Why Post-Acute Care Will Decide CMS TEAM Success

Episode Contents

• 0:00 Introduction to NovaNav
• 1:10 Guest Introduction: Dr. Hans Van Lancker
• 5:10 Orthopedics under CMS TEAM: defining success across the full episode of care
• 10:59 CMS TEAM care coordination: aligning the team beyond the surgeon
• 14:02 Home care and workflows that mimic patient advocacy
• 17:45 Building a culture around patient advocacy
• 19:16 Post-op home care: supporting caregivers and increasing patient confidence
• 23:10 Using technology to free up time for top-of-license work
• 27:55 Episode wrap-up

Key Takeaways

He discusses the challenge of accountability when surgeons and hospitals are financially responsible for outcomes that depend heavily on post-acute settings, care coordination, and patient adherence. The conversation explores the future of home recovery and how health systems can reduce post-operative variability.

Transcript

Welcome to the Surgical Journey, a podcast about putting patients at the center of surgical care. From preoperative readiness to recovery at home, we talk about the real processes and data that shape outcomes. Each episode features conversations with health system leaders, surgical teams, and technology experts who are changing how patients move through surgery and recovery. At NovoNav, we focus on making surgery easier for patients and their care teams.

That means clearer communication, reducing administrative burden, and smarter use of data. In this series, you'll hear how that work plays out in real clinical environments. Let's get into the conversation with our host, Lisa Miller. Welcome to the Surgical Journey.

Today, I have Dr. Van Laver here with me. Welcome to the Surgical Journey. Great.

Thank you for having me. I want you to share a little bit about yourself, but just for the audience, you chair orthopedics over the entire bone and joint department at Cambridge Health Alliance. So you oversee a lot of aspects of musculoskeletal, and I'd like you to share more. So you have a really big role to play there at Cambridge Health Alliance.

I would just like the audience to hear a little bit about you. And I know prior to, or maybe not prior to, but one of your big interests is engineering. And I got a chance to watch a video of you and your son tinkering on the weekends. And so I think what might come of that is also your entrepreneurial thinking, your innovation, and just your ability to kind of see different things from different aspects and bring it into your work.

So Dr. Van Laver, would you share with everyone a little bit about you? Yeah, absolutely. So I think you got it right there.

I really do like, the way that I put it is I like fixing things. That can be something mechanical, that can be fixing very broken bones, which is what I'm clinically trained to do. I'm an orthopedic trauma surgeon, but I did specialty training there to deal with the most complex of fracture injuries and orthopedic trauma. And I picked that because it's always been an interest of mine.

Since I was a kid, I've enjoyed putting things back together, seeing how they work, understanding how they work, and making them work better. And that applies both to clinical aspects of medicine, the mechanical things in my hobbies, which are building cars and boats and buildings. And it also applies to making things work better operationally. So fixing the way that we deliver healthcare, fixing the way that our practice runs, fixing the way that we communicate, fixing the way that we interact with our patients.

There's so much opportunity in healthcare to do things better. And for me, it's been a really exciting place to be because I've been able to take that interest and continue to foster innovation and see new solutions to problems, working with different companies and incubating new ideas through what we see as being the problems in healthcare. So I love that. And I think when you're on the front lines and you are fixing and you're seeing things, so whether that's like your hobbies you mentioned, I would imagine, I'm going to take a guess because I don't know this for sure, but you're probably the doctor, the leader that walks the halls, that does want to see things on the front lines.

And I think when you see things on front lines, you're able to fix things. You're able to see what's broken or how they connect, which I think is really important in healthcare. So I would imagine you're a frontline leader. Yeah.

I mean, I think you can't know what's broken unless you spend time using it yourself. And that's how I've learned so much on how to fix things is that I've, be it in a race car or in a boat, pushing things till they break, pushing things and understanding sort of where that limit is. And it's the same thing, right? We're growing rapidly at CHA, especially in orthopedics and across the network.

