How NorthBay Healthcare Handles Bundled Payments and Benchmarking
The Interdisciplinary Conference on Orthopedic Value-Based Care, aka #LeadingVBHC, held in January provided many valuable insights for all those in attendance, including CODE Technology. At this first-ever conference, we had the opportunity to interview some of the industry’s most interesting thought leaders on a wide range of topics surrounding the new era of value-based care. Click here to see our comprehensive coverage from #LeadingVBHC.
We caught up with NorthBay Healthcare two months after the conference to see how #LeadingVBHC influenced them. There were multiple lessons to be learned. The team attending #LeadingVBHC consisted of nine members, varying in disciplines from the director of outpatient specialties to anesthesiology.
“We all know attending this conference is important for patient outcomes, and we all know it’s important for financial reasons. So, everybody just got behind it,” Cynthia Giaquinto, Program Manager for Orthopedics at NorthBay Healthcare told CODE.
For some background, NorthBay Healthcare is an independent organization comprised of two different hospitals: NorthBay Medical, a 150-bed facility in Fairfield, California; and Vaca Valley Hospital, a 44-bed surgical center Vacaville, California, that houses the joint replacement program.
#LeadingVBHC Action Items
For all the various disciplines present at the conference, there were two common themes the team was interested in – bundled payments and benchmarking.
“It’s very important to be well educated about bundled payments so we can figure out if what we’re doing is right. We were also happy to be able to network with others to see where our program stands against some of the bigger guys. We had a very multifaceted agenda,” said Giaquinto.
But what happens after the conference is what really counts. What takeaways are actually applied to practice following these types of conferences?
Bundled Payment and Assigned Case Managers
For NorthBay, they’re starting with bundled payments. After the conference, Giaquinto told CODE, “We started to explore the need for an assigned case manager for bundled payment patients. That wouldn’t mean just joint replacement. That would mean also cardiac.”
Despite the delays with bundled payments, NorthBay Healthcare isn’t pushing the brake pedal. “We’re pretty sure that CMS is going to continue forward with this process. We always are proactive. We don’t let things sneak up and smack us in the face. We’re ready to go when things happen.”
Therefore, NorthBay’s bundled payment initiatives aren’t limited to just joint replacements and cardiac. “During flu season, our case managers put the priority on getting patients discharged so we can open beds and admit more people waiting in the emergency room. … When we’re looking at bundled payments, we realized that a case manager needs to be working with these people immediately in order to help facilitate a quicker discharge, which would help our cost needs.”
Other conversations taking place post-conference focus on benchmarking and transparency.
“We’re trying to establish a baseline and look at our costs. In our organization, it’s been a challenge to get … but having those baselines, now we’re going to have to set up some measures and figure out how we are going to improve.”
Giaquinto also went on to say, “Surgeons are very competitive natured people. As we measure their outcomes and they get paid on performance, it’s going to be more and more important. Then they can start to network, and say “Well, you’re doing pretty well. What’s happening on your end that’s making you so successful?”
When all’s said and done after #Leading VBHC, these initiatives: benchmarking and bundled payments – combined in a value-based system contribute towards CEO Gary Passama’s motto: “whatever’s best for the patient.” It appears as if NorthBay is on the right track.
We go more in-depth about how NorthBay Healthcare is moving towards value-based health in our interview conducted by CODE CEO Bre Cunningham. Read the transcription from our whole interview below with Dr. Jesse Dominguez, anesthesia medical director, and Cynthia Giaquinto, Program Manager.
Bre Cunningham: Organizationally, how was your program structured?
Dr. Dominguez: NorthBay is an independent organization. It doesn’t belong to Sutter or Kaiser or any of these other organizations. It’s an independent organization in Solano County, northern California. And with that, there’s two hospitals. There’s NorthBay Medical Center in Fairfield, California, and that is 150-bed hospital, and we do ortho there. Then there’s VacaValley Hospital in Vacaville, where we house our joint replacement program.
Cunningham: Are surgeons employees of the hospital or private practices?
