Medicare Shared Savings Program

The Medicare Shared Savings Program (MSSP) is a voluntary advanced alternative payment model managed by the Centers for Medicare & Medicaid Services (CMS). This value-based care program allows physicians, hospitals and other healthcare professionals to form accountable care organizations (ACO) to collaboratively manage the care for Medicare beneficiaries. While the program has evolved over time, the focus has remained the same – to achieve myriad aims of improving quality outcomes, reducing unnecessary medical expenditures and enhancing the provider and patient experience.

Orlando Health’s MSSP ACO, known as Orlando Health Collaborative Care (OHCC), participated in its tenth program year in 2022. During this time, the ACO was afforded relief for the public health emergency and extreme and uncontrollable circumstances, due to the global pandemic and multiple hurricanes that hit the Central Florida and West Florida regions during the performance period. These circumstances had impacts on overall spending, hence driving up expenditures during the time period. Consequently, the ACO did not earn incentive or receive a penalty for the period and is actively engaging in plans to see successful results.

In 2023, OHCC launched an internal workgroup with a primary focus on developing more tailored quality initiatives aimed at enhancing care experiences for patients. Through this workgroup, OHCC has implemented a variety of initiatives to improve performance in this payment model, including:

Transitional Care Management Program

OHCC has refined its multi-disciplinary care management model to timely connect patients with necessary resources immediately following hospital encounters. This care protocol is meant to ease the transition for patients and their families as they progress from the hospital setting back to their homes, ensuring patients have everything they need for a smooth recovery. OHN utilizes this program to ensure patient care is seamless and so patients have access to additional support services they may need to prevent future hospital readmissions, including connectedness to social support and behavioral care programs. This updated care management model has increased patient engagement, now averaging higher than 70% patient participation rates, which is roughly double the engagement for similar programs nationally.

Annual Wellness Visit Initiative

A new initiative was launched with the goal of providing additional support to Orlando Health’s primary care providers to ensure eligible patients are increasingly scheduled for their annual wellness visits (AWV). Monthly outreach reports have been developed to identify patients with the highest risk for adverse care events and who do not have scheduled appointments in the performance year. The report also stratifies patients based on hierarchical condition category gaps, recognizing patients who may need additional assistance in scheduling their AWV and for extended care visits. These outreach campaigns bolster the team-based approach already in place between OHCC quality reporting resources and its aligned provider practices to close care gaps, eliminate barriers to care and address several social determinants of health issues.

Risk Adjustment Reporting

Transparent risk adjustment reporting has been developed within Orlando Health’s Epic comprehensive health record (CHR) system, also known as ELLiE, to offer providers and operational leaders near real-time feedback and insights on risk adjustment coding performance and prioritization of opportunities. A risk adjustment coding dashboard has been developed which allows providers to track their performance within ELLiE and act on opportunities, as needed, at the point of care. These additional reporting and supportive staff resources have enabled OHCC aligned providers to both (a) more accurately capture the risk of their patients in the medical record, and (b) provide for a more efficient office encounter that allows the clinical team to spend more time in the appointment with the patient.

For information on current performance, please visit our site here: Orlando Health Collaborative Care.

Comprehensive Care for Joint Replacement (CJR)

Comprehensive Care for Joint Replacement (CJR) is a federally mandated bundled payment program administered by the Centers for Medicare and Medicaid Services (CMS) to promote better outcomes in total hip, knee and ankle replacement surgeries. This all-inclusive payment model focuses on the complete care journey for Medicare beneficiaries undergoing these orthopedic operations, beginning at the time of their initial hospital admission and concluding after a 90-day post-acute period.

CJR-eligible patients are proactively identified in Orlando Health’s comprehensive health record, known as ELLiE, so their care can be optimally managed throughout the episode period. Once patients are determined to have met program-specific enrollment criteria, a CJR flag is appended to their medical chart up to 30 days in advance of their scheduled procedure. This flag remains tied to the chart throughout the clinical episode to ensure care teams accessing ELLiE or EpicCare Link are aware of the patient’s program eligibility and can more effectively coordinate care with the patient’s entire care team.

As the clinically integrated network is constantly striving to deliver excellent results in quality and outcomes, it regularly evaluates aggregate program and individual patient cases to seek out process improvement opportunities with its multiple partner organizations. One way this is accomplished is through collaborative multidisciplinary meetings at each of the Orlando Health hospital sites, including the monthly Bundled Operational Leadership Team meetings, as well as the standing Orthopedic Service Line and Corporate Collaborative Best Practice meetings. Partners in the skilled nursing facility and home health agency space are also invited to join the Post-Acute Care meeting series to help establish processes that best serve the CJR population.

These meetings have led to significant clinical and process standardizations; as a result, patients undergoing major joint replacement surgery can rest assured they will receive a consistent and seamless care experience regardless of which Orlando Health hospital they choose for their care. At each site, best practices have been implemented to ensure patients routinely have access to joint education classes, receive standardized pre-admission testing protocols, have proactive next site of care planning discussions and can access timely follow-up care.

Pre-Surgical Care Management Program

In addition to the myriad systemwide initiatives to manage bundled payment cases, Orlando Health Network launched a pilot program at Orlando Health South Seminole Hospital in November 2022 to further enhance the clinical experience by pre-optimizing CJR patients for their planned surgical care.