We're growing in the use of technology. And that's giving us an understanding as to where are the limitations? Where are the stress points? Where are the pain points for the physicians, for the patients?

And I love uncovering those things because then they're problems to solve and they keep me engaged and active. And that's what's rewarding about work. Yeah. I love it.

So thank you for that little pre-conversation, but I think it's relative and it matters as we go through the questions, because I think it's probably a lot of the way you think and the way you operate is from that point of view. So you often talk about building a new model of healthcare delivery that truly works, right? I've read a couple of things that you've written. So when you look at orthopedics through the lens of CMS team, what fundamentally has to change in how systems define success across an episode of care?

So, you know, CMS team is the government's attempt at value-based care, trying to sort of create a new model and prove a model that could potentially work for value-based care. And they select a few different diagnoses, many of which are orthopedic. There's always been some, not always, but for the recent past, there's been some work within orthopedics on value-based care and funnel payment along with CMS. From my perspective, it's still fundamentally a bit simple in the sense that the CMS mandate is that the way to achieve success is through, you know, obviously, the thing that's good about it from a value-based perspective is that it's pay per outcome versus, you know, pay per service, right?

So you're paying for a good outcome and sort of you get paid better if that outcome is better, which I fully support, right? I think it makes sense to pay for good care, right? And sort of in a way, warranty things for where there may be a problem. And motivating people to be a part of the decisions and really be active in the decisions that are being made so that things don't get unnecessarily expensive or there aren't complications is a really intelligent thing to do.

That said, the control of all of those pieces of the care pathway are not on one person, yet the result rests with one person, really. I mean, it does rest with the system. It rests with the system and the physician. And your outcome from a financial perspective is dependent on so many other aspects of care that, you know, we really, like, that's where I mean that it's a very kind of oversimplified version of that and that we're not actually creating accountability to everybody involved.

And I think that's where, you know, I've found success in building incentives and building buy-in with the team in creating as much accountability to everyone that I possibly can, be it financial accountability, you know, some type of benefit when things go right. And that's where I am a bit, you know, I think this is an evolution for us. And, you know, CMS team is better than maybe the last iteration, but we're still missing a piece of this when I look at the whole picture of, you know, getting it right. So, I never thought of it from that perspective.

It's true because it really does lay on hospital surgeon. And there's so many... The highest cost piece is actually post-acute care. That's right.

So, you know, it's really hard for, you know, other than in the preoperative selection of patients, the preoperative education of patients, you know, and the optimization as best we can do preoperatively, I don't have a whole lot of control over post-operative care other than making sure that I'm available to help troubleshoot. But patients need what they need post-operatively. So, it's a tough spot. See, you wonder how that will evolve because I think it's a great point.

Now, I know that there's incentives and, you know, there's collaborators and you could bring collaborators in, but, you know, you make a really great point at the end of the day outside of that of really kind of activating that mechanism, the true mechanism, the true is really on hospital physician and everything does happen post-acute. You know, it's something that, you know, it's a good point. And that's where the financial aspect spirals out of control is in the post-acute care, not, you know, unless you have a major complication surgically, but that's very rare. And we tend to control those things very well.

Right. You know, because the patient is still directly under our care. It's when they're not. And then, you know, the tools to be able to affect really positive change to the post-acute care setting don't exist yet.

And that's where I think there's, you know, it's asking us to do something without the set of tools that we need to really do it as best we possibly can. And, you know, I think that's an opportunity, right? Because you see a problem and then you can find a solution and build a solution. But, you know, that care coordination piece, you know, we're trying to figure out a way right now to build a solution for that that maybe works for us, maybe works for other people.

But, you know, how do we bring the right technology in place, the right people, the right resources to make sure that things don't get off the rails? Well, I guess that's the best segue into, I mean, I don't, maybe not a specific question, but maybe how are you viewing bringing care coordination together? It's probably the use of technology. There's culture.

You know, there's probably many aspects. So how are you doing that? So, you know, I think one simple way to start there is to continue to expand. We've created some really novel incentive programs for our physicians that have been really successful in driving the care costs down.

