Demonstrating OT’s Value in Bundled Payment Models for Total Joint Arthroplasty Episodes: A Scoping Review and Recommendations

PURPOSE: To improve quality and limit costs of care for total joint arthroplasty (TJA) episodes among an aging population, the Centers for Medicare & Medicaid Services have piloted alternative payment models (e.g., Bundled Payments for Care Improvement and the Comprehensive Care for Joint Replacement initiatives). These models connect accountability for episode outcomes and quality through shared reimbursements among providers. Preliminary results indicate bundled payment models have effectively reduced costs as well as acute and postacute care (PAC) utilization without lowering quality. However, despite occupational therapy’s key role and presence throughout the TJA care continuum, emerging evidence inadequately describes occupational therapy’s role in bundled payment models for this patient population. Therefore, the purpose of this study was to 1) quantify and describe the characteristics of studies examining the effects of bundled payment models on PAC utilization in TJA episodes and 2) identify opportunities and implications for future research and clinical practice.

DESIGN AND METHOD: Guided by Arksey and O’Malley’s (2005) scoping review framework, we devised a search strategy in consultation with university librarians and searched seven databases (e.g., MedLine, Scopus, and CINAHL). Inclusion criteria were: 1) published between 2013-2019; 2) written in English; 3) acute care, post-acute care, or home with no PAC settings; 4) elective primary TJA as primary diagnosis; and 5) peer-reviewed quantitative studies including articles and abstracts. Two occupational therapists completed screening and extraction with supervision from two experienced health services researchers. The initial search generated 588 studies. After review at the title, abstract, and full text levels, 23 studies met inclusion criteria. Few studies in the final sample reported functional status, self-care outcomes, and level of occupational therapy services provided.

RESULTS: All studies (n = 23) primarily analyzed electronic health records or Medicare claims data. No studies included authors with an occupational therapy credential. While eight studies reported access to physical therapy services, only one study reported access to occupational therapy services. One study reported Activity Measure for Post-Acute Care scores, and one study reported patients’ needed assistance to complete activities of daily living. All studies reported resource utilization (e.g., length of stay and cost) post-TJA. No study reported measures of participation and patient-reported outcomes. 13 studies reported discharge disposition of patients. Last, no studies described occupational therapy’s standard clinical contributions to TJA care such as education, durable medical equipment provision, discharge planning, and environmental modifications.

CONCLUSION: Research on PAC utilization in bundled payment models for TJA episodes focuses on outcomes such as length of stay, cost, and discharge disposition. However, despite its essential role at each stage of the care continuum, occupational therapy has had limited representation in evidence. Researchers and clinicians must advocate for developing evidence such as case studies, outcomes studies, and descriptions of the profession’s essential role in care teams as the models are implemented. Developing evidence will facilitate articulation of occupational therapy’s effectiveness in improving outcomes in bundled payment models for TJA.

IMPACT STATEMENT: This study highlights opportunities and recommendations to demonstrate occupational therapy’s value in TJA care. Practitioners and researchers must advocate for the profession’s key role in optimizing quality and cost outcomes in the implementation of bundled payment models for TJA.

References

Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616

Piccinin, M. A., Sayeed, Z., Kozlowski, R., Bobba, V., Knesek, D., & Frush, T. (2018). Bundle payment for musculoskeletal care: Current evidence (Part 1). Orthopedic Clinics, 49(2), 135–146. https://doi.org/10.1016/j.ocl.2017.11.002

Pritchard, K. T., Fisher, G., McGee Rudnitsky, K., & Ramirez, R. D. (2019). Policy and payment changes create new opportunities for occupational therapy in acute care. American Journal of Occupational Therapy, 73(2), 7302109010p1. https://doi.org/10.5014/ajot.2018.732002

Siddiqi, A., White, P. B., Mistry, J. B., Gwam, C. U., Nace, J., Mont, M. A., & Delanois, R. E. (2017). Effect of bundled payments and healthcare reform as alternative payment models in total joint arthroplasty: A clinical review. Journal of Arthroplasty. https://doi.org/10.1016/j.arth.2017.03.027