Dominguez: I would say there’s a mixture. First, we have our own employed physicians. They’re all contracted into the NorthBay foundation. All their offices are staffed by NorthBay employees. That’s one group of surgeons. We also have surgeons that are affiliated with the Sutter Health Care organizations that are also participating in our joint program because they, in Solano County, don’t have a joint program. They do joints, but they actually come over here and do their joints with our program.
Cunningham: Oh wow.
Dominguez: Yeah, it’s actually kind of a win for us.
Cunningham: I’m sure Sutter’s happy about that … not.
Dominguez: Sutter doesn’t like that whole thing and they’re trying to structure something. They have something going in Sacramento, but not in this county.
Cunningham: That speaks highly of your program.
Dominguez: Yeah, I think so. Cynthia really deserved all the credit for this. All of us, they call us physician leaders and champions, but really it’s the nurses that do the work, so I’m going to turn things over to her.
Cunningham: Ok Cynthia, how do you get a budget in place for your program, for these value-based initiatives, and what does your capital structure look like? Let’s just say you wanted to get a software product or bring on a new, full-time employee, or researcher for the program. What does that look like in your organization?
Cynthia Giaquinto: Interestingly enough, we’re a smaller organization, so in the past, we found that if it’s an important initiative, the money appears. I’m not sure where they pull it from, but the resources are there and suddenly we will go ahead and put something in place.
Most budgets have built in some contingency plan for things that crop up, but we’ve never been told, ‘No we can’t do this because we don’t have the money,’ or anything like that. We realize how important it is, everyone’s on board. When we come to having to purchase new software or something like that, then it becomes a little bit more of an issue and we have to go through committee and make sure we can find that money, but somehow we do find it.
Cunningham: Just to get a little more nitty gritty about what your joint program looks like, can you tell me the leadership structure or the organizational structure of the actual joint program itself?
Giaquinto: My position is program manager for orthopedics, and I have the fracture and joint replacement programs. My position is actually an outpatient position. But yet, I am totally functioning within the hospital. Better yet, today we had a joint replacement interdisciplinary committee meeting, and had 18 people there from all disciplines.
Cunningham: What? That’s awesome.
Giaquinto: I know, it’s pretty incredible. You know how you go to some meetings and they’re skeletal crew and nobody’s talking. Well, this is very interactive. It really warms my heart when I go to these meetings and see how everybody is on board.
Cunningham: Who all makes up that inter-disciplinary team?
Giaquinto: The director from the outpatient orthopedics side. It’s great to have him there because he’s got the doctors and he’s got rehab. Then we have the manager from the peri-op, the director from peri-op, the physical therapist is there, both inpatient and home health.
We have a PACU nurse, we have case management, a restorative nursing assistant that works with me. She’s also an outpatient person, but yet, she works in the hospital. I know, it’s kind of screwy there but it seems to work for us.
Cunningham: Forgive me, I haven’t heard of that term ‘restorative nursing’ before. What was that?
Giaquinto: Restorative nursing assistant, RNA. So, she is a CNA but has a few physical therapy follow-ups. They work very closely with a physical therapist and occupational therapist, so when they’re not on the floor working with patients, she’s able to help teach some of the other CNAs the ins and outs of moving patients.
Cunningham: That’s so cool. How long have you had that before? I’m sure that’s a huge asset.
Giaquinto: It’s a huge asset. We put it in place probably seven years ago.
Cunningham: Holy smokes.
Giaquinto: It’s really nice to have her. What she does is, if we don’t have many joints that particular week, maybe three or so, she’ll also help out on the unit to help the other CNAs. So, she’s not just strictly to those three patients. It’s a nice relationship. Even though they know she’s dedicated to the joint patients themselves, she can also help out elsewhere, which is really nice.
Cunningham: That’s great. Are you also part of that interdisciplinary team?
Giaquinto: In today’s meeting we also had the home health PT, which was great. Then there were some of the core nurses.
