Top Perf
Year Volume Complications
Q2 '14 - Q1 '15 577 10
Q2 '15 - Q1 '16 593 9
Q2 '16 - Q1 '17 608 15
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Our results
1.58
1.91
1.54
1.711.62 1.64
0.00
0.50
1.00
1.50
2.00
2.50
2015 2016 2017
LOS All Hips
LOS All Knees
Length of Stay
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Discharge Disposition
56.8%
77.0%
86.4%
26.6%
7.1%
1.4%
16.6% 15.5%12.1%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2015 2016 2017
Home Home Health Sub-Acute Nursing Facility
Hips
29.0%
71.0%
78.0%
48.2%
14.0%
8.0%
22.7%
14.9% 14.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
2015 2016 2017
Home Home Health Sub-Acute Nursing Facility
Knees
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0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
1st Q 2016 2nd Q 2016 3rd Q 2016 4th Q 2016 1st Q 2017
ReadmissionKnee/Hip allpayer O/E
ReadmissionKnee/HipMedicare O/E
Readmission Data Q1 2016 - Q 1 2017
Readmissions
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Customer Satisfaction
80
82
84
86
88
90
92
94
96
98
100
1st Q2016
2nd Q2016
3rd Q2016
4th Q2016
1st Q2017
Communicationwith Doctors -All DB
Communicationwith Doctors -NJ Peer Group
Communication with Doctors
80
82
84
86
88
90
92
94
96
98
100
1st Q 2016 2nd Q2016
3rd Q2016
4th Q2016
1st Q 2017
Ratehospital-All DB
Ratehospital-NJ PeerGroup
Rate Hospital
Percentile Scores-Top Box, Press Ganey Survey, Joint InstituteAll Database includes 2247 other like-facilitiesNew Jersey Peer Group includes 56 like Facilities in NJ
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Our Results
AtlantiCare Regional Medical CenterNew Jersey Rankings
22
Cohort Quality Rank
Joints 3/44
Spinal Surgery
20/24
Ortho Overall
4/30
Cohort Volume Rank
TKR 3/44
THR 3/44
Hip Fx 11/44
B&N 20/27
FUS 9/27
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2017 Star Report
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Lives Saved List
• CPM identified 53 patients (2015- 2017) who received potential life saving interventions such as stents, CABG, and TAVR (all performed here at AtlantiCare).
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Our Journey-Same Day Joints
• Surgery at 7am, discharge by 5pm.
• Plan to move to ASC in 2 years
• Schedule patient as SDS, authorize outpatient
• Brief stay on Orthopedic unit
• Over 35 successful joint replacements
• All discharged to home, no post acute services
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Patient Selection Criteria• Primary TKA/THA only• ASA 1 or 2 • Age <65• BMI <30• Hemoglobin
– >13 (males) – >12.0 Females
• Well controlled DM, dyslipidemia, Asthma
• Patient must be able tolerate ASA for anti-coagulation prophylaxis
• Patient must be motivated and active prior to surgery
• Ideal home situation
Contraindicated in patients with :• Cardiac stents, valves• Hypertension (multiple medications)• DM (uncontrolled or newly diagnosed)• CAD/CHF• OSA/COPD• CKD• Liver disease• History of VTE (PE, DVT)• Urinary issues (incontinence, retention,
BPH)• Neurological disorders (Parkinson’s,
dementia, stroke, TIA, spinal issues)• Psych disorders (major depression,
bipolar, schizophrenia)• Chronic steroids• Drug abuse• Hematologic issues • History of falls/osteoporotic fractures
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Anesthesia Considerations
Pre-Op Intra-op Post-op
• Celebrex 200mg• Oxycontin 10 mg • Gabapentin 300 mg• Tylenol 1000mg
• Short acting spinal• IV Hydration 1-2 Liters• Decadron & Zofran• TXA• Adductor blocks (knees) • Periarticular injections
(by surgeon)
• Fentanyl/morphine• Toradol• Zofran• Rx for Oxycodone,
Tramadol, Zofran
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Patient Expectations
• Starts with the surgeon
• Same message at each touch point
• Preoperative Joint Class
• RN navigator
• Discharge instructions
• Follow up phone calls
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Opportunities• Pain control/Reduction in opioid use
• Readmissions
• ED/ Urgent Care
• PCP follow up
• Post discharge follow up phone calls
• Spread best practices to Joint program overall
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Questions?