Current research on major joint replacement points to successful uses of home health care as the post-acute care setting for patients. Merits of home-based care include reduced cost, improved clinical outcomes, and increased patient satisfaction. Now, with the recently introduced Centers for Medicare and Medicaid Services Comprehensive Care for Joint Replacement (CJR) Model, which will begin on April 1 of this year, home health sits at the forefront of providing cost-effective and high-quality patient care for patients following hip and knee replacements.
The low rates of 30-day readmission for patients with MS-DRG-470 (major joint replacement) (the 30-day readmission rate nationally is 3.54% from home health, compared with 6.83% from skilled nursing facilities), make the benefit of home health, especially after hip and knee replacement, crystal clear and should help CMS and those participating in the CJR Model to better understand the best means of treating patients.
Knee replacements are one of the most common surgeries performed on Medicare beneficiaries, underscoring the need to develop models that improve patient care delivery, including enhanced efficiencies and reduced costs. Nationally, nearly 10 percent of total home health Medicare Part A home health claims are for patients receiving care after a major joint replacement or reattachment of lower extremity without major complications of comorbidities. Among home health claims, major joint replacement is over three times more common as an MS-DRG than the next most common MS-DRG. In 2013, almost 200,000 home health Part A claims were filed nationally for patients after hip and knee replacements, signaling a need for high quality, safe, and cost-effective models of care after such orthopedic procedures. According to the Clinically Appropriate and Cost-Effective Placement report from 2012, when home health agencies are the first setting of care, Medicare sees an average of over $5,000 in cost savings for each MS-DRG 470 patient’s episode (defined as inpatient hospitalization and the 60 days post-discharge).
In addition to the clinical and cost savings benefits above, recovery and therapy in the home setting allow clinicians to address the unique needs of individual patients, make families feel more comfortable in assisting with care, and assists patients to more quickly resume activities of daily living, such as bathing and dressing. The Cleveland Clinic Model for Home Care After Knee Replacement, profiled in the Cleveland Clinic Journal of Medicine supplement article, “In-home care following total knee replacement,” provides an excellent example for the future success of the CJR Model.
The article outlines The Cleveland Clinic Total Knee Care Path, an integrated care approach, emphasizing home health care in discharge planning and care transitions. Patient and family education is critical and should begin early and remain consistent. The following goals are emphasized in the Cleveland Clinic program:
- Shared decision-making
- A home care environment that includes support of family and friends
- Patient and family education to enhance shared decision-making
- Return to the home environment as soon as it is deemed safe
- Elimination of unnecessary or duplicative treatments, tests, or interventions
- Acceptance of multiple plans or paths in response to changing clinical conditions
In the 10 years since the Cleveland Clinic has integrated home health care into recovery from a total knee replacement, results have been very positive, including a reduction in the average acute care hospital length of stay, increased discharge to home rates, reduced readmission rates, and lower costs to the overall system. In fact, patients discharged to home use fewer resources and cost the system one third as much as patients who receive inpatient post-acute care. Discharge to home rates rose from 32 percent to 74 percent, and hospital stay length decreased by an average of almost one full day, saving money by limiting longer facility stays.
The CJR Model represents a step forward in promoting quality care for patients, as the home is, when clinically appropriate, an ideal setting for patients after an acute care stay when coupled with skilled home health care services. By looking at the readmissions and cost data, along with the successful CCJM Model, we can get a clearer picture of the ways of home health can be utilized to maximize outcomes, reduce cost, and improve patient experience.