Managing Behaviors in Bundled Payments: Patients, Physicians, and Organizations

Although many people write about implementing bundled payments, few articles provide a level of detail about what works and how to administer key aspects of care redesign within a physician group practice. As a follow-up to a previous article on setting expectations, Jason McCormick, Manager of Process Improvement at Campbell Clinic Orthopaedics in Germantown, TN, shares another key approach to a successful bundled payment program: managing behaviors. Campbell is one of the orthopedic groups we, Signature Medical Group, work with directly as a Convener in the Bundle Payment for Care Improvement (BPCI) initiative. Jason agreed to discuss how identifying, managing, and redirecting behaviors are essential to success in bundled payments.

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Jason McCormick explains:

At Campbell Clinic, we laid the foundation for participating in the BPCI initiative by analyzing our data and setting expectations for how we would manage an episode of care. Based on our knowledge and expectations going into the program, we developed what we thought was a strong program that would identify patient needs, prepare patients for their post-surgical journey, and provide the highest quality care. We knew there would be a learning curve with our first BPCI patients as we worked with partners, patients, and organizations to ensure successful outcomes.

Within our first few weeks of participation in BPCI, we found the learning curve was steep as unexpected variables came from all angles. We were constantly being faced with new situations, obstacles, or hospital processes we did not anticipate when we first developed our program. The common theme to these unexpected variables was recurrent maladaptive behaviors by patients, physicians, and organizations. We quickly realized our success would be dependent on managing these behaviors.

Managing Patient Behaviors

The Campbell Clinic recognized for many total joint replacement patients, maladaptive behaviors are habits patients have had for years. These habitual behaviors, such as smoking or maintaining an unhealthy diet, can lead to postoperative complications. These complications are reduced when patients address the habits prior to surgery. Campbell Clinic has recently implemented a medical management program, utilizing a Nurse Practitioner, who works with surgical candidates to help patients meet goals to minimize unhealthy behaviors prior to surgery.

Campbell Clinic has also successfully managed patient behaviors through requirement of a physical therapy pre-habilitation appointment prior to surgery. By educating total joint replacement patients on the postoperative routine and exercises required following discharge from the hospital, patients have improved post-acute outcomes and restored functionality sooner than those who had not attended pre-habilitation prior to surgery. Unlike the management of already existing unhealthy behaviors, pre-habilitation is a way to encourage healthy new behaviors.

Managing Physician Behaviors

Physicians have a significant impact on the BPCI initiative through their knowledge of the program, joint replacement protocols, engagement with BPCI, and interactions with patients. Campbell Clinic found when physicians are asked to be active participants in developing the initiative, they are more invested in the initiative. When physicians are invested, they are instrumental in helping their patients buy into the initiative as well. Engaged physicians are able to better manage patient behaviors.

Campbell Clinic created an internal committee of total joint physicians to help guide clinical conversations, decisions and ensure physician voices were heard. This group was instrumental in collaborating with practice administration to identify best practices and create standardized protocols. Managing physician behavior through standardization of protocol has resulted in more streamlined care and improved patient compliance with post-surgery orders.

To maintain physician engagement with BPCI, practice administration needs to provide consistent and continuous support as physicians navigate this new and unfamiliar journey in bundled payments. The Campbell Clinic total joint physicians have immediate access to staff who understand the BPCI initiative when questions arise. It is important physicians get immediate answers to their questions regarding a patient’s care plan and BPCI protocols so the physicians do not view BPCI as a burden preventing them from doing their work. It is our goal to take the guesswork out of BPCI and allow our physicians to concentrate on delivering the highest quality care.

Campbell Clinic keeps physicians up-to-date on bundled payment developments including the latest data regarding overall BPCI performance and individual performance and trends. When problems are identified within our own practice, physicians are notified immediately of the issue and what potential fixes are available. This may be as easy as changing post-acute providers from one partner to another, or as difficult as trying to identify causes for a high readmission rate and offering to review case details with the physician.

Managing External Organizational Behaviors

Probably the most difficult of all behaviors to control is that of the hospitals, rehab facilities, and any other facilities or providers not associated with your organization. These facilities or providers do not have the same motivation your practice and physicians may have, so it is common to see conflicting patient orders or requests when working with BPCI patients. Conflicting orders can confuse the patient and cause them to become concerned about their course of treatment. It is always best to manage issues with external providers from an administrative standpoint.

Hospital behavior must also be assessed and managed. It is imperative the hospital adhere to the course of treatment identified by the orthopaedic physician and not make separate discharge plans for the patient. Campbell Clinic addressed this issue by changing standing orders regarding discharge plans for BPCI patients. The discharge plans for BPCI patients must now be aligned with the plan of care communicated by Campbell’s BPCI case manager and operating physician.

The behavior of other partner facilities and providers is managed through data review to make sure our expectations are being met. If a facility is not meeting the originally established expectations, the facility is notified and Campbell Clinic patients are shifted to other partner facilities. Campbell Clinic has found this method to be an extremely valuable tool to keep external partners accountable for their decisions and their actions regarding BPCI patients.

These Best Practices are Replicable and Scalable

Campbell Clinic is fortunate to have extremely talented physicians who are committed to the quality of care they deliver. We have also been fortunate to have a group that collaborates together to discover best practices and protocols in every aspect of clinical quality care and the business of health care. But, when it all comes down to it, I believe any organization can experience similar success in bundled payment programs if they focus on setting expectations and managing behaviors.

Thank you Jason for your insights.

By the Signature Bundled Payment team and Jason McCormick, Manager of Process Improvement, Campbell Clinic

Contact Signature at SMGbundles.com for more information or assistance in working with bundled payments.

Contact Jason at jmccormick@campbellclinic.com or connect with him on LinkedIn.

Ann Conrath