So it's how do we continue to evolve those and directly relate them to sort of the outcomes with regard to CMS team? So that's the first piece. And that's evolution of some of what already exists. And then, you know, continuing to think about how we can make that work better for this program.

But, you know, and then the other part of it is how do we incentivize the other parts of the team to contribute in the same way, right? Because the surgeon can only do so much. I mean, we can control cost of care in the operating room. We can, you know, and that's one thing that we've been successful in designing.

But, you know, then it's the post-acute care piece. It's the continued patient education, patient communication piece. So we're working on the education side, right, to get that consistent and standardized so that we don't lose track of things there. And everybody has access to the same consistent education.

And technology is a really big partner there. But then it's also, you know, after the surgery, consistency to the post-op. You know, care piece with regard to, you know, we've created protocols around anticoagulation, around follow-up, around closure, around really trying to standardize that. So there's zero variability.

But we did that ever before CMS teams, their team was part of the problem, you know, part of the problem to solve, part of the opportunity. But the continued sort of, you know, ability to keep the patient in the lowest cost, kind of safest place, post-acute care is where things get hard. So, you know, and for us, is there a way to implement technology to sort of maybe track where that patient is in their journey? Is there a way to have, you know, really what we feel we need at this point is a nurse navigator, someone to really sort of be on top of, you know, understanding where these patients are on their journey to help get them to the best place.

I'm a big proponent of home care, you know, patients going home, having the resources and the monitoring to take care of them safely at home. People do better at home, they recover faster at home, they're safer at home. There's so many good reasons to get people home, lower infection rates, etc. But sometimes patients don't have someone who can help them at home or a safe home and understanding and preoperatively assessing those pieces is a whole nother part of this.

So, as you can tell, there's many facets to the way that you have to think about this. So, I want to talk about home care. I mean, we're deviating a little bit, but I love the conversation about care at home. I agree.

My mom has had a total knee. She did go into rehab for a while. My mom actually fell a couple years ago and I think the fall was worse than her knee. But she actually did okay.

And they were like, rehab or home? And I'm like, I'll take her home. And I got her home and, you know, we figured it out. I mean, it wasn't easy, but I'm so glad I made that decision.

And I was on the phone. I had a nurse navigator. We spoke every day, sometimes twice. I was really proactive, like, you know, but we did it.

And I think you're 100% right with the right nurse navigators with the right, like, oversight or feedback. We can have patients, even in maybe, I don't want to, you said it well, like, you want to make sure they're safe and there's quality and know that there's someone caring for them. I think even loved ones would rather have their family member or whomever home. I think even economically, I mean, obviously, from a love-love perspective and a care perspective, economically, I think it makes a lot of sense too.

I agree. No, economically, it absolutely makes sense. It makes sense from a patient outcome perspective. I think the one thing that you said that really stands out, but I think it's also a really important part of this is that patient advocacy piece, right?

So, you know, you clearly spoke up for your mother to make sure that she got the best care possible, right? And I think not everyone has that, you know, working for them. But how do we create a scenario where that happens more automatically and really, we know what the best place for these patients is. And that's sort of what the default is, as opposed to what happens right now, which the default is that if no one does what you did, the patient ends up at rehab because it's sort of like, well, we know that, you know, we can send them there and they'll be okay, right?

But it's probably not what's best. And we know it's not what's best from a cost perspective. And now there's a problem where we might actually get dinged if they go there. So, you know, but are we really engaging everybody that we should to try to get that patient to the right place?

And that's where I think this sort of, it doesn't quite work yet, right? Because we don't, we haven't brought everybody into the decision, into the process. So I think that's the opportunity, well, it's by many opportunities, right? I agree with you.

So recently I saw a situation just with, again, a family situation. And I think the default is, well, they would tell me if it was okay to bring them home. You know what I mean? Like the default is like, well, I'm not really supposed to speak up.

