From Excellent Surgery to 30-Day Accountability: CMS TEAM Explained

Episode Contents

• 0:00 Introduction to NovaNav
• 1:06 Guest introduction: Dr. Robert Hymes
• 2:05 CMS TEAM overview
• 7:30 Post-discharge accountability in CMS TEAM
• 13:04 Cultural shifts required for CMS TEAM success
• 18:21 Reframing outcomes through events avoided
• 21:44 The importance of care navigation
• 23:20 How to succeed with CMS in 2026
• 25:15 The role of technology in CMS TEAM
• 28:30 Episode wrap-up

Key Takeaways

He explains why the biggest risk under TEAM is failing to redesign post-discharge recovery, especially discharge disposition, patient engagement, readmissions, and complications. The conversation explores the cultural shifts required for success, including aligning surgeons, reducing variation, and rounding as a true multidisciplinary team.

Transcript

Hi, Dr. Himes. Hello, Lisa, how are you? I'm good, how are you?

Well, I am frozen in Northern Virginia. That's right, how did your house make out? Yeah, no, I mean, we're fine, just getting around, navigating the streets. Today's okay, yesterday was a little bit tricky.

It's dangerous, walking, condition, driving, walking, right, anything. That's correct. We're going to see an uptick in slip and falls, you know, over the next few days, that's for sure. I was, yeah, when you mentioned that, I thought of that.

I'm like, you know, I know I'm in Florida now, but I was in New Jersey and I took a couple of spills in New Jersey. We had stairs and my mom lived in the back house and I would have to check on her during storms. I would have inevitably, she would be fine, I wouldn't be. Yeah, I mean, it's, we see this whenever we get big snow, the snow melts, but, you know, ice will be around for the next several days as it's really cold.

And people will get, you know, stir crazy in the house and you go out and slip and fall. Yeah, so you're going to be busy. We're going to be busy. So I'm going to, I know we're recording, they just automatically does that, but we'll kick off the call.

So thank you for giving me feedback. It was really helpful, obviously, being on our webinar before to get a feel for what you're thinking is. And so this is somewhat casual in some respects, but it's formal, you know, like we want it to be, you know, really good, but just comfortable conversation. So I mean, I may start off with a little bit more formality, just introducing you.

Okay. But outside of that, if you hear me, okay, I have a new screen and everything. So I'm trying to get adjusted to my new world. So I'm a little probably bolder than normally I am.

Yes. Yes. No, I can hear you fine. Okay.

Excellent. So I'm going to kick it off and then we can, we're not going to, this is not going to be on video, just so you know, it is going to be a podcast. Just, you know what I mean? So just so we're not using it in any kind of video setting.

Okay. All right. So I'm going to kick off. Okay.

So welcome to the Surgical Journey, NovaNav's weekly podcast, where we bring on experts and physicians and key thought leaders in the space of the patient journey, the surgical journey. So today I'd like to welcome Dr. Robert Himes. He's a board certified fellowship trained orthopedic trauma surgeon with over 20 years of experience.

He serves as the chairman of orthopedic surgery at Inova Fairfax Medical Center. The campus musculoskeletal service line section chief for trauma and fracture care is also a professor of medical education at the University of Virginia Medical School. He is widely recognized for his leadership in advancing trauma care protocols and education, helping hospitals improve outcomes for patients and complex orthopedic injuries. So, so Dr.

Himes, welcome to the podcast. Thank you, Lisa. Great to be here and looking forward to a wonderful discussion today. Excellent.

So I've, I've, I've had the benefit of having a few conversations with you. So I was really looking forward to today's podcast because I know the topics you speak about CMS teams is not only relevant, but I think it comes from a very unique perspective. So as an orthopedic surgeon, how do you see CMS teams changing the day to day responsibilities of orthopedic leaders beyond surgery itself? Yeah, Lisa, that's a great way to get our discussion started.

And so just as a bit of a background, my hospital and healthcare system, all five hospitals have been selected by CMS to participate in the team model. And, and so I'm helping with the overall leadership group and then directing the surgical hip and femur fracture pathways. And so we jumped into this at our institution, our health system, as soon as we got word, so about nine months ago. And the message that we're trying to deliver is we are changing excellent surgery, which we've always prided ourselves in doing into total episode accountability.

We still want to do excellent surgery, but it just just doesn't stop there. So, you know, we understand we have to own 30 days of outcomes and spend. And through some learning and some research and some data analysis, you know, Lisa, it's really become about the post acute discharge. Where are patients going?

