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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.