In our program, even though the joint replacement program resides within one of our surgical units, the nurses all belong to that surgical unit, not to the joint replacement program. So, their wages, their budget and all that goes to the unit. However, we have trained core nurses that work in the joint replacement program and that has been really effective because the nurses know the program very well. They know where the patient should be on their pathway. They’re building good relationships with the surgeons. When they’re working in the middle of the night, that surgeon knows that this nurse knows what she’s talking about. It also prevents them from calling in the middle of the night for things that the nurses know are normal and are able to sort through. So, it’s been huge just to have a core group of nurses.
Cunningham: Yeah, I would imagine.
Giaquinto: So, at this meeting, we have a few nurses, night shift and day shift were represented today. Usually, we even have a PM nurse there as well. Then we have the surgical lead. In our hospital in the OR, we have a lead. So, she was there and the PA that works with one of the surgeons. We had two surgeons there, one that does knee and shoulders and one that does hips and knees and we had the same-day center nurse and those people do the teaching or help with the teaching; they do the pre-op two weeks prior to surgery, and they admit the patients the day of surgery. So that’s who was there today.
Cunningham: That’s awesome.
Giaquinto: Normally, we have pharmacy there but they weren’t today. Oh, and our nutritional services. We have a dietician there. She was there also.
Cunningham: How often does that group meet?
Giaquinto: We meet every other month. If we’re getting close to our disease-specific certification, we’ll meet every month to make sure everything’s in place.
Cunningham: Which certifications do you do?
Giaquinto: We have knee and hip disease-specific certifications.
Cunningham: For JCO?
Giaquinto: Yes, for joint commission? Yes.
Cunningham: Well, I guess they don’t like to be called JCO anymore.
Giaquinto: Not anymore.
Cunningham: What intrigued you about this value-based care conference?
Giaquinto: Well, with bundled payment coming, we need to be well educated about that and figure out if what we’re doing, are we doing the right things for that.
The other thing is to be able to network with others to see where our program stands against some of the bigger guys. It was very multifaceted agenda. There were so many different things we could go look at. When we sent our team down, we split up, went to different things, came back around, and reported back to each other what we learned. That was helpful.
Cunningham: What disciplines were at the conference?
Giaquinto: Myself, the program manager for orthopedics, the director of outpatient specialties, the director of peri-op, the manager of peri-op. Our lean director went, so that as we go forward and we want to make sure we’re doing everything according to lean six sigma initiative. Our quality director went, our medical director for the joint replacement program went. Let me see who else was with us. I feel like I’m leaving somebody out. Oh yes! Two anesthesiologists. We didn’t have anybody from IT because they couldn’t make it but we would have liked that.
Cunningham: That’s a big group. That just goes to show you, it goes back to that first question about the budget, and it just sounds like there’s overall support for this initiative.
Giaquinto: Exactly. We all know it’s important for patient outcomes and we all know it’s important for financial reasons. So, everybody just got behind it. How we got that, it was sharing emails. When it would come out, I would send out the email and say, “This looks great. We should go to it,” and, “I suggest we take these people.” Somebody else would email back, “And we should also take these people.” The CNO was very supportive in all of that.
Cunningham: Love it.
Giaquinto: Some of them even paid for their own way, so there were different ways we got there.
Cunningham: I love it. That’s so great. In the final wrap-up session of the conference, there was a great comment by one of the anesthesiologists there and she had said, “What do we do next?” She challenged the audience to take one piece of information and to make one change that could be done in that next week. What were some of the changes that you made in your practice as a result of this conference? If any?
Giaquinto: We definitely have. We’re also bringing our peri-operative surgical management team with the joint replacement as well. As we learned in the conference, many people start with their joint replacement programs because they’re smaller and they’re working with standardization and all. So, when we got back, we set up monthly meetings to make sure we had forward momentum. So, our PSH team will meet monthly.
We’re starting to have discussions about what services are essential to help meet our cost needs. Is it essential to send an occupational therapist out to the house for home health? Is it essential that everybody have physical therapy to come into their house at home health, or can we send some of those directly to our outpatient, and how do we coordinate it? How does our physical therapist let the doctors know that I think this patient could go directly to outpatient, OP? We’re having some of those discussions.
