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Baskets of Care Initiative
The concept of baskets of care that was included in the 2008 health reform law seeks to bundle
payments for a set of health care services together in ways that will create incentives for health
care providers to collaborate and develop innovative ways to deliver effective, high quality, and
lower-cost health care services. The 2008 health reform law defines a “basket” or “baskets of
care” as a collection of health care services that are paid separately under a fee-for-service
system, but which are ordinarily combined by a provider in delivering a full diagnostic or
treatment procedure to a patient.
The Institute For Clinical Systems Improvement is under contract with the Minnesota
Department of Health to facilitate the community-driven baskets of care development process.
In early 2009, the Commissioner of the Minnesota Department of Health convened the Baskets
of Care Steering Committee whose members have medical, health care delivery, and health care
administration expertise and represent stakeholder groups that may implement or use baskets of
care. In addition to identifying the initial seven baskets of care, the Steering Committee is also
charged with playing an active role throughout the course of developing and defining the baskets
of care.
The Steering Committee identified the seven initial baskets of care as the following:
Asthma (children)
Diabetes
Low Back Pain (acute)
Obstetric Care
Preventive Care (adults)
Preventive Care (children)
Total Knee Replacement
Baskets of Care Subcommittees, whose members represent relevant stakeholder groups and
medical expertise, were given the task of recommending definitions for each basket of care.
The seven subcommittees have defined the initial recommended scope for each basket of care
and reached consensus on recommended basket components based on evidence and evidenceinformed standards of practice. These preliminary recommendations are now available for
public review and comment. Each subcommittee was charged with creating a basket of care that
will serve as a uniform package of health care services while allowing for innovations in the
implementation of the basket of care. Each basket of care is defined with varying levels of
specificity. The establishment of a uniform definition for each basket of care will be essential to
facilitate consistency and comparability.
The following observations and considerations were consistently acknowledged by the seven
subcommittees:
Critical to the success of care delivery is:
Patient involvement
Care coordination
Portability of patient information
Ability of all providers to participate in delivery of baskets and collaborate
with each other on the delivery components
Correlation with the health care home concept
Payment re-design innovation is a must
In addition to care received as a part of a basket of care, patients can continue to
receive health care services that fall outside of the scope of a basket of care through
their existing health insurance coverage. Baskets of care are not meant to limit the
care received by individuals.
Life events may transition a patient in and out of a basket.
On the following pages you will find the preliminary recommendations for the scope and care
components for one basket of care. You may find it helpful to refer to meeting materials posted
on the Baskets of Care section of the Minnesota Department of Health’s Health Reform website
(http://www.health.state.mn.us/healthreform/baskets/index.html). The Minnesota Department of
Health is committed to the community-driven nature of the baskets of care development process.
Comments and feedback on the preliminary recommendations for the scope and care
components for each basket of care are being solicited through Monday, April 6, 2009.
Following the public comment period, the seven subcommittees will reconvene to review the
submitted comments and will review and refine their draft scope and care component
recommendations before presentation to the Steering Committee. The Steering Committee will
then review each subcommittee’s recommendations and provide final recommendations on a
uniform definition for each of the seven baskets of care to the Commissioner of the Minnesota
Department of Health; recommend quality measures for the baskets of care; identify operational
and administrative challenges associated with market adoption of baskets of care and participate
in identifying solutions to those issues.
Total Knee Replacement - Baskets of Care Scope and Components
For Public Feedback
3/25/2009
Scope
The total knee arthroplasty basket of care is for adults 18 years of age and older electing
unilateral primary (first time) total knee arthroplasty as recommended by orthopedic
consultation, with a body mass index less than 35, and any known systemic disease determined
to be stable (as evidenced by an ASA score of 3 or below). The basket of care begins when the
patient is evaluated for a preoperative history and physical by a qualified provider, as required
prior to the surgical procedure, and ends 90 days after the procedure.
Refer to attachment A for a list of Never Events that were they to occur would not require
additional financial considerations beyond that provided by the established basket.
Care Components
Description
Preoperative Phase
• Preoperative evaluation (H&P)
If indicated after medical investigation;
electrocardiogram, coagulation studies,
hemoglobin, potassium, chest x-ray
• Pre-surgery education including:
Procedure education
Physical therapy education & exercises
Deep vein thrombosis prophylaxis
(mechanical & chemical)
Nutrition discussion (referral if indicated)
Smoking identification (referral if
indicated)
• Case management for planning post
hospital discharge
Rationale
As outlined in the ICSI 2008 Preoperative
Evaluation Guideline
Decreased length of stay when patients
understand expectations prior to admission
Pre-planning reduces unnecessary hospital
days
Operative/Acute Care Phase:
• Anesthesia services
• Operating room services
• Knee prosthesis
• Imaging
1 set postoperative films and other imaging
as indicated
Refer to Additional Considerations section
below for expanded comments
Description
• Laboratory
Postoperative hemoglobin and other
laboratory studies as indicated
•
Deep vein thrombosis prophylaxis
Mechanical (TED stockings, plexipulse)
Chemical (anticoagulation medications)
Laboratory tests as indicated; international
normalized ratio (INR) if on Coumadin
• Post procedure facility services (hospital
