1. Hip Fracture Potpourri
- Fixin’ em, Takin’ care of ‘em, and Gettin’ Paid for ‘em
Samir Mehta, MD
Chief, Orthopaedic Trauma & Fracture Service
University of Pennsylvania

4. APMs
From 2019 through 2024
Qualifying APM participants will receive a lump sum incentive payment equal to five percent of the prior year’s estimated aggregate expenditures under the fee schedule
Qualifying APM participants will not be subject to MIPS adjustments
Eligible APMs are the most advanced APMs that meet the following criteria according to the MACRA law
Accountable Care Organizations
Patient Centered Medical Homes
Bundled payment models.
Base payment on quality measures will be comparable to those in MIPS

5. Examples of APMs CJR – Comprehensive Care for Joint Replacement
Not “Bundled payment” (BPCI)
Retrospective bundled payment model designed by CMS that holds hospitals accountable for episodes of care extending 90 days post- discharge (includes all related Part A and Part B services) for lower extremity joint replacement procedures
Includes a per-episode discount of up to 2 percent and is mandatory in 67 geographic areas, defined by MSAs (see below). Began April 1,
SHFFT – Surgical Hip and Femur Fracture Treatment
Was to be included as part of CJR

6. PS
Arrival at 1130
Xrays at 1245
Hip Fx noted and transfer process initiated
Accepted at 1623

7. PS
Admit to Ortho
Consulting services
Posting for OR

8. PS Hospitalist risk stratified Anesthesia faculty evaluated on floor
OR at 745 PM

9. 64 yo female

10. The Vision
Provide coordinated care for geriatric hip fracture patients from the point of entry into the health system through recovery
Program formed as a result of geriatric hip fracture care pathway work started in 2015
Current Team
Nursing
Social Work
Anesthesiology
Internal Medicine- Hospitalists
Geriatrics
Orthopaedic Surgery
Physical Medicine & Rehabilitation
Emergency Department
Physical Therapy
Patient Safety & Quality
128 Patients in CY2016

11. Movement to Ideal State Pathway
Pt Reported Outcomes & Functional Assessments
Pre-Admit and Direct Admit from Nursing Home
Coordinated UPHS Outpatient Care
Hip Fx Alert
Additional Clearances Expedited
OR Cost Containment/ Vendor Selection
New ED Order Set/Protocols (HUP/PPMC)
Fast Track/ Daily PT
Standard ACC-based Risk Stratification and Pre-Op Clearance
Enhanced SW within 24 hours
Preferred Post-Acute Partners & Pathways for Partners
Disposition Planning Protocol
New IP Pain Protocols / IV Tylenol
(Reduce Delirium)

12. <24 Hours to OR
Surgical Delay of more than 12, 24, 48 hours significantly increased the adjusted risk of 30 day mortality
Surgical Delay of more than 24 hours significantly increased the adjusted risk of 90 day mortality
Nyholm et al., 2015

13. ED Order Set / Hip Fx Alert

14. Risk Stratification Guidelines
One page guideline for hospitalists and geriatrics
Highlights that the priority is to “identify any acute medically modifiable risks that can be mitigated within a short window (e.g. improved status within 1-2 days)”
Guidance on testing, overnight risk stratification, and placement on orthopaedic service
Created as a collaborative effort with sign off from:
Hospitalists (Kendall Williams, MD; Laura Kosseim, MD)
Geriatrics (Alysa Krain, MD)
Orthopaedic Surgery (Samir Mehta, MD)
Anesthesiology (Nabil Elkassabany, MD)

15. Clinical Metrics Measure Time to Surgery 36 hours 16.5 hours
National Average (IGFS Member Facilities*)
Penn Medicine PPMC (Jan – June 2017)
Time to Surgery
36 hours
16.5 hours
Length of Stay
6.4 days
4.8 days
30 Day Readmission
14.5%
8.33%
Mortality in Hospital
3.1% 0%
% of Patients Co-Managed by Medicine or Geriatrics
50%
100%
*International Geriatric Fracture Society (IGFS) is a national organization committed to the treatment of geriatric fractures. PPMC plans to apply for certification in FY18.

16. Discharge Disposition

17. IV Acetaminophen Trial
IV Acetaminophen anecdotally correlated with reduced pain, opioid consumption and delirium (and therefore reduced LOS)
P&T Approved 6 month trial for up to 3 post-op doses of IV tylenol (switch to PO as soon as possible post-op)
Pain scores, opioid consumption, and delirium collected via retrospective chart review
Mark Neuman, MD and Keith Connolly, MD led this work
42% v 17%