We’re also exploring the need for assigned case managers. One of the things that happen in our facility is that, especially during flu season, our beds were so full that our case managers … The priority in their mind was to get the patients discharged so we could open beds up and admit more people that are waiting in the emergency room. That happens throughout.
But when we’re looking at bundled payments, we realize that a case manager needs to be working immediately with these people to help them facilitate a quicker discharge. That would help cost needs as well. So many of them are doing well and ready to go.
We started to explore the need for an assigned case manager for bundled payment patients too. That wouldn’t mean just joint replacement. That would mean also cardiac or whatever else gets added. Then we got news that those are being delayed a bit so that’s nice.
Cunningham: Yeah, they are rumored to be delayed even yet again, until January.
Giaquinto: Yeah, that would be fine with us, but we’re not going to stall our momentum. We’re going to be ready. We’re going forward.
Cunningham: Can we talk a little bit about that? What is your motivation to not stop based on those regulations coming through? What are some of the conversations that you’re hearing or that you’re having because that’s something that we talk about a lot internally.
Giaquinto: One of our vendors is on the Advisory Board, so we often will keep up with them and their recommendations. It’s going to go forward, we just don’t know what exactly it’s going to look like or when it’s going to happen. But we’re pretty sure that CMS is going to continue forward with this process. I think our motivation is, and one thing I love about working here is we always are proactive. We don’t let things sneak up and smack us in the face. We’re ready to go when things happen.
We’ve had such success with our joint replacement program that we feel like we have a model in place. We need to tweak that a little bit better and then we can roll it out to the next one. Our fracture program in our next one. Our cardiac program is after that. We are just forging ahead, knowing that we have to be ready when it happens.
Again, it comes from the top down. If we didn’t have that senior management saying, ‘We agree with you,’ and, ‘Go forward,’ it wouldn’t happen.
Also, we’re working on clinical pathways for the fragility fracture program. Our fragility fracture program is virtually non-existent at this point. We tried a few years ago to put one in place and it didn’t work well, so we backed off, modified it, and we’re going forward again with putting something in place that makes sense in the workflow. Learning what we’ve learned in the joint replacement program, we’re using some of those same strategies to build the fragility fracture program. We want to be ready on that account, too.
Another thing that was in the works before we went to the conference, but has stepped up, even more, is working with our vendors to contain costs. We heard that loud and clear at the conference.
Cunningham: I love that goal. Taking a step back, what are the most important value-based care and payment goals that your organization has established? It sounds like one of those big goals is cutting costs when and if appropriate. How did you guys come up with that goal and, also, how are you measuring its success?
Giaquinto: Not very well yet. At this point, we’re just trying to establish baselines and look at our costs. In our organization, it’s been a challenge to get a number for what it cost the organization to have a joint replaced. That’s kind of been elusive, but we pursued our financial people to help get those numbers. We finally have gotten some information around that. Now, having those baselines, now we’re going to have to set up some measures and figure out how we’re going to improve it.
Cunningham: I just find it amazing. I’ve worked with several hospital systems large and small and it is always amazing how difficult that data is to come by.
Giaquinto: Right. Having that data has helped us a lot with purchasing to get the vendors situated. What we found out is we’re paying a large amount of money on our vendors, compared to hospitals around us. We discussed at our meeting, they’re not going to step up and tell us, “You’re paying a lot more than so and so down the street.” It was imperative that we did that. That has been a big help, but that was in place before we went to this conference, but it has gone forward because of that as well.
Cunningham: I love that. That’s fantastic.
Giaquinto: A couple other goals we established is to refine our standard order set to make sure that we’re giving the care in a standardized manner, especially when we’re talking about our fracture program. We’re also exploring a surgical optimization clinic. We heard a lot about that at the conference that it really helps to have the patients come in in a one-stop shop and be seen and optimized as best they can at that point. We think that’s going to work for us.
Cunningham: Is case management going to be a part of that, do you think?
Giaquinto: Right now, for joint replacement, they are a part of our teaching. They come in two weeks prior to the surgery and they do the pre-op class and they talk to the patients and find out what they need and all that. I’m sure we’ll extend that to the optimization clinic as well. But, there’s another position there for that assigned case manager, another job for that assigned case manager to do. So, we can support the need for that.