What about readmissions, complications, patient engagement? All of those things we just we really sort of we're focusing in on and have a keen eye. We're thinking about navigation. How do we how do I align surgeons?

How do we have these conversations of, you know, you're an excellent surgeon and you're actually great. But there's some variation in implants of length to stay. And we really have to care about discharge disposition. So a lot has changed and my financial fluency is improving.

But all of those things are necessary as as the day to day responsibility leading my team. So I'm going to go a little deeper on that, just that question. You said two things that really jumped out at me, which is that you have to align surgeons. Right.

So you probably have a good amount of surgeons in your department and then probably collaborating in the greater health system. And I would love to get your kind of thoughts on that, because I'm sure it comes up regularly. Number one. And then we'll start there.

OK. Yeah. So there's you know, within the health system, we have what we call we have employed physicians. I'm an employed physician.

And so my partners and then we have aligned physicians. Those are physicians who do their surgeries within the health system. And then we have just a couple of outliers who are so old. I call them old school, even though some are my age or younger, who, you know, still have this sort of I'm the doctor.

I'm a physician. I can do what I want. So the different conversations. Easy with the employed physicians, my partners.

They all get it. What's good for the health system is good for patients is good for us. The aligned physicians. Similar conversations.

It's hey, you know, it's not about the what you want to do, but it's about this pathway we're developing. And come on in. Let's you know, what do you think? Here's a pathway.

What are your thoughts? You know, we bring them under the umbrella and have conversations early. So it's not hey, this is what you need to do. But this is what can we do together?

Right. And then that that small group of sort of anti leave me alone. I'm the Lone Ranger still trying to figure out that group of surgeons and how to have conversations with them. Yeah, I love that.

What can we do together? But you're we're going to I don't want to jump too far ahead, but you're really a culture kind of leader. So I love that thinking is what that's a culture of leadership. Correct.

Right. Let's do this together. Not not do what I say, but let's do this together. Yeah, I love that.

I'm with you on that journey on this journey. Yes. You mentioned also in your answer initially was greater financial acuity. So do you I'm really just curious, generally speaking, like when you went to med school and you're a resident and throughout your career, you've you've had to gain more financial acuity.

Has that been more so recently? Is that, you know, getting not just cost per case, but maybe understanding reimbursement models or things like that? Yeah. So I think we do a really poor job in this country of educating physicians and nurses and physical therapists on costs.

Right. Medicine is a business that everyone knows, except for health care providers. And I learned this just on my journey, my leadership journey. And and being able to sit in the room, the board meeting, sit in and talk to administrators, sit in the C-suite and understand the language has become it's extremely important.

And I think all physicians, all health care providers have to understand at a really deep level, hospital and health care finances. It's super important. I mean, it's we could talk. That could be a podcast all in of itself.

You can actually convey. I agree. I wanted to touch on it because it was so well said. But maybe it leads us into the next question, because CMS shifts accountability deep into post-charge, post-discharge period.

So from a clinical leadership perspective, what do you feel or see could be the greatest risk of failure if hospitals don't redesign recovery? Or how we have recovery is managed. Yeah. So so we're looking at the post-acute discharges, active active care.

It's not, hey, what's going on? But it's how are we going to stay engaged with our patients when they leave the hospital? Specifically, where are they going? Who's in touch with them?

How are we you know, how are we monitoring these patients? Are we accessible for questions? I'd like to answer the question over the telephone or however the patient wants to communicate text. However, rather than see them in the emergency department.

So so the discharge disposition where patients are going is super important with CMS teams. And we start we have those conversations with patients and their families and caregivers on admission. Where are we going to go? Who's at home?

How can we make home safe? Home can be safe. And disarming the patients who come into the hospital thinking that they have to go to, quote unquote, rehab. One of the other things I would say is that in terms of post post-discharge, you know, we don't you know, no one owns that patient.

So we don't we don't want to have a thing of the surgeon. Oh, that's my patient. Right. But we want to we want to think of this as this is a patient for all of the care team.

And that we're all invested in that patient's well-doing when they leave the hospital. So, again, there's two things that jumped out at me, and it's true. I've spoken to Amr a lot about if you're waiting to the patients ready to get discharged to prepare them, then it's too late. Right.

That phone call, that that process, as you said, has to start, you know, on admission. Yeah. And I think that's a key. Just go ahead and let you finish.