You know what I mean? Even younger people, I've watched, I'm just like, wait a minute, you're allowed to be in the conversation respectfully. You're allowed to be in the conversation, you know? And I think, well, they didn't tell me that.

And I'm just like, well, wait a minute. You might have to be more inquisitive or is there an alternative? So what happens, you know, my personality is a little bit different, probably same with you. But how do we educate?

I mean, we always talk about education, about wounds and about ready, getting ready for the surgery, but maybe like educating about advocacy. Because I think we don't do that enough where we give the patient, not because it's anything wrong, but just the opportunity to have more of a voice or their family members. I agree. I think that's a really important point.

And I think there are ways you can build it into the culture of your department. And that's what I think we've done really successfully is that, you know, we've driven through, you know, evidence-based care, through education of the team, through, you know, a recognition of the fact that actually it's better for us as providers to not have patients admitted somewhere. But really, the culture in our department is to try to get everyone home that we can. And it was not three years ago.

But, you know, it was something that was important to me. It's something I really saw the benefits and kind of felt the need to move on. And we went from like a four-day length of stay to a point four-day average length of stay. And the patient satisfaction scores improved.

The provider satisfaction scores have improved. And patients do better, right? The complications go down. You know, patients are less likely to have a blood clot.

They're less likely to have, you know, these complications when they go home and they move. And they're, you know, they tend to be happier too. Right. Are you doing anything in that?

I want to talk about technology in a couple different places. So particularly in the home care setting, like hospital at home, how are you thinking about some of those things? Like what you can enable patients and their families to utilize? I mean, I think there's so much opportunity in that space.

I've been a big proponent of it, you know, for many years. One of my friends and mentors is Raphael Rutkowski who actually, you know, founded Medically Home and really sort of pioneered a lot of that care at home model. And, you know, I think we're just starting to understand how and where it fits. I think we've found some places where it can fit extremely well, you know, especially with these chronic patients who may have had a long hospital stay with really minimal necessity of being in hospital, but need some degree of continued monitoring.

In the surgical space, you know, it hasn't been done as much yet. I think there's absolutely opportunity to substitute, you know, care at home versus acute care if we can operationalize the rehabilitation piece of it. Right. So I think that's the hardest part.

Yes. And, you know, and that's, we need to get people up every day. We need people that can help with that. You know, are there ways to train family members appropriately?

Could we, you know, and the way that I like to think about it is, well, that's going to cost less to the system. If we can appropriately train someone and actually compensate them for the work that they do in a way that's meaningful, the work that they do with their family member, what a great way to engage them in the care of their family member, you know, and, you know, build in incentives to really everybody involved. That's what I would love to see. Right.

Like we haven't gotten there yet, but, you know, if someone's son or daughter is helping care for them at home, well, we should compensate them. Absolutely. For it. You know, they're getting, they're going to cost a lot more to compensate a nurse to see them at a level of care that they don't actually need in a nursing home versus, you know, someone who they know, who they're safe with, et cetera.

Yeah, I agree. I think in some states they're doing a little bit of that now in terms of, I'm here in Florida and I know Florida does that a little bit with, you know, for family members that care for, you know, their, you know, for seniors or which I think is, I think is great. I think more of that. You wonder on the team's incentive, would they allow for that, right?

Because they allow for a patient incentive and you wonder if they would. I've never thought of it. That's a really great idea. So the use of technology, you know, at NovaNav, our technology, you know, we have a digital care pathway.

So we're, we're, we're working with physicians and hospitals from pre-op to, as you talked about, post-op. How comfortable are you with using technologies to have the patient, you know, work in, in an environment where they're self-reporting and that you could see their progress? How comfortable are you? I mean, I, I love that.

I think I'm as, I'm as comfortable with it as I can get the patient to be comfortable with it, right? I think that's, for me, that's the sort of rate limiting step, especially with, you know, elderly orthopedic patients. We have to design tools and use tools that, you know, are easy to implement in that way. And I think that's also where, you know, family engagement is really, really positive.

