The Comprehensive Care for Joint Replacement Expanded (CJR-X) Model is a mandatory bundled payment model that includes 90-day Medicare lower extremity joint replacement (LEJR) episodes spanning inpatient, outpatient, and post-acute care. CMS has proposed a start date of October 1, 2027, with more than 2,500 hospitals required to participate.
Hospitals will be held financially accountable for quality outcomes and total episode spending relative to regional, risk-adjusted target prices, with two-sided risk beginning as soon as the model starts. With this in mind, early preparation is essential for hospitals to position themselves to succeed.
In our last CJR-X article, we shared data-driven strategies and best practices that support performance in the model. This article will cover another key driver of success: redesigning post-discharge care pathways to help control spending and improve outcomes.
On average, more than 40% of episode spending occurs during the 90-day post-discharge period. More importantly, most of the “controllable” spending occurs during this time frame. Under episodic payment models like CJR-X, success is defined not just by efficient inpatient or hospital outpatient department throughput, but also by how effectively hospitals manage recovery, prevent complications, and discharge the patient to the most clinically appropriate setting. Post‑discharge care pathways that begin discharge planning well before surgery and assign an accountable care team member to support the patient across their surgical journey, from pre-operation through post-discharge recovery, can help hospitals achieve these goals.
Below, we explore these best practices and more, based on our experience supporting more than 400 hospitals in Medicare bundled payment programs.
Focus on Longitudinal Recovery
Historically, discharge planning has focused on safely transitioning patients out of the hospital. However, in CJR‑X, the expectation is fundamentally different: providers must optimize the entire recovery journey. This includes redesigning the discharge planning process so that patients receive the right level of care in the most clinically appropriate setting, while also reducing avoidable readmissions.
This shift requires a standardized, proactive approach to care pathways. Rather than defaulting to available post-acute care (PAC) providers, successful organizations implement a structured decision framework that matches patient needs with the post‑discharge setting, e.g., home with in-home therapy, home with therapy and additional home health support, or a skilled nursing facility (SNF). These decisions should be informed by clinical and social risk factors, so that higher‑risk patients receive additional support in the right setting.
Shift Discharge Planning Upstream
One of the most effective best practices in models like CJR‑X is moving discharge planning upstream, often months prior to an elective surgery. High-performing organizations begin care pathway design as soon as the decision for surgery has been made. At this stage, hospitals should risk-stratify patients based on comorbidities such as uncontrolled diabetes or high body mass index (BMI), as well as social determinants such as caregiver availability and home environment.
Elective patients identified as high-risk can be routed to prehabilitation programs to help improve readiness before surgery. This may include glycemic control, weight management, or addressing social barriers such as transportation or home safety. Early intervention can help providers reduce complications, improve the likelihood of successful discharge to home, and improve patient outcomes.
Adopt a “Right Site of Care” Approach
Another defining feature of organizations that have succeeded in prior LEJR bundled payment models is adopting a “right site of care” philosophy. For many elective joint replacement procedures, discharge to home can be a clinically appropriate and effective option. At the same time, facility-based PAC settings remain critical for patients who require additional clinical support or intensive therapy.
This approach focuses on aligning each patient to the setting that best matches their clinical needs, functional status, and available support system. Rather than a one-size-fits-all default, high-performing organizations use structured clinical criteria to guide these decisions.
To support this approach, organizations engage patients and caregivers early in the process. Education begins well before surgery and helps patients understand the range of recovery pathways available, including the benefits and expectations associated with each setting. Preparing caregivers and setting appropriate expectations is critical to supporting a smooth and successful transition after discharge.
Create a Holistic, End-to-End Discharge Plan
A hallmark of successful post‑discharge pathway redesign is a comprehensive, longitudinal discharge plan that serves as a “true north.” This plan is created pre-operation and follows the patient throughout the care continuum, documenting goals, anticipated discharge setting, equipment needs, caregiver responsibilities, and contingency plans.
Maintaining continuity in planning and communication helps organizations reduce handoffs, enhance patient trust, and improve adherence to the care plan. Many high-performing programs assign a dedicated care navigator who engages with the patient before surgery and remains involved throughout recovery, supporting consistency and accountability.
Build High-Value Post-Acute Networks
Improving care pathways for LEJR episodes also requires strong alignment with post‑acute partners. Successful hospitals will move beyond ad hoc referral patterns and instead build high-value PAC networks based on transparent performance data. Key metrics include length of stay, readmission rates, functional outcomes, and overall cost of care.
High-performing PAC providers distinguish themselves by delivering shorter stays, fewer complications, and better functional gains while actively collaborating with hospitals on care protocols. Just as importantly, they are willing to engage in data sharing and continuous improvement initiatives. These partnerships help enable more consistent, predictable outcomes across the episode of care.
Base Discharge Decisions on Patient Readiness
In optimized pathways, discharge timing is driven by the patient’s readiness, not by hospital throughput pressures. A patient should not leave the hospital until all elements of the post‑discharge plan are in place, including medications, durable medical equipment, scheduled therapy services, and scheduled follow-up appointments.
This level of coordination helps reduce the risk of gaps in care that can lead to complications or emergency department (ED) visits. In addition, some high-performing organizations are implementing mechanisms to provide rapid access to care post‑discharge, such as dedicated call lines or virtual check-ins, to address issues before they escalate into ED visits or readmissions.
Drive Accountability Across the Continuum
Finally, success in LEJR episodes requires clear care team accountability. Given the number of stakeholders involved, including surgeons, hospitals, ambulatory providers, and PAC partners, defining responsibilities for managing the patient throughout the episode is essential.
Without this clarity, gaps in follow-up and communication can undermine outcomes. Establishing a designated care coordinator or managing entity responsible for following the patient throughout their care journey supports consistent oversight and helps address issues promptly.
How Forvis Mazars Can Help You Prepare for the CJR-X Model
Our value-based care team has extensive experience supporting hospitals in episodic payment models, including TEAM, ASM, CJR, BPCI-A, and more. We can help you develop a multipronged strategy to prepare for CJR-X, including assistance with discharge planning and PAC network development. If you have any questions or would like assistance with CJR-X, please reach out to our team today.