I think that's key. Yeah. So on admission. So in the emergency department.

And this has been a part of the huge cultural shift that CMS teams is really demanding. And so on admission, our orthopedic residents, our APPs, our ER physicians are now starting to socialize the concept of going home if it's safe and appropriate or going home with some resources. Same thing with our nurses and physical therapists and the surgeons. We've realized that the post-acute discharge location is important.

And so early, early, early, we engage the patient, the family and caregivers. Yes. And I think also it's so aligned because CMS is requiring that primary care provider to be identified and brought in as part of that digital care journey. You know, we'll talk about in a minute, but that's part of that pathway that that, you know, PCP has to be brought in.

That's correct. Yeah. We haven't quite figured that out yet. We were live as of January 1st, the 27th.

And so, you know, the first year of CMS teams, there's no downside. So we're a year to get our act together. And so we're still trying to figure out that primary care piece because it's it's it's it can be complex. Yeah, I would imagine that jumped out at me when I read it.

The second thing you also mentioned that I loved was the I'd rather get a text or a call versus an ER visit. Correct. So, I mean, it kind of speaks to a little bit what we're doing in Nova now, but just generally speaking, can you speak about that? Because it's really a question I have for you later about technology.

But we could jump in now as it relates to. A little bit of that, that thinking. Yeah. So, I mean, as part of part of CMS team and health care systems, hospitals can be penalized for quality, for for decreased quality.

Right. Which includes readmissions and complications. And how do we get ahead of that? So a wound that is a surgical wound that is warm post-op A3, that's normal, but it's normal for me.

It's normal for you. But for patients who've had who had their first operation, that may not be normal. It's a little red and warm. And so they come to the emergency department that generates, you know, that generates costs and tests and inefficiencies.

So that's where we have to figure out how we can communicate with these patients to answer any questions and to prevent unnecessary over-utilization of resources. Yes, I agree. I think that's, you know, that's one of our core beliefs is really helping clinicians being able to have the visibility and be able to have those conversations. Like you said, text call before.

And if and if and if certainly if it requires an ER visit, then that gets handled right immediately. And, of course, you'd want to know that. My third question for you is many health systems focus first on pathways and analytics. In your view, what cultural shifts inside orthopedic departments are actually required for team to succeed?

And this is what I loved about your presentation a few months ago on the cultural aspect is some great slides. I would love for you to share more about culture. Sure. Yeah, this is this is I think this is where we will win.

It's the change in culture from everyone involved with patients and CMS team patient. It's it's understanding what CMS is just telling everyone is we have to change health care. We have to deliver better quality, decrease costs with the increase of value. And so getting everyone to look at their role in health care and their role in the CMS team's patients.

And to understand that just because I did it this way the last six or seven years doesn't mean that that's the right thing to do. So give you a prime example from from my partners, me and my partners. Rounds used to be this thing where it was like, how fast can you get through rounds? Now we round as a team with our nurse, the nurse manager for the day, with our case manager, with the physical therapy director, with an APP, an orthopedic trauma surgeon.

And we walk around and we go into as a team, go into every room and have a conversation, have conversations with the patients. And it takes a while. It can take a good chunk of time, especially when patients are just distributed throughout the hospital. But that's been a huge culture change for us that we've accepted.

I'll give you a culture change that we're struggling with. And that's with our our physical and occupational therapists who make just, you know, who make discharge recommendations. I think you should go to a skilled nursing facility or I think you should go to acute inpatient rehab for whatever reasons. And and we're saying we need to get more patients home.

Data clearly shows that home can be better for some patients. And we're saying let's not imprint our patients on post-op day one. You know, they had surgery yesterday, 22 hours ago. And your therapist is saying, hey, you can't get up and walk.

You got to go to rehab. Well, let's give them a couple of days of time before we make those those those designations. And and it's been a huge amount of pushback. And I understand it.

The therapists are saying, hey, you're taking my autonomy. And I go and I say, Lisa, say to them, welcome to medicine. Right. I lost my autonomy a long time ago.

So. But, yeah, those are just two examples of the culture shifts and changes that we're making with CMS teams. Yes. So on the rounds with teams, can you have you seen.

Like measurable, quantifiable results by doing that. Absolutely. Absolutely. So patients, we have great stories of we're going to talk to someone on post-op day two, one or two.

And we go, how are you doing? Here's your X-rays and all the medical stuff. And then we talk about what's home, like what's home, like who's at home with you and where would you like to go after discharge? And there are patients who think that they have to go to, quote unquote, rehab.