You know, I, I love the idea of capturing the data in real time, you know, being able to have reportable data because that's an important part of the whole CMS team reimbursement piece is, you know, is having the data and being able to report a certain amount of the data. And so, you know, it's absolutely what we need. It's understanding how to implement it, understanding how to educate patients around it, and then understanding adherence, you know, how to make sure that we, you know, enhance adherence and, and making it simple, right? So I think when that can be, you know, eliminating the need for, for logging in to be able to report the patient report outcomes, that may be a barrier to entry that, that we need to sort through.

Those kinds of things I think are important to think about in the implementation of that. But I'm, you know, I love, I love more technology, you know, when we can show that it, it drives change and improves patient and provider satisfaction and reduces unnecessary work, right? I mean, I think one thing we need more of in healthcare is, is the optimization of the work so that it's all top of license for everybody involved, right? We, we all spend a fair amount of time doing work right now that's, that doesn't feel like, you know, what we were best trained to do.

And, you know, I love technology that eliminates that work, you know, at any level, because there's just not enough humans to take care of everybody. So, you know, as opposed to replacing the surgeon with a robot, which may be an aspirational. That is very aspirational. But, but let's, let's first like replace the work that the surgeon shouldn't be doing and get the surgeon doing the work that they're most trained to do.

And, and, you know, and giving them tools to do that even better. I think it's a great point, right? I mean, we hear so much about the da Vinci's and the robots and every, you know, but yet are we optimizing for real business applications or administrative applications first? Like what are those micro applications?

And there's so many that have not, they're not being used to address that first to make you more efficient. And, and I, you know, I, I like our current offering of robots is actually does, does what I think robots, you know, can, should do. And that will continue to evolve where they make parts of the procedure more consistent, more streamlined, more simple, so that you can be more efficient and not focus on, you know, not focus on things that, that actually can be solved that way and spend your time on the real sort of more complex reasoning that has to occur, you know, in, in, in surgery and inpatient care. So is there anything that you think in particular on the, on the operational side that you like to focus on?

Is it the, you know, giving nurse navigators, you know, more ability with technology to utilize, like you said, you know, having the real time reporting and, and even if the patients, I mean, we see the patients do report. We see it's either the patients or their family members. So we see that they want to have a vehicle to connect. Actually, they probably don't want to bother you or bother the nurse or call the office.

They want to have a real time vehicle too. Are there any, any other places that you feel like technology can be used on, you know, being more innovative, being more entrepreneurial? Absolutely. I mean, I think we uncover a new one every day.

It feels like, you know, we were running lists of different ways. We feel like we could get incubated solutions to some of the problems that we, we encounter. The, you know, with regard to the post-acute care piece, you know, I think having parameters and having a tool that allows you to sort of see where patients are and if they're falling off of the curve would be really useful. And then, you know, empowering someone in a navigator position to then be able to act on, you know, and triage those patients to needing something done sooner rather than later is really helpful and would be, you know, would be of high value.

Ensuring that we're capturing the outcomes, the patient report outcomes and the clinical outcomes, you know, to the best degree possible, I think is obviously paramount. And then, you know, having tools to be able to redirect them if they're not where they are. And, you know, it's one thing to know that things aren't working well. It's another thing to know, you know, what are the ways that we can potentially fix that, you know, learning from other institutions, I think is a great opportunity there and sharing that information.

Yeah, I love that. I think that's a great way to kind of wrap up, but I love the redirection. I love the sharing of knowledge because I don't think we get to be successful in models like TEAM or CJR by working in individual silos. I think the success, we've got to have shared knowledge in order for everyone to succeed.

I just don't think it's going to work. You know, there's so many great thinkers in different places and we need to come together. But Dr. Van Lekker, thank you for your time today.

Thank you for being on the Surgical Journey podcast. I loved the conversation. So I hope we get to do it again. Knock it out.

Take care. Thanks for listening to the Surgical Journey. Join us next time as we continue examining smarter, more connected approaches to perioperative care.