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For Bundles to Work, Doctors Need to Think Different

Article · December 20, 2016

Bundled payments are a key strategy in the large-scale shift to value-based payment models. A growing number of observations show bundles to be saving money and enhancing patient care — outcomes that transcend party lines.

When successfully implemented, bundled payments create meaningful change in the way care is organized, providing improved coordination over the course of a patient’s episode of care. (For purposes of this post, “episode of care” refers to an acute illness or procedure and the subsequent recovery period.)

One of the most important changes spurred by bundles lies in how physicians may adjust the way they practice. Much of the opportunity to improve value lies in removing needless spending during the period following a hospitalization. For patients, this means spending more time recovering at home and less time in facilities. So what do doctors need to do differently to enable a home recovery?

Here are three keys for surgeons, primary care physicians, hospitalists, and medical specialists to make bundled payment programs work.

Assume leadership of the “next site of care” decision during hospital discharge planning.

Physicians can no longer default to the discharge team — case managers, physical therapists, nurses, and social workers — when deciding on the next site of care. Instead, physicians will be called upon to be the team leader as next site of care planning is carried out. This involves understanding the patient needs that determine the most appropriate next site of care and grasping the differing capabilities of home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term acute care hospitals (LTACs).

There are some key considerations regarding patient needs and abilities. Can a patient physically and cognitively perform activities of daily living? How much help does he or she need in making a transfer? Is a capable caregiver available at home? What are the patient’s needs for therapy and skilled nursing? Physicians will work closely with the discharge team to assemble these data and gain an accurate picture of a patient’s fitness to recover at home versus in a facility.

If recovery in a facility is most appropriate, the physician can work with the team to determine the best type for the patient. For patients requiring short-term rehabilitation, and for those for whom facility versus home discharge is unresolved, early involvement of a home health agency during the hospitalization may allow for more informed next site of care decision-making, as well as close follow-up after discharge (whether or not there is an intervening stay in a facility).

Ensure that patients are mobilized early and often.

Regardless of a patient’s principle diagnosis and comorbid illnesses, functional status has a major impact on recovery. During hospitalization, patients remain in bed too often, as the staff focuses on delivering medications and other treatments. The deleterious effects of immobility are well documented. Bundled payment models provide new incentives to avoid keeping patients in bed needlessly, as immobility and deconditioning increases the chances for facility-based care after discharge.

An early mobility program is carried out by non-physicians but requires engagement of the lead physician. These programs use protocols to mobilize patients, often deploy nurse’s aides or the equivalent to perform mobilization, and take steps to ensure patients move regularly while in the hospital. A good early mobility program uses physical therapists judiciously, reserving them for complex cases and avoiding routine consultation simply to mobilize the patient.

Ensure that patients’ goals of care are elicited, and when appropriate, palliative or hospice care is delivered.

Physicians must have the conversational skills to draw out patients’ goals of care, especially where advanced or severe chronic illness is involved. Patients are often relieved when their physician brings up the matter of care goals. In some cases, onerous interventions like hospitalization, emergency room visits, or procedures may be avoided in keeping with a patient’s wishes.

When it comes to life-limiting illnesses such as cancer or advanced heart failure, physicians should have an approach to identifying patients who would benefit from palliative or hospice care beyond a care goals conversation, and delivering such care when appropriate. One approach is for the physician to ask himself or herself this question: “Would I be surprised if the patient died in the next year?” A “no” answer has been shown to have good ability to predict death within a year.

Recently, a colleague questioned the need for, and appropriateness of, having physicians apply the skills described here — which often require new learnings for doctors. I offered this musical metaphor: the physician plays in the band, but is also its leader. The world of value-based health care is a new genre, requiring that the band leader not play all instruments but understand and direct how each creates new rhythms, melodies, and harmonies. For a patient in a bundled payment episode to recover successfully in the least restrictive, most appropriate setting, all members of the band must be in sync, following the cues of its leader: the physician.

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