Cunningham: That’s awesome. The conference emphasized the importance of interdisciplinary approach as a key to success. It sounds like your organization is doing a fantastic job fostering that approach. One of the questions I have for you is, how did you go about setting up that team?
Giaquinto: I think it’s important to identify your champions. I’ve been here for 30 years so I know the people that work here pretty well. Those relationships are important because then you’re able to find the champions, who’s behind this, who’s interested in this because some people frankly are not. You find the champions and you bring them together and you start an interdisciplinary committee, again, with your senior management approval and also senior management representations needs to be on the committee as well. By bringing those different people together, I think, you need an orthopedic surgeon to be a champion, as well. We also have on general … Oh, that was another person who went to the conference with us. We had a general surgeon with us as well.
Cunningham: That’s awesome. That’ll be helpful for as you expand into other initiatives. That’s really smart and very forward thinking.
Giaquinto: Exactly. So, again, we identified him as a champion of this and his interest in it. So, now he’s on the PSH committee. That’s kind of what we did. We went after those who were interested and wanted to go forward with it.
Cunningham: What has been the biggest challenge associated with inter-disciplinary work?
Giaquinto: I would say maintaining momentum. We’re all so busy there are competing schedules, competing organizational priority. There’re so many priorities as you know and, so, how do we keep this one in the forefront and keep the initiative going?
Cunningham: What about meetings? Do you have any strategies for having effective meetings when you get such a big inter-disciplinary group together like that?
Giaquinto: Absolutely. Having a couple co-chairs to play off each other and get things going I think is important. Plan the meetings as far out as possible. Always have an agenda. In this organization, we try to send agendas out a week beforehand, so people have a chance to look at what’s going on.
Cunningham: How are you measuring your progress as a result of those meetings?
Giaquinto: That’s probably one of our biggest stumbling blocks at this point. What do we want to measure and how do we want to measure that?
Cunningham: The conference also emphasized the benefit of having informative data to monitor, improve, and communicate your performance. What, if any, outcome data are you currently collecting? Costs? Patient-reported clinical costs?
Giaquinto: We report for the joint replacement program because we’re probably going to use those same type of measures as we report out. Of course, we measure the length of stay and readmission. In joint replacement, we’re also measuring the use of the total joint commission data that we report to them for our certification. We make use of a urinary catheter, early mobility, pain management, patient satisfaction, discharge disposition, surgical site infections, and we’re going to start looking at PROMs as well, patient-reported outcome measures.
Cunningham: How are you going to plan on collecting those PROMs?
Giaquinto: We don’t quite know exactly. We have an ambulatory IT that’s working on that. Another one, though, is we do report to the AJRR and we were doing it manually.
Cunningham: AJRR is going to be accepting PROs here pretty soon. That’ll be nice, too.
Giaquinto: That will be nice. We’ll definitely use that when we can. In the meantime, and I can’t answer that exactly how they’re getting the information for the PROM as well.
Cunningham: I believe it is now part of the joint commission certification, right?
Giaquinto: Not that I know of yet, unless I’ve missed something. I don’t know that they are asking for PROMs at this point.
Cunningham: It sounds like you guys just got some baseline information about the cost data. It sounds like now that you have that, you’ll be building on that and finding ways that you can continue to track, monitor, and use that data to make effective change?
Giaquinto: Absolutely. I’m collecting some of the data through chart audit. Our QI department does, our IT department does, and, of course, our infection department does as well for the SSI information.
Cunningham: How often are you reporting on those clinical findings?
Giaquinto: At least quarterly. It depends on my JRP meeting, it’s every other month. For the joint commission, those are monthly.
Cunningham: The last questions I have … One is, what challenges have you had of putting that data to use. In other words, you get all this information – have you had any challenge bringing meaningful action around it? Let’s just say, that you’re noticing a trend in your surgical site infections. Do you ever have issues using that data to make effective change?