And we say, no, you know, if it's safe, you can go home. And there's delight on their faces. Like, you mean I don't have to go? I've heard some of these places are awful.

No, you don't have to go. And so. So, yeah, so that is that's subjective. We have our data from 24 and 25 on on patient discharges and locations.

Well, obviously, we're tracking for 26. So talk to me in April. We'll have our Q1 data and I'll let you know if we're making a difference or not. But subjectively, I think we are.

Yeah, I would I would imagine so. I just know those times when when I've had a care team come in with a loved one. You know, the conversations are typically very different, definitely deeper. But there it just it's just I feel like I've I've gotten more information, been able to ask questions.

There's more diversity of questions from the team. It just it feels like it would. I think you address things early. No questions.

It's always like, oh, I should have asked that question, you know. Right. Right. I think from a patient and family perspective, they gain a lot.

So and so when we walk in with five or six people, you know, the reception is wow. Like the patient goes, you really care about me. Like we're all here and everyone has a voice. Everyone is you know, everyone talks.

It's a conversation. It's it's surgeon led, but it is a conversation and all the team members have voices. Yeah, that's great. I love that.

One of the big conversation points in. But even probably before I would imagine you had care navigators. I think you are part of CJR other bundle payments, but I believe care navigators are, you know, big conversation or are important part of the plan. So they're often positioned as the solution under teams.

But, you know, what does an effective navigation model really look like to improve outcomes without overwhelming surgeons and staff? Right. Just how many more people can you add to it? Right.

Yeah. So, you know, the navigators must be clinical. Not this is not an administrative thing. So to be effective, they literally have to live inside the orthopedic department or service line.

We have to know their names. We have to trust the navigators. This is not some centralized call center. But these are these are behind any type of interface or have to be real people and in people with authority with some guardrails.

But navigators have to be able to make decisions, adjust payments, trigger urgent visits to the clinic. No surgeon likes more patients in the clinic that aren't surgical consults. But that's the reality. And I think that, you know, for navigators to be successful, like I imagine you would we would measure them in events avoided, not in how many things that they've done or how many calls that they made or left voicemails.

Right. But it's hey, an ED visit was was avoided or readmission was prevented. That's the value of a navigator. You measure that.

I've never heard anyone measure that. We haven't yet. And, you know, again, I mean, there have been bundles in the past, but the readmissions and the ED visits and sniff days are clearly going to be important for CMS team model. And so that's what I think we should measure, not, you know, how many how many calls they made to patients on post-op day one.

Sure. Yeah, that's a part of it. But it's yes, we post navigation. We prevented four people from leaving the sniff because of whatever and checking into the hospital, which we have.

We have patients who go to skilled nursing facilities and you get there and turn around and take an ambulance, call 911 and come back to the hospital. You know, it's interesting because I've never heard anybody say that, like, we should be measuring for events avoided or ED discharge, you know, and it's true. Like we measure for volume of calls or touch points. And, you know, it's always what you measure matters.

And so if you're measuring one certain aspect where you're going to get more of that, it's just interesting. And I think you're absolutely right. That's a different way to to really show value or show outcomes. Yeah, it's going to be hard, though, because how do you measure something that didn't occur?

That's right. It's easy to pull up a dashboard and say the navigator made 42 calls yesterday. That's great. But it's but what's important is of those 42 calls.

What did that how did that move the ball ahead in terms of CMS teams and increasing our quality? That's right. And you mentioned one other aspect before we jumped. We have like two more questions that they have to live in orthopedics.

You have to know their name, you know, and that's and I know in other hospitals that similar that similar, you know, could happen not everywhere, but that's certainly important for you and your team. And it's not administrative. I find a lot of times it's call centers, it's administrative. And I can give a personal example.

My my mom's fine, but she had an ER visit. She's fine. And and so next day I got a call from the ER and, you know, and they're like, how has everything going? And I actually had a question like any question like I do have a question.

And normally I don't because I have enough, you know, friends and family and in health care. So I start because I'm not a clinician. Oh, wow. And I'm like, well, that was exactly.

Yeah. And, you know, like like for cabbage, I mean, our cardiac surgeons, their navigators like live on the cardiac floor and they round with them and they go to lunch together. And so that's that's already embedded. And same thing with spine.