In this program, a pre-surgical care manager position was established to serve as a liaison between the patient and their entire care team, which includes everyone from pre-admission testing through the post-acute care environment and everything in between. This position has been shown to provide patients and their caregivers with an added layer of support prior to surgery. Education is offered on what to expect throughout the joint replacement care journey, including how to best prepare for surgery, what to expect during the inpatient stay, understanding the discharge plan and what to anticipate after leaving the hospital. This resource also ensures patients are connected with the network’s CJR care team personnel who ensure patients have the tools and support they need throughout their post-hospitalization recovery period.

As part of this pilot program, Orlando Health also created an educational pamphlet to share information on the program and showcase the OHN CJR care team resources with staff names, credentials, contact information and pictures, so enrolled patients can easily identify their support team. This team also connects with patients up to 30 days prior to their scheduled surgery once they complete pre-admission testing. Results of the physical examination, bloodwork and other diagnostic testing determines if patients meet criteria for medical clearance, but they also enable the pre-surgical care manger to perform a more detailed look into opportunities to ensure patients are best prepared for their surgery beyond the clinical care considerations, such as preemptively planning anticipated aftercare services. 

Clinical orthopedic coordinators then assist in this optimized orthopedic care model by enrolling patients in pre-operative joint-care classes. Given the known benefits of the joint-care classes as they relate to length-of-stay management, readmission reductions and pain-score improvements, patients are strongly encouraged to attend with their planned post-surgical caregiver, however, they are not required to participate in these sessions. The classes feature education regarding every stage of the care journey, from surgery to rehabilitation to recovery to home. Importantly, the clinical orthopedic coordinators are also embedded into the acute care stay process for the patient, regularly analyzing data to identify areas of opportunity and coordinate care between the members of the inpatient care team.

Once discharged form the hospital, patients connect with the aforementioned OHN CJR care team who stay connected to patients telephonically for 30 to 60 days, as needed. This team ensures necessary orders are placed, medical equipment has been received, medications are reconciled and physical therapy is underway. This team also works with the post-acute facilities to reinforce discharge instructions, support fall prevention and provide referrals to community agencies for social support services, such as transportation or financial assistance programs. Patients are encouraged to use this comprehensive resource for any questions or concerns, related to or unrelated to the procedure, throughout their entire clinical episode to ensure a safe and speedy recovery.

High-Performance Skilled Nursing Facilities

As part of its bundled payment efforts, Orlando Health Network has aligned with a select group of six high-performing skilled nursing facilities (SNFs) which have been identified as leaders in managing post-surgical orthopedic cases. These partner sites have proven their ability to successfully manage clinical care experiences at their facilities, thereby delivering better outcomes and reducing “days away from home” for the patients.

SNFs chosen for this high-performance network were selected based on several metrics, including all-cause hospital readmission rates, total cost of care effectiveness, length-of-stay management and quality of care ratings as measured by CMS star ratings, among others. Prior to hospital discharge, patients are informed of all available SNF options and are presented with additional performance information for network-aligned entities as they make their decisions.

To ensure accountability with meeting high-performance network standards, aligned facilities meet on a bimonthly basis with the network’s medical director and team to review performance. The group collectively identifies trends and builds performance action plans as areas of opportunity are determined. Through this collaborative effort, multiple improvement plans have been implemented and are regularly monitored for effectiveness.

Several best practices for in-network SNFs have also been established to optimize patient care experiences and to remove barriers to safe and effective discharges. Compliance with these practices has been shown to reduce complications and unnecessary acute-care utilization, thereby translating into a better quality of life for the patients. During the regularly scheduled meetings, patient cases are reviewed in depth to assess best practice adoption, including ensuring the partner facilities meet the following criteria:

1. Perform risk assessments and care plans within 24 hours of admission and engage in early discharge planning conversations with the patient and caregiver(s).
2. Monitor chronic condition management and routinely escalate any clinical concerns to the OHN CJR care team to prevent rehospitalizations.
3. Provide patients with education on self-care, medication management, fall prevention and chronic condition management to mitigate exacerbations.
4. Ensure necessary outpatient therapy and home health services are scheduled prior to discharge to reduce gaps in care and allow for a timely start to services.
5. Allow patients to return to the facility within 30 days of discharge, if it is medically appropriate, to avoid unnecessary emergency room or hospital care.

Medicare Advantage Bundled Payments

In 2021, Orlando Health agreed to participate in the United Healthcare Medicare Advantage Bundled Payment Program. In this program, the health system is assessed on its ability to manage cost and quality outcomes across several episodes of care which span a 90-day post-hospitalization period following care at a participating Orlando Health inpatient or outpatient facility. Similar to the Comprehensive Care for Joint Replacement (CJR) bundled payment program, patients aligned to this program are closely monitored throughout their at-risk post-discharge period.

Orlando Health is also responsible for meeting quality metrics for the eligible population of bundled payment patients, including advanced care planning, all-cause hospital readmissions and multiple patient safety indicators. In a given plan year, if Orlando Health satisfies or exceeds these quality targets and generates financial savings to the plan based on a retrospective bundled payment cost methodology, it becomes eligible for financial incentives.

As a result of strong performance in 2022, Orlando Health Network earned an incentive by successfully delivering high quality care and by generating cost savings of nearly $1,000 per episode. The full list of conditions and procedures managed under this arrangement are listed below.

1. Chronic Obstructive Pulmonary Disease
2. Congestive Heart Failure
3. Coronary Artery Bypass Graft
4. Major Hip/Knee Joint Replacement
5. Percutaneous Coronary Intervention
6. Sepsis
7. Simple Pneumonia
8. Spinal Fusion
9. Stroke
10. Urinary Tract Infection