The Comprehensive Care for Joint Replacement Expanded (CJR-X) Model signals a major shift in how hospitals must think about orthopedic care, particularly for lower extremity joint replacement (LEJR) procedures. Under traditional fee-for-service reimbursement, providers are largely paid for the services they deliver. However, under CJR-X, hospitals are accountable for the quality and total cost of care across a 90-day episode. This means success is determined not just by what happens in the operating room, but also by how effectively organizations identify, manage, and support patients across the entire continuum of care.
For many organizations, this requires adopting a population health mindset. Rather than focusing only on the surgical procedure, hospitals must identify high-risk patients so they can intervene proactively to help prevent complications, readmissions, emergency department (ED) utilization, and excessive post-acute spending.
How Can High-Risk Patients Affect Performance in CJR-X?
Based on our experience supporting hospitals in prior bundled payment models from the Center for Medicare and Medicaid Innovation (CMMI), a relatively small subset of patients often drives a disproportionate share of episode spending resulting from avoidable complications, readmissions, and discharges to a higher-resourced post-acute setting than is clinically appropriate.
These high-risk patients frequently present with chronic conditions, adverse social determinants of health (SDOH), unmet behavioral health needs, substance use disorders, obesity, smoking history, frailty, or inadequate caregiver support at home. These factors are often identifiable in advance, and hospitals may be able to address them before surgery occurs by putting processes in place to identify which patients are at risk of avoidable negative outcomes and implementing care pathways to help address the drivers of poor outcomes.
Hospitals are aware these patients exist. However, the challenge is that the warning signs are often scattered. Risk indicators may be documented in a preoperative clinic note, another provider’s medical record, an anesthesia assessment, medical claims data, or a care management note. Historically, many hospitals have lacked a coordinated approach to LEJR episodes and a unified process to aggregate risk signals. As a result, many high-risk patients progress through the system without receiving appropriately targeted interventions, which often leads to potentially avoidable complications and excessive costs later in the episode.
A population health strategy helps address this challenge by viewing patients holistically rather than through isolated clinical encounters. It creates a structured process for identifying risk, stratifying patients, and deploying resources based on need.
What Predictors Should Hospitals Look for in High-Risk Patients?
Providers have often defined high-risk patients primarily based on medical comorbidities. While the presence of one or more chronic diseases is one important predictor of episode performance, a population health framework recognizes that medical diagnoses alone do not tell the patient’s entire story.
Organizations also need to understand what is happening outside the hospital. For example, does the patient have adequate support at home to safely recover after surgery? Do transportation issues create barriers to follow-up care? Are there unmet behavioral health needs? Is there an untreated substance use disorder that could complicate recovery? These are all factors that significantly influence outcomes during a 90-day episode.
For elective orthopedic procedures, like many of those included in CJR-X, modifiable risk factors such as obesity, poor glycemic control, and smoking status are particularly important. A recent history of smoking, for example, is associated with impaired wound healing, increased infection risk, higher readmission rates, and greater overall episode costs. Hospitals can often help address these risks through a smoking cessation program before surgery if they can identify them early enough.
This broader view of risk illustrates why population health is so critical under CJR-X. Organizations that focus only on surgical care miss many of the factors driving clinical outcomes and financial performance.
When Should Hospitals Begin Risk Identification for Patients in CJR-X Episodes?
Each patient should undergo a standardized risk assessment process as early as possible before the start of a CJR-X episode. An effective approach combines multiple sources of information, including claims history, prior admissions, ED utilization, clinical risk factors, SDOH, and information contained in the medical record. Hospitals can then incorporate these data elements into a risk-scoring methodology that stratifies patients into high-, moderate-, and low-risk categories.
Together, these combined data sources create a more complete picture of patient risk and support more effective intervention strategies. Without this level of proactive risk stratification and identification, hospitals may be forced into a reactive model. By the time complications emerge, organizations may have limited opportunities to influence outcomes or episode spending.
How Does Coding Accuracy Support Population Health?
Accurate coding influences risk adjustment and target prices, mortality metrics, quality scores, value-based purchasing programs, and financial performance in CJR-X. Organizations that fail to capture patient complexity accurately may appear to be performing worse than they are, because expected outcomes are understated relative to patient acuity.
Identifying high-risk patients requires hospitals to have strong processes in place related to documentation and coding. Patient acuity must be appropriately reflected both in outpatient Hierarchical Condition Category (HCC) capture (even if the diagnosis code does not immediately relate to a reimbursable service) and in inpatient coding practices.
How Does Risk Stratification Help Hospitals Allocate Resources?