Giaquinto: No. I find this organization is pretty responsive to data and will respond to whatever is necessary, will do whatever is necessary. What I find is we sometimes suffer from too much data, and if we’re not going to do something about it, my vote is not to track it.
Cunningham: That’s smart.
Giaquinto: For example is, for our follow-up phone call we would call at six months and then we would call at a year. But at a year, we found that we weren’t really using that data for anything. It was difficult to get ahold of patients sometimes. So, we were able to stop doing that. We don’t call at the one year mark anymore.
Cunningham: I love that. I think that’s so smart. I totally agree with that, that if it’s not actionable, why track it? As we talk to organizations, we see a lot of people struggle with that, so it’s great that you’re just saying, ‘Not helpful, not doing it.’
Giaquinto: Let me give you another example. For our pain management questions, we would go in and look at the number they were telling us their pain was at, then we’d get an average. So, we’d get some data on it, but then, what do we do with it?
The joint commission suggested that we change our question to, ‘While you were in the hospital, did the staff manage your pain all of the time?’ So, we’re looking for the top box on that. ‘If not, why not?’ That’s been so much more effective. We’re able to do something about it if we’re able to get some data on it. We’re very good on that. Our patients give us “all of the time” most of the time.
Cunningham: Well, that is really smart. Just kind of restructure it until, like you were saying, instead of an average of what they were reporting, but almost like a net promoter type question.
Giaquinto: Right. Then we could do something about what their suggestions were rather than just looking at a number and saying, ‘Well, what do we do next?’
Cunningham: That’s a great example. What did you learn about cost and outcome data at the conference that would be used to help improve your organization’s performance and value propositions?
Giaquinto: Know your data, number one. Everybody there could just report on their data so well and I think that’s a bit elusive here in our organization. So, just really need to nail that down. And then, we need to be very transparent about it.
Cunningham: On that note, when it comes to transparency, when you present information, such as re-admission data, SSI data, are you presenting that blinded or do you present that information laying it, like this is the surgeon, this is the care team, etc?
Giaquinto: It’s pretty much blinded right now. They are, I noticed, in some others, not so much what I report out, but I noticed when they’re looking at some other things. They’re starting to unblind that so that we can look at outcomes based on physician performance instead. I noticed there’s a trend towards that.
Cunningham: I’ve always been surprised at that. The nurse in me was surprised, but I’m amazed at how many organizations are leaning towards a very transparent culture. In our software, you have the ability to either blind or not blind. It used to be that everybody was blinding. Now people are super transparent and posting scores up, which is interesting. I think it’s helpful. Surgeons are very competitive-natured people.
Giaquinto: I agree. As we measure surgeon outcomes, and they get paid on performance, it’s going to be important. Then they can start to network, ‘Well, you’re doing pretty well. What’s happening in your end of it that you’re doing so well with that?’
Cunningham: That’s so great you guys were doing this before it was before it was cool.
Giaquinto: Before it was necessary, too. What was really great when we brought it up, we brought a organization called Orthopedic Advantage. That person came out and taught us how to bring a program up. Then our hospital actually sent us to Waco to look at a joint replacement program. A team of us went out there to look at how they did things. We split up, the PTs went with the PTs, the nurses went with the nurses, and we all came back and shared our data with everyone.
Cunningham: I have to ask. Your leadership structure, do you guys have some players that have been in there for a long time?
Giaquinto: Yes. In fact, it’s interesting that you ask because our CNO is only here the last year, but our CNO before that was here for 25 years. Our CEO has been here 35 years. In fact, he’s retiring this week.
Cunningham: What a legacy he’s leaving behind.
Giaquinto: I know. It’s always been his motto to whatever’s best for the patient. He’s been great in leading this whole group in doing what we have to do. He also relies on his CNOs and his other senior managers to know what it best for their department. If you don’t have that top structure and that top support, it would be really hard to try to make anything happen.
Cunningham: Totally. It’s amazing to see how much support and infrastructure you have. Everyone’s drinking the Kool-Aid, which is amazing and what you need to be able to really knock it out of the park with a program like this. That’s so exciting. I like it. If I need a hip replacement I’m going to come to NorthBay.