Case Management Society of America


Navigating Excellence: Professional Case Management Driving Exceptional Results in Value-Based Care Models


The Centers for Medicare & Medicaid Services (CMS) is in the process of transitioning from traditional fee-for-service reimbursement to a value-based care (VBC) model, providing payment to providers based upon quality care and outcomes for the millions of Medicare beneficiaries receiving medical services. As the baby boomers continue to age, there will be an increase in the number of total joint replacements due to a history of an active population as well as the increase in obesity rates. According to the American Academy of Orthopedic Surgeons (AAOS), by the year 2030, there will be a projected increase of 673 percent in total knee arthroplasties (TKA) and a 174-percent increase in total hip arthroplasties (THA). As part of this process, Medicare developed the Bundled Payment for Care Improvement program (BPCI) in 2015 for provider groups or hospitals that volunteered to participate. In the BPCI program, the participants receive financial incentive reimbursement based upon a target price that is set by the provider’s historical claims data for various DRGs. The current BPCI program runs through the end of the third quarter of 2018. BPCI includes all medical costs incurred during the time period ranging from 30, 60 or 90 days (as selected by the provider) after the episode is initiated.

In the orthopedic BPCI program, multiple procedures can be included, such as total hip replacements, total knee replacements, certain types of hip fracture repairs, total ankle replacements, spine procedures and shoulder replacements. In 2016, Medicare implemented the Comprehensive Care for Joint Replacement (CJR) Program, which includes 67 metropolitan areas in the U.S. and approximately 800 hospitals. These hospitals are mandated to participate in the program, which includes patients who are undergoing hip and knee replacements during a five-year period. For the first three years of CJR’s planned duration, the hospitals are competing against their historical costs; however, in 2019-2020, the hospitals will be reimbursed by the average cost within a region. The difference between the two programs is who is “in the driver’s seat”: the physician’s office (BPCI) or the hospital (BPCI or CJR).

Historically, medical and surgical care has been fragmented as each provider along the continuum of care “did their own thing.” This fragmented care is partially due to a lack of communication among providers, leading to increased medical costs, duplication of care, readmissions, prolonged post-acute services and lack of knowledge and expectations for Medicare patients. The desired outcomes for a bundled program include decreased inpatient length of stay, decreased complications of surgery, significant decrease in hospital emergency room visits or readmissions, decreased utilization and length of stay in skilled nursing facilities (SNF), decreased use of home healthcare as well as outpatient physical therapy, and a quicker and smoother recovery for the patient through patient education. It is important that the provider adjusts from requiring additional resources based upon need and accommodation of the patients’ desires, to a stringent regimen of medically necessary services and the input of case management. It is not unusual for providers under the plan to strive for discharge to home.

In order for the bundled program to be efficient, the provider needs to align with a strong post-acute care network and philosophy. Post-acute providers include SNFs, assisted living facilities, home health agencies, outpatient physical therapy, local urgent care centers, as well as primary care providers. By reaching clinical and financial outcomes, the physician practice or hospital will earn additional income and Medicare will save money. If clinical and financial outcomes exceed the target price, the physician practice or hospital is responsible for paying penalties to Medicare.

Patients need a team approach and the coordination of care, which is the core of the case management program in BPCI and CJR. These relationships occur through communication among case management, the patient/family and post-acute providers. The orthopedic case manager discusses discharge needs when the patient is scheduled for surgery and develops a discharge plan based upon patients’ medical necessity and medical comorbidities. If the patient has medical comorbidities that could possibly lead to post-operative complications, the case manager will make suggestions to the surgeon that the patient have further work-ups and clearances and, potentially, postpone the surgery until the patient is optimized. The team players include the patient, caregiver, case manager, physician, hospital staff (hospitalist, RNs, PT), consulting physicians, SNF, HHA, and outpatient physical therapy. All team members are aware of the purpose and role of the case manager, as well as and the expectations of the bundled program in terms of positive patient outcomes with decreased utilization of services. The case manager meets regularly with all post-acute providers on expectations and outcomes of their agency. This communication helps to avoid complications that previously warranted a visit to the local emergency department and possible inpatient admission. Due to improved communication among post-acute providers and the orthopedic case manager, patients are instead able to be seen by their surgeons or primary care providers, which is more cost effective.

The orthopedic case manager develops a relationship with patients when they are scheduled for surgery and begins to initiate a discharge plan from the acute care setting. The patient, caregiver and surgeon are included in the planning process. Case managers are aware of the importance of a smooth transition of care from hospital to home or from SNF to home. In addition, the case manager understands the medical and psycho-social needs of each individual to ensure the safety of the patient. The case manager contacts the patient within 24 hours of hospital discharge and performs a medication reconciliation, as well as ensuring the patient is aware of therapy needs.