Once hospitals identify and stratify patients according to risk, they can deploy resources more effectively. High-risk patients may benefit from referral to an optimization clinic, intensive care management, nurse practitioner support, or multiple preoperative interventions before receiving surgical clearance. Moderate-risk patients may require targeted support from a care manager or orthopedic navigator. Low-risk patients may only need routine pre-anesthesia evaluation and participation in preoperative education programs.
This tiered approach reflects a central principle of population health management: allocating resources according to need rather than treating every patient the same.
Because resources are finite, hospitals cannot provide intensive care management to every patient. Risk stratification helps organizations focus their most expensive interventions—for example, intensive patient navigation—on the patients whose outcomes and costs are most likely to improve as a result.
How Do Navigation & Care Management Support Performance in CJR-X?
Instead of handing off high-risk patients between multiple departments and providers, hospitals should consider assigning a dedicated care navigator or case manager who becomes involved in the episode prior to surgery and engages with the patient throughout the recovery period. This individual can help address social barriers, facilitate communication, coordinate services, monitor progress, and intervene before small issues become major complications.
For example, the care navigator can be the patient’s point of contact if they are experiencing complications. The navigator can help triage the issue and arrange for a next-day follow-up appointment with the orthopedic surgeon if it is clinically appropriate. Our experience has shown that providing a resource to help address questions and facilitate access can reduce unnecessary ED visits and admissions.
How Can Hospitals Scale Care Navigation Based on Risk & Volume?
The appropriate navigator-to-patient ratio varies based on patient complexity, episode design, and the intensity of touchpoints incorporated throughout the care pathway. There is generally a “sweet spot” where navigators can effectively manage a defined panel of patients while maintaining proactive outreach and timely intervention. Rather than prescribing a specific staffing ratio, organizations should align navigator capacity with anticipated episode volume, risk stratification, and program goals.
For higher-volume organizations, this may require multiple navigators assigned across orthopedic service lines. For lower-volume hospitals, a dedicated full-time navigator may not be necessary. Navigation responsibilities can often be integrated into existing care management resources, incorporated into an LEJR education program (“joint camp”), or piloted within elective LEJR episodes before expanding to other high-risk surgical populations. The objective is not necessarily to add staff, but to provide patients with a consistent point of contact throughout the episode who can coordinate care and address barriers before they result in unnecessary utilization or complications.
How Should Hospitals React to High-Risk Flags?
Most hospitals already have tools that identify high-risk patients. The problem is that just having the tool does not change operational behavior. Successful organizations connect risk identification to automated workflows. A high-risk designation should automatically trigger specific interventions, which may include assigning a care manager, scheduling earlier follow-up appointments, referring the patient to an optimization clinic, increasing outreach frequency, or engaging social work resources.
How Can Hospitals Engage Surgeons in Population Health Strategies?
Surgeons play a critical role in establishing evidence-based criteria for factors such as glycemic control, body mass index, and smoking cessation. When surgeons see how preoperative intervention helps improve outcomes, reduce complications, lower revision rates, and enhance Merit-Based Incentive Payment System (MIPS) performance, it can become significantly easier to achieve their participation.
Hospitals can further support physician engagement by providing care navigators, analytics, dashboards, and gainsharing opportunities that create alignment around episode performance.
How Can Governance Support Success With High-Risk Patients in CJR-X?
Perhaps the most important lesson from earlier bundled payment initiatives is that improvement efforts must be institutionalized. Organizations that rely heavily on a few key individuals often experience performance deterioration as turnover occurs. Processes fade, accountability weakens, and outcomes regress.
To help avoid this mistake, hospitals participating in CJR-X should establish a clear governance framework that includes a designated episode owner, routine cross-continuum reviews, formal reporting structures, steering committee oversight, and accountability measures tied to high-risk patient management. Regular review of outcomes, root-cause analyses, and operational barriers should occur at both the management and executive levels.
How Forvis Mazars Can Help With CJR-X Population Health Strategies
Ultimately, population health is not a separate strategy from CJR-X. It is the operational foundation upon which long-term success in the model can be built. Key drivers of CJR-X performance, including readmissions, complications, post-acute utilization, patient outcomes, quality scores, and episode spending, can be traced back to how effectively hospitals identify and manage their highest-risk patients before problems occur.
Based on extensive experience assisting hospitals in previous alternative payment models, our value-based care team understands the population health strategies that can support success in CJR-X. We can help you assess your organization’s current approach to population health and identify and implement strategies suitable to the patients and communities you serve. If you have any questions about CJR-X or would like assistance preparing for participation in the model, please reach out to our team today.