CJR: A Performance Evaluation and Future Implications

The Comprehensive Care For Joint Replacement (CJR) model was designed to make participant hospitals accountable for both the quality and cost of Lower Extremity Joint Replacements (LEJR) procedures. Hip and knee replacements are two of the most commonly carried out LEJR procedures. With the CJR model, the CMS intended to reward participant hospitals for coordination with physicians and Post Acute Care (PAC) providers.

 CJR was introduced in the year 2016 and it has a mandatory randomized design where hospitals were selected to participate in the initiative. The model engaged hospitals with varying levels of infrastructure, expertise and facility utilization to achieve the best care quality for patients. All this, while keeping the cost to Medicare, as low as possible.

As is the case with bundled payment models, CJR adopts an episode-based approach. Each episode of care extends through 90 days after the discharge of the patient. The care bundle includes all Medicare-covered items and services. Hospitals incentivized by Medicare under the inpatient prospective payment system (IPPS) are randomly selected to receive ‘reconciliation payments’ that are derived from a retrospective payment methodology.

The Score Card

 Using Medicare payments data for joint replacement surgeries, the CMS has been able to determine the effectiveness of the model. A conceptual framework that considers a wide range of data sources such as claims, hospital surveys, site visits and personal interviews with doctors was leveraged to determine the performance of the model.

The evaluation shows many positives. Some of the most promising statistics from the evaluation are shown below:


The data presented above is from the work of researchers from the Harvard T.H. Chan School of Public Health in Boston. It considers the progress of the CJR model in the first two years. The research encompasses the evaluation care episodes from over 75 Metropolitan Statistical Areas (MSAs) and around 800 hospitals that participated.

This data was compared with the claims data of close to 1000 hospitals that were part of the ‘control area’ to get the information on how effective the CJR model has been since its inception.

Participation in the CJR Model

The CJR model is set to be in commission till December 31, 2020. Since the end of the second performance year, participation in the CJR reimbursement mode has been made voluntary by the CMS, in 33 MSAs. This is the case for rural care facilities and low volume providers as well. Reimbursements are initiated based on episodes of care, that are categorized into Diagnosis Related Groups (DRG).

Two of the commonly used ones are DRG 469 and DRG 470. They cover major joint replacements of the lower extremity with(DRG469) and without major complications and comorbidities (DRG470).

Participation in the CJR model gives eligible hospitals the standard benefits that come with adopting bundled payment models.

Enhancing the Joint Replacement Experience through Patient Engagement (PE)

 Traditionally, care providers used to hand out printed materials and sometimes schedule online classes for patients to prepare them for the LEJR procedures. Since it is an outpatient procedure, efficient communication about what to expect and how to take care of the implant after surgery is paramount to its success. Outpatient procedures usually have lesser number of touchpoints between the patient and the provider.

This leaves undesirable gaps in communication about what is required for the patient to make the rehabilitation process more effective. Consequently, the elimination of these gaps is vital to the prevention of rehospitalization.

The following points cover why hospitals participating in the CJR model to should think about implementing Patient Engagement programs:

  • Hospitals usually arrange for surgeries in Ambulatory Surgery Centers (ASCs). They are designed to house less number of clinicians and support staff. There is usually not a lot of scope for patient education programs in such a healthcare setting. Implementing a patient engagement portal or an m-health gives a patient a self-help tool which care providers can also use effectively to send personal care information.
  • A holistic patient engagement program that targets patients specifically based on their diagnosis helps make communication between the ASC staff and the patient more effective. All answers are instantly made available proactively in the form of FAQs, online chats or chatbots.
  • Patients scheduled for an LEJR procedure are often required to prepare for the surgery by performing a routine of pre-prescribed exercises. The best way for physicians to know if patients have performed the exercises is by seeking accountability through an online portal or m health app.

Implementing the ‘Engagement’ Process

There are three main areas that care facilities participating in the CJR model can explore.

Reduce Patient Anxiety and Fear: It is natural for patients to experience fear and anxiety about a complex medical procedure such as joint replacement. Intuitive content that is supplemented with videos about the details of the medical procedure educates patients adequately. By informing patients about how to cope with pain and control ailments with regular medication is the most effective initiative that care providers can take with LEJR procedures.

A 2019 research report on the Annals of Translational medicine journals show that 78% of patients who participated in a surgery program were successfully discharged after the surgery and sent home. Only 48% of patients who did not participate in this program enjoyed a successful discharge after the TKA surgery.”

Track and Report Progress: Traditionally, upon the completion of LEJR procedures, patients were sent home with documentation that contained a list of exercises for patients. This was about it! Today a close association with a healthcare IT technology expert sets doctors up with customized mobile apps. Patients can download these apps and get access to a library of exercise videos that help them recover safely in the convenience of their home. These apps also enable therapists to track the progress of recovery by helping patients determine the range of motion and status of completion of exercises.

An app named ‘myHip&Knee’ used by The Holland Orthopaedic & Arthritic Care Centre, Toronto empowers patients with the following features:

  • Pre-surgery preparation schedule
  • Access to Exercise videos
  • Pictures and content for self-help
  • A customizable care plan for recovery after surgery
  • Glossary of terms and links to articles on LEJR procedures
  • Daily Health Check Prompts

Action-Oriented Empowerment: Mobile apps and PE portals can only lead a horse to water. Patients still need an action point, an incentive to participate more in the rehabilitation process. In application prompts such as surveys, personalized messages and intuitive smart notifications through customized content delivery complete, the purpose of PE apps.

Physitrack a home exercise adherence app helps patients to work closely with their therapists to create personalized care plans. Patients can increase or decrease the intensity of exercises. This ensures the continuity of their rehabilitation process since patients are encouraged not to give up by focusing on their personal needs.

 Interested to know more about PE? Reach out to us today at info@nalashaa.com

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Puneeth Salian

Puneeth Salian

A writer in Healthcare domain, who is also a science and technology enthusiast. Enjoys creating interesting pieces that elucidate the latest Healthcare IT trends and advancements.
Puneeth Salian

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