In order to meet patients’ needs for rehabilitation after a TKA or THA, physical therapy is required starting the day of surgery. Physical therapy continues after hospital discharge, up to six to eight weeks for the average patient. Traditionally, the home health agency (HHA) was contacted by the hospital discharge planner and would send registered nurses and physical therapists into the home for up to approximately three weeks. Traditional home health is provided by an HHA and billed under Medicare Part A. Physical therapy under part A is reimbursed at a much higher rate than the exact same treatment under Part B. The therapy team of the preferred HHAs have been instructed on the orthopedic protocol and the anticipated number of visits for each patient as well as each surgeon’s preference for therapy goals. The majority of patients will be seen between four to six visits over a two-week period and then transition to outpatient physical therapy. Also, HHAs often provide skilled nursing care in addition to the physical therapy. The addition of nursing care and the typical long duration of therapy provided in the home by the HHAs results in higher reimbursement rates, at an approximate cost of $2,500-$3,500 per episode of care. These expenses are included in the bundled program.

Patients who do not have a lot of comorbidities and have able caregivers are sometimes sent to outpatient therapy after hospital discharge. The decision is made by the surgeon during the pre-op visit and by the orthopedic case manager during the assessment phase, prior to surgery. If outpatient physical therapy is determined, the case manager ensures the patient is scheduled for the first visit within three to four days of surgery. The case manager will help identify therapy clinics that are known to the practice for providing good outcomes.

In 2015, the orthopedic case manager at The Jewett Orthopaedic Clinic in Winter Park, Florida, was looking for a way to reduce home health costs. She contacted CORA Physical Therapy and asked if it would be possible to develop a home program for Medicare patients; the program was implemented on Oct. 1, 2016. As a Certified Rehab Agency, CORA provides home therapy to TKA and THA patients under Medicare Part B, with a typical home visit costing approximately $100. Over the first six months of the program, CORA’s home therapy division averaged 3.78 visits per patient, resulting in an average projected cost savings of $2,000 to $3,000 per patient. The orthopedic case manager communicates discharge plans with the hospital discharge planners for the patients who are appropriate to return home with CORA’s program.

The goal of home physical therapy is to achieve safe independence in gait and activities of daily living as a result of the home program. Ideally, a patient will go to the outpatient physical therapy center at least once prior to the surgery for assessment, education and to develop a relationship with the therapy team. Patients complete necessary paperwork and are educated on home exercise programs that will strengthen their muscles prior to surgery. The therapists also educate patients on the exercises they need to do post-operatively, as well as gait training with an assistive device. Patients report that developing this rapport has lessened their anxiety prior to the procedure. The therapy team is educated on the importance of communicating expectations to the patients, such as going home in lieu of SNF, home exercise program compliance, and pain management. Therapy attempts to schedule the patient’s first home visit within twenty-four hours of hospital discharge. Patients are seen at home until the initial short-term goals have been achieved and they progress to an outpatient physical therapy clinic close to their homes.

Therapists at the local outpatient clinics have noticed that patients are progressing more quickly through their outpatient care, because they are starting with increased strength and range of motion and knowledge on continued expectations for improvement. At the outpatient clinic, therapists continue to work with the patients on increased range of motion, strength, and return to normal gait and function for approximately twelve visits over a one-month period. Patients are returning to a higher level of function and better outcomes, proven by lack of need for an assistive device and progression to independent fitness and improved quality of life.

Several physicians have stated that they have seen an improvement in patients’ progress when they are seen at their two-week post-op visit. Physicians have also reported a decrease in phone calls about possible concerns, like infections or lack of progress with therapy, and patients have told them they have been very happy with this service.

Medical care continues to evolve in terms of procedures and reimbursement. The ultimate goal for all is for improved outcomes for patients while controlling costs. Communication among all team members will be imperative to assure alignment with this initiative.

Sally Darlin, PT, ATC, LAT, CEAS, is vice president of operations and home therapy for CORA. She joined CORA Physical Therapy in 1999 and currently oversees the 35 clinics in Orlando, Volusia, Brevard, Polk and Highlands Counties, and established the home therapy program in October of 2016. She attended the University of Florida for B.S. degrees in Athletic Training (1988) and Physical Therapy (1990), and became a Certified Ergonomics Assessment Specialist in 2011.

Sherri Eisenstein, BSN, RN, CCM, has clinical experience in the areas of inpatient surgery, labor and delivery and home healthcare, and has been a case manager since 2005. In 2015, she started at The Jewett Orthopaedic Clinic as a nurse case manager to develop and implement Orlando’s first Medicare bundled payment program for patients having lower joint replacements. She attended the University of Maryland School of Nursing.