NR 517 Week 8 Delivery Reform Proposal, Hip Fracture Example

Delivery Reform Proposal: A Hip Fracture Pathway With Surgery Within 24 Hours, Geriatric Co-Management and Nurse Follow-Up, Checked Against the Payments It Would Live Inside, Including the Revenue Success Would Remove

Student Name

College of Nursing, Chamberlain University

NR 517: Policy & Economics of Healthcare Delivery

Instructor Name

Month Day, Year

Delivery Reform Proposal: A Hip Fracture Pathway With Surgery Within 24 Hours, Geriatric Co-Management and Nurse Follow-Up, Checked Against the Payments It Would Live Inside, Including the Revenue Success Would Remove

The Proposal

I propose that our community hospital adopt a hip fracture pathway with three parts. First, surgery within 24 hours of arrival for medically stable patients, with an escalation process when the operating room schedule cannot accommodate it. Second, daily co-management by a geriatric medicine clinician from admission, focused on delirium, pain, medications, nutrition and discharge planning. Third, the nurse-led follow-up program costed earlier this term, with three scheduled telephone contacts in the month after discharge. The pathway would apply to every patient admitted for operative treatment of a broken hip or femur, about 110 a year.

The Clinical Case

Each part rests on evidence. In a study of 42,230 adults undergoing hip fracture surgery in Ontario, Pincus et al. (2017) found that among propensity-matched patients, those operated on after 24 hours had higher 30-day mortality, 6.5% compared with 5.8%, and more complications, 12.2% compared with 10.1%. A meta-analysis of orthogeriatric care models by Grigoryan et al. (2014) found lower in-hospital and long-term mortality with orthogeriatric collaboration, with long-term mortality reduced by about 17%, and a shorter length of stay, particularly in shared care models. The follow-up calls rest on weaker evidence and are included because they address the 30 days after discharge that the hospital is now accountable for.

The Payment Arrangement It Must Live Inside

The pathway has to be checked against how the hospital is paid for these patients. Most are in traditional Medicare, which pays the hospital a fixed amount per stay according to the diagnosis-related group. Since January 2026, the hospital has also been in the Transforming Episode Accountability Model, which holds the hospital partly responsible for Medicare's total spending through the 30th day after discharge, with a reconciliation payment or repayment depending on how that total compares with a target and on quality results (Centers for Medicare & Medicaid Services, n.d.-b).

Under the fixed stay payment, a shorter stay lowers the hospital's cost without lowering its payment, so earlier surgery and co-management, if they shorten stays as the meta-analysis suggests, save the hospital money. Under the episode model, fewer complications, shorter facility stays and fewer readmissions lower Medicare's episode spending, which may bring the hospital a reconciliation payment. On both counts the pathway appears to pay for itself. The proposal would be naive to stop there.

The Revenue Success Would Take Away

Lower case payments from fewer complications. The diagnosis-related groups for hip and femur procedures pay more when a patient has a major complication or comorbidity. A patient who develops pneumonia or severe delirium after surgery can move the case into a higher-paying group. If the pathway prevents those complications, some cases will be paid at a lower rate. The hospital is paid less for patients who do better, and the finance office should see that line in the proposal rather than discover it later.

Less revenue for partners. Shorter and fewer skilled nursing facility stays mean fewer paid days for the local facilities the hospital depends on for other patients. Surgeons and hospitalists who bill separately for managing complications will also bill less. None of this reduces the hospital's own income, but it affects relationships the pathway needs.

A tension with the three-day rule. If co-management shortens the stay below three inpatient days for a patient who still needs a skilled nursing facility, traditional Medicare will not cover the facility stay, since coverage requires at least three consecutive inpatient days (Centers for Medicare & Medicaid Services, n.d.-a). The pathway must not push a patient who needs facility care home early to save a day. The discharge plan must be decided on need, and the stay must be long enough to protect coverage when facility care is needed.

Costs of the Pathway

The pathway's new costs are the geriatric clinician's time, about 30 minutes a patient a day for an average of three days, and the nurse follow-up program, estimated at about $11,600 in its first year. Operating room access within 24 hours may require opening an additional morning slot, whose cost depends on how often it is used for other cases. The finance office should cost the geriatric time and the operating room change before approval.

Who Must Agree

The pathway depends on three groups who do not report to nursing. The orthopedic surgeons must accept an escalation process when their schedule would push a repair past 24 hours, which may mean operating at less convenient times. The hospital medicine group must share care with a geriatric clinician, which changes who writes orders and who is called at night. And the operating room committee must decide whether to hold a morning slot for fractures. Each group should see the evidence on mortality and complications and the payment analysis above before the pilot begins, because each is being asked to give something up, and each will want to know why.

Why It Is Still Worth Doing

Even after counting the revenue lost to fewer complications, the pathway is likely to benefit the hospital through shorter stays and possible episode reconciliation payments, and it is very likely to benefit patients through lower mortality and fewer complications. The earlier evaluations of bundled payment for joint replacement found that savings came mainly from fewer facility discharges without an increase in complications (Barnett et al., 2019). This pathway aims for savings from better care rather than from discharging patients faster, which is the kind of saving the episode model's quality adjustment is designed to reward.

The request is for a one-year pilot, with four measures reported quarterly: the share of patients operated on within 24 hours, 30-day mortality and complications, length of stay, and the proportion leaving for facility-based rehabilitation, with falls and readmissions after discharge tracked alongside. If complications and mortality do not fall, or if patients sent home fare worse, the pathway should be revised or stopped.

The pilot should also report what it cost. If the geriatric co-management time proves larger than estimated, or the extra operating room slot is often unused, the finance office will need those figures to judge whether the pathway can continue after the first year, whatever its clinical results.

References

Barnett, M. L., Wilcock, A., McWilliams, J. M., Epstein, A. M., Joynt Maddox, K. E., Orav, E. J., Grabowski, D. C., & Mehrotra, A. (2019). Two-year evaluation of mandatory bundled payments for joint replacement. New England Journal of Medicine, 380(3), 252-262. https://doi.org/10.1056/NEJMsa1809010

Centers for Medicare & Medicaid Services. (n.d.-a). Skilled nursing facility (SNF) care. Medicare.gov. Retrieved September 30, 2026, from https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care

Centers for Medicare & Medicaid Services. (n.d.-b). Transforming Episode Accountability Model (TEAM). Retrieved September 30, 2026, from https://www.cms.gov/priorities/innovation/innovation-models/team-model

Grigoryan, K. V., Javedan, H., & Rudolph, J. L. (2014). Orthogeriatric care models and outcomes in hip fracture patients: A systematic review and meta-analysis. Journal of Orthopaedic Trauma, 28(3), e49-e55. https://doi.org/10.1097/BOT.0b013e3182a5a045

Pincus, D., Ravi, B., Wasserstein, D., Huang, A., Paterson, J. M., Nathens, A. B., Kreder, H. J., Jenkinson, R. J., & Wodchis, W. P. (2017). Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. JAMA, 318(20), 1994-2003. https://doi.org/10.1001/jama.2017.17606