Page 14 - South Florida Hospital News July 2021

Cover Story: Navigating Bundled Payments

Continued from page 1 healthcare system. Engaging providers more compassion, which aligns with the Advanced Care Planning as one of the

support personnel. Here at Holy Cross (physician/surgeon/nurse/thera pist) in a Holy Cross Health mission and core val- quality measures of the BPCI-A program.
Health, our model allows easier access to model that supports standard work and ues that include reverence, stewardship Patients can identify a healthcare surro-
our clinical and support teams for our being able to demonstrate the value add and integrity. In BPCI your reimburse- gate or proxy if they are unable to docu-
Advanced Payment Model Population and resultant benefits to patients, ment is not just for the acute admission, ment a plan at that time.
(BPCI-A, ACO & CJR) which is led by providers and healthcare system presents it covers the post-acute care costs as well. I have observed that many healthcare
our Population Health Nurses (PHNs) its own challenges. Healthcare systems Our financial responsibility for the surrogates feel conflicted when the
who assist our patients/families navigate participating in these risk model pro- patient continues beyond the hospital advanced directives do not clearly state a
our complex healthcare system. grams also need to be agile so they can walls and for a period of 90 days after patient’s wishes. We recommend that
Our PHNs and other members of our respond to the programmatic changes their hospitalization or their outpatient these discussions pertaining to advanced
care management team focus on transi- from Medicare. procedure. directives take place in advance so there
tion management with an emphasis on From a programmatic perspective, I Collaborating with our Community are no questions and there is no confu-
proactive patient management this have found the three-day waiver in BPCI- Partners including other Hospital Sys - sion should a health episode arise.
includes early identification of patient Advanced to be misaligned with the tems, Skilled Nursing Facilities, Home Palliative care and hospice care servic-
needs while in the post-acute setting and objectives of the initiative. Health Agencies helps to facilitate the es are also not appropriately utilized. It
addressing barrier(s) to care, some of The waiver could potentially help ease of information sharing that allows makes sense to have access early for
which are socially influenced. avoid readmission during days 3 through for continuity of care. It promotes com- chronic conditions such as Chronic
Care Redesign: The heart of care 90, unfortunately it can only be used munication between providers and with Obstructive Pulmonary Disease (COPD),
redesign has cultural underpinnings and within the first 30 days after discharge. providers and patients and their families. Congestive Heart Failure (CHF) or End
very early in our process of redesigning There is already a provision that allows An important element in healthcare Stage Renal Disease (ESRD) so teams
care we identified the need to change our Skilled Nursing Facility admission dur- that does not get the necessary attention that are experienced in helping to man-
approach and terminology when our ing this period once the patient meets is that of advanced directives and their age chronic conditions can assist in help-
patients were leaving the hospital. We the qualifying 3 midnight stay while an importance in guiding healthcare deci- ing to improve a patient’s quality of life.
started to socialize the term transition inpatient so this waiver does not provide sions that support honoring a patient’s
among our colleagues with a focus on any benefit to program participants. wishes when they can no longer speak
moving from discharge to a transition Communication and Accountability for themselves.
process. Across the Continuum of Care: At Holy A person-centered approach to health- Lorraine Marshall, Director Population
Standardizing care delivery using evi- Cross Health, we call this “transitioning care promotes educating patients on the Health/Clinical Executive Integrated Care
denced based best practices across the patient.” It’s more than just a dis- importance of documenting their wishes Coordination at Holy Cross Health, can be
healthcare settings – hospital, subacute charge, it’s a warm hand off to additional and sharing this document with their reached at (954) 202-4942 or
and home – helps to improve quality of healthcare providers that are part of the healthcare providers. Its importance was lorraine.marshall@holy-cross.com.
care and success for the patient and the continuum of care. Transition conveys reinforced when CMS introduced

E-mail Your Editorial Submissions to
editorial@southfloridahospitalnews.com

14 July 2021 southfloridahospitalnews.com South Florida Hospital News