Orthopaedic Co-management Development of a Fracture Liaison Service for Northern Arizona Healthcare

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1 Orthopaedic Co-management Development of a Fracture Liaison Service for Northern Arizona Healthcare Tim Bonatus, DO Northern Arizona Orthopaedics

2 Orthopedic Co-Management 2012 Northern AZ Healthcare (NAH) Strategic Plan Ortho & Spine largest & most profitable SL 14 Orthopedic Surgeons -2 Practice Groups 1 Physician Owned Surgery Center Orthopaedic Management Company LLC 6 Managers (Dir., 2 Practice CEOs, 3 surgeons)

Surgeons -2 Practice Groups 1 Physician Owned Surgery Center

3 Co-Management Quality Initiatives 2012 (tactical initiatives, 2 year agreement) Value of Co-Management Appraised, Tiered $ goals Patient Satisfaction OR First Case On-Time Start Surgical Infection Prevention Protocol DVT Prophylaxis Protocol & Compliance Demand Matching Total Hip & Knee Implants 2013 Continued 2012 PII s e-documentation, EMR Trauma Implant Consolidation Joint Replacement Program and Spine Redesign 2014 (more strategic) 6 Care Process Models Query Response Time AJRR Commercial Bundled Payment Pilot, considering CMS BPCI TJAs Quality Dashboard developed (Midas Statit)

Knee Implants 2013 Continued 2012 PII s e-documentation, EMR Trauma Implant Consolidation Joint Replacement Program and Spine Redesign 2014 (more

4 Co-Management Quality Initiatives 2012 (tactical initiatives) Patient Satisfaction (FY2010/ % Excellent, FY15YTD 77.9% OQC) OR First Case On-Time Start (FY10/ %, FY %. Surgeon late 0.6% 6/963) Surgical Infection Prevention Protocol compliance/infection Rate (FY11 SSI 1.7% TKA, FY14 0.2% 1/506 TKA, 0% 0/273) DVT Prophylaxis Protocol & Compliance ( %, %) Demand Matching w/ LE joint replacement implants ( %, %) 2013 Continued 2012 PII s e-documentation ( %) Trauma Implants ( %) JRP and Spine Redesign 2014 (more strategic) 6 Care Process Models Query Response Time AJRR Also worked on Commercial Bundled Payment Pilot and currently considering contracting with CMS BPCI for joint replacements (was Jan, 2015 now July, 2015) Quality Dashboard (Midas Statit)

5%) Demand Matching w/ LE joint replacement implants (2012 95.0%, 2014 98.9%) 2013 Continued 2012 PII s e-documentation (2014 94.5%) Trauma Implants (2014 87.

5 Geriatric Hip Fracture Program Background, supported by Synthes 30% increase estimated between 1999 & yr mortality reported 20-40% Delays in fx. care = increased risk of mortality Complimentary program to JRP Collaboration between multiple groups Anesthesiology, Orthopedic Sx, Hospitalists/ Geriatricians, Cardiology Standardized Care Process, Order Sets, Work-Up, scripted Communication, e.g. Ready for Surgery

care = increased risk of mortality Complimentary program to JRP Collaboration between multiple groups

6 Geriatric Hip Fracture Program Results Achieved Metric Baseline (FY12) Goal Results Since Implementing (January 2012) Length of Stay 7.5 days 5.5 days 5.7 days (n=317) Decreased Admission to OR time Average Hours in Emergency Dept hours Less than 24 hours 24.6 hours 3.6 hours Less than 3 hours 2.5 hours Quality Readmission/Rate 11.9% 30-day readmission (2 yrs) 6% 30-day readmission 5.7% 30-day readmission (n=16/317) Mortality rate 2.6% Mortality 1.3% Mortality 2.5% Mortality (n=8/317)

6 hours Less than 24 hours 24.6 hours 3.6 hours Less than 3 hours 2.5 hours Quality Readmission/Rate 11.

7 Osteoporosis Evaluation Labs part of Geriatric Fracture Admission Order Set. Calcium, Vitamin D, others Own the Bone, FRAX fracture risk assessment tool Patient Education Letter to Patient, PCP at Discharge

$fracture risk assessment tool Patient Education$

8 Clinical Collaboration Care Process Models (CPMs) Create a standard of care for patients based on best practice, evidence-based medicine Reduce Unnecessary Variation Individualize to patient need Physician Led To improve quality of care by reducing unnecessary variation Reduce mortality, readmissions and complications

Variation Individualize to patient need Physician Led To improve quality of

9 Ortho CPMs 6 CPMs have been developed All six went live on January 1 st, 2015 Osteoporosis Osteoarthritis Hip Replacement Knee Replacement Shoulder Replacement Spine Surgery Other CPMs: CHF, DM, ACS

10 CPM Creation Process Literature Search/Best Practice Consensus Develop the Provider Reference Created PowerPlans (standard orders) Standardized Patient Education Develop Control Plans Metrics

11 Provider References Osteoarthri*s CPM

12 Next OSL Initiatives Care Process Model Maintenance Spine Surgery, THA, TKA, TSA, OP, OA Outpatient Spine Surgery CPM Patient Reported Outcomes Project Geriatric Fracture CPM Fracture Liaison Service

13 Fracture Liaison Service (FLS) All Pathologic Fractures (due to bone fragility) follow-up in a Centralized Clinic. Started with hips, then expand to other fractures Seen by a PA with interest and certification in Osteoporosis Management. Surgeon Supervises If Post-Op and within The Global, can bill for the Osteoporosis Care. Patients & PCPs impressed Brings Patients to Office Supports Population Health Care

$Started with hips, then expand to other fractures Seen by a PA with interest and certification in$

14 Complete Osteoporosis Evaluation in Post Op Global 1. Remove sutures, staples, wound check F/U Labs, Order DEXA, Teachable Moment 2. X-rays Clinical Follow-up Fracture DEXA performed 3. Final Fx Follow-up, X-rays DEXA reviewed, Medical Rx Started Letter with plan, recommendations to PCP and Patient

Moment 2. X-rays Clinical Follow-up Fracture DEXA performed 3.

Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015

Leveraging the Continuum to Avoid Unnecessary Utilization While Improving Quality Leadership Summit for Hospital and Post-Acute Long Term Care Providers May 12, 2015 Karim A. Habibi, FHFMA, MPH, MS Senior