You know, the programs that are, I think, moneymakers for hospitals have long understood the importance of navigation. And so for hip fractures, which is sort of been something that we just do because it's the right thing to do. Now, I'm having to make the case for navigation is important as well. Yeah.

That's great. Great insights. Looking ahead a few years, what do you think will separate orthopedic service lines that thrive under teams? Right.

So you said this year you were not at risk. We can kind of have more room to figure things out. So what makes those minds that are able to thrive versus those that struggle once, you know, really in 11 months, there will be some sort of downside risk. Yeah, exactly.

So part of it is what we've been talking about is is establishing a culture of we're in this together. And that CMS team is not just some thing that, you know, some financial thing that we got to deal with, but it's understanding that this is the new reality of medicine. It's only going to get bigger. It's going to grow.

And so I think that hospitals and health care systems that understand and adapt early. And we'll thrive. Right. It's it's those who, you know, who can manage variation.

We talked about having uncomfortable conversations with outliers. It's socially appropriate for the physical therapist in the room to say, no, Dr. Hines, I disagree. I think this patient to go to acute inpatient rehab for that, that, that, you know, those that's absolutely acceptable.

So a lot of stuff that's going to separate the winners from the losers. We talked about the financial fluency and understanding where the money is, is leaking or hopefully being saved for your system. And then we were trying to set up a dashboard and that dashboard needs to be real time or close to real time, because knowing something happened 65 days from now with a patient, that's not as good as knowing what's happening in real time. So a lot.

Yeah, it's a lot. It sounds like it's not going to be one or two things. It's seven or eight things that's really going to matter. And, you know, I want to just wrap up the last question.

And with really your view on technology, just generally speaking, I mean, it's all different ways. You see in this teams allows or really wants to promote the use of technology and connecting patients and even other of their bundles. You know, they're really they're looking for providers to provide or, you know, to have technology to use in the care. Even the rural health care fund technology is a big aspect.

So as that extends, the responsibility extends outside. I love what you say. Active care. I'm sorry.

I want to make one more point. You don't talk about the care as different when they leave, which I think is really great. You talk about it as active care so that active care continues. What role do you think technology should play in improving how patients recover, stay connected?

Super important, right, because everyone has an iPhone or some type of mobile device. And that technology could function as an early warning system. Right. It's not not a replacement for conditions, but it is.

Hey, Dr. Himes, something's going on and you need to know. Right. That would be that's a great utilization for technology.

The force multiplier for navigators. So really good tech and bad navigation. That doesn't work. Or if we have I think we have good navigation, human good navigators, but bad tech.

That's still not as good as having really good tech and good navigation. And, you know, it's got to be seamless. It's got to work quietly in the background. You know, it's not a bunch of text.

It's got to be easy to use. One, you know, one one interface that's intuitive, you know, things that we want from all of our tech. And then I think the last thing is I certainly don't want I don't think any surgeon wants tech that is just going to increase our cognitive burden. Right.

So we get secure chats and text and pages. Just it just has to be a platform that filters the noises and just gives us what we need to know. Yeah, I agree. Again, I I love how you said it needs to work quietly in the background and probably just do the job or what it's supposed to do.

And not to create another thing that you've got to watch or another ding that goes off increases the cognitive burden. I agree. I've been thinking a lot about technology so much recently just because I see, you know, hospitals having to make decisions and then being additive. And I think you really put it, you know, said it precisely very well.

It just needs to do what it needs to do quietly in the background. Correct. It's got to be scalable. It's got to, you know, it's got to be something that doesn't not something that works for me or just for my group, but doesn't work for the cabbage group or for the, you know, the major bowel.

That's that's not good tech. Right. Right. Right.

Super narrow that everyone's got to bring in their own tech. Right. Yeah. That's not helpful for the system, nor is it, you know, financially wise either.

Correct. So, Dr. Himes, I've always enjoyed speaking with you in our life. And so thank you so much for the conversation today and your wisdom.

And I really, really value your experience to be able to share with all of us. I mean, you've got tremendous expertise, particularly around the bundle. So thank you. I appreciate your time.

You're welcome, Lisa. Great talking to you. Thank you, Dr. Himes.

It's just so good. Are you are you are you heading out now? No, no, I'm not. I have a CMS teams task force at five o'clock and a half hour.

That's our that's our biweekly sort of CMS team leadership group. So I'm good. Yeah, you're good. I give you a little time to maybe get a cup of coffee or something.

Thank you very much, Dr. Himes. Have a good day. All right.

Bye bye.