days, transitional care unit (TCU), home
health, alternative sites)
• Medications
Prophylactic antibiotics
Continuation of home medications
• Pain Management
Intravenous and oral medications
Patient controlled analgesia
Femoral nerve block
• Physical therapy
Therapy sessions twice a day
Durable medical equipment (gait aids,
continuous passive motion (CPM) if
indicated)
Rationale
Significantly reduces the risk of postoperative
thromboembolism; additionally, machines like
plexipulse can control pain and reduce edema
Typically involves 3 hospital overnights;
represents opportunity for variation based on
care delivery system arrangements
Antibiotics to prevent infection; limited to 24
hours post procedure
Femoral nerve blocks increase the use of
anesthesia resources, but significantly impacts
post-op function and rehabilitation leading to
decreased length of stay
• Occupational Therapy (if indicated for
discharge to home)
• Medicine Consultation
Follow-up visits as needed
Medical management for medications/
conditions not related to the surgical procedure
• Case Management (inpatient)
Mobilize preoperative plan for disposition or
any changes necessary
Post Hospital- 90 days after
procedure:
• Postoperative follow-up surgical visits
Typically three visits: at 2 weeks, 6 weeks and
3 months
• Physical therapy
Therapy sessions typically 2 -3 times/week for
4 weeks
Therapy sessions
Durable medical equipment (gait aids,
continuous passive motion (CPM) if
indicated)
Description
• Occupational therapy (if indicated for
discharge to home)
• Deep vein prophylaxis
Mechanical (TED stockings, plexipulse)
Chemical (anticoagulation medications)
Laboratory tests as indicated; international
normalized ratio (INR) if on Coumadin
Rationale
Continued prevention of thromboembolism
• Pain management
oral medications
plexipulse for pain & edema if indicated
• Imaging
plain film of knee
Frequently knee film immediately postoperatively is of poor quality
• Home Health
• Transitional Care Unit
Transitional care unit, especially with shorter
hospital stay
Attachment A
Never Events
• Surgery on the wrong body part
• Wrong surgical procedure performed on patient
• Object left in patient after surgery
• Death of patient, who had been generally healthy, during or immediately after surgery for a
localized problem
• Patient death or serious disability associated with the use of contaminated drugs, devices or
biologics
• Patient death or serious disability associated with the misuse or malfunction of a device
• Patient death or serious disability associated with intravascular air embolism
• Patient death or serious disability associated with patient disappearing for more than four
hours
• Patient suicide or attempted suicide resulting in serious disability
• Patient death or serious disability associated with a medication error
• Patient death or serious disability associated with transfusion of blood or blood products of
the wrong type
• Patient death or serious disability associated with the onset of hypoglycemia, a drop in blood
sugar
• Severe pressure ulcers acquired in the hospital
• Patient death or serious disability due to spinal manipulative therapy
• Patient death or serious disability associated with an electric shock
• Any incident in which a line designated for oxygen or other gas to be delivered to a patient
contains the wrong gas or is contaminated by toxic substances
• Patient death or serious disability associated with the use of restraints or bedrails
• Any instance of care ordered by or provided by someone impersonating a physician, nurse,
pharmacist, or other licensed healthcare provider.
• Abduction of a patient
• Sexual assault on a patient
• Death or significant injury of a patient resulting from a physical assault in the hospital
Note: This list has been abbreviated from the complete list of 27 Never Events to only consider
those applicable to the Total Knee Replacement population
Supporting Rational and References
These care components are supported by the following evidence and guidelines:
ICSI Preoperative Evaluation Guideline – 2008
Rooks DS. Huang J. Bierbaum BE. Bolus SA. Rubano J. Connolly CE. Alpert S. Iversen MD.
Katz JN. Effect of preoperative exercise on measures of functional status in men and women
undergoing total hip and knee arthroplasty. [Journal Article. Randomized Controlled Trial.
Research Support, N.I.H., Extramural. Research Support, Non-U.S. Gov't] Arthritis &
Rheumatism. 55(5):700-8, 2006 Oct 15.
Coudeyre E. Jardin C. Givron P. Ribinik P. Revel M. Rannou F. Could preoperative
rehabilitation modify postoperative outcomes after total hip and knee arthroplasty? Elaboration
of French clinical practice guidelines. [Review] [33 refs] [Journal Article. Review] Annales de
Readaptation et de Medecine Physique. 50(3):189-97, 2007 Apr.
Crowe J. Henderson J. Pre-arthroplasty rehabilitation is effective in reducing hospital stay.
[Clinical Trial. Comparative Study. Journal Article. Randomized Controlled Trial. Research
Support, Non-U.S. Gov't] Canadian Journal of Occupational Therapy - Revue Canadienne d
Ergotherapie. 70(2):88-96, 2003 Apr.
Ritter MA. Lutgring JD. Davis KE. Berend ME. The effect of postoperative range of motion on
functional activities after posterior cruciate-retaining total knee arthroplasty. [Journal Article]
Journal of Bone & Joint Surgery - American Volume. 90(4):777-84, 2008 Apr.
Lenssen AF. de Bie RA. Role of physiotherapy in peri-operative management in total knee and
hip surgery.[erratum appears in Injury. 2007 Oct;38(10):1224].[Review] [12 refs] [Journal
Article. Review] Injury. 37 Suppl 5:S41-3, 2006 Dec
Kennedy DM. Stratford PW. Riddle DL. Hanna SE. Gollish JD. Assessing recovery and
establishing prognosis following total knee arthroplasty. [Case Reports. Journal Article] Physical
Therapy. 88(1):22-32, 2008 Jan.
Additional considerations identified by subcommittee:
• The subcommittee discussed the variation in knee prosthesis costs (with an average
approximate cost of $4000 per prosthesis). The subcommittee acknowledged that there are
more expensive products and that these are typically chosen for patients of younger age and/
or for degree of physical activity. This may represent variation in the basket such that
specific tiers are required.
• The subcommittee identified examples of situations that could involve care beyond the scope
of this basket i.e. postoperative complications, which would require a methodology to
address.
• The subcommittee acknowledged the opportunities for innovation as it relates to
management of patient immediately post-operatively.