Experts predict that the number of primary total knee replacements will increase 673 percent by 2030. How can health systems improve outcomes for patients receiving joint replacements while also controlling costs? One way is to discharge patients home instead of to a skilled nursing facility after surgery. In this post, Dawn Scott, Clinical Services Director at Franciscan St. Francis (a participant in IHI's Joint Replacement Learning Community) offers tips for increasing the likelihood of a home discharge after joint replacement surgery. Scott will share more learning as guest faculty for the IHI Expedition: Preparing for New Models of Joint Replacement Care.
Not every approach to patient care leads to better outcomes and gives health care organizations more financial control. For our organization, one such approach has been improving the discharge to home process for patients after having hip or knee replacement surgeries.
Knee and hip replacements are two of the most commonly performed surgeries in the US, with well over one million procedures done every year. A number of studies indicate that joint replacement patients have similar or better outcomes after receiving therapy at home compared to inpatient rehabilitation programs. As more health systems enter bundled payment arrangements that encourage them to deliver excellent care at a lower cost, appropriate and safe discharge to home after joint replacement surgery is going to be a key element of success.
Building upon what we learned from Dr. Jeff Pierson of Joint Replacement Surgeons of Indiana, his staff, and his patients, Franciscan St. Francis Health has developed practices that we believe have contributed to a notable percentage of patients returning home after surgery: We discharged 77 percent of our joint replacement patients to home (with or without home health services) between June 2014 and March 2015, including revision patients. (Dr. Pierson discharged over 90 percent of his patients to home.) Based on our experience, we’ve developed some tips we hope others can use to improve the discharge process for their patients.
Convey a consistent message about the discharge planFor our patients, the surgeon sets the stage at the initial visit, telling the patient, “I believe you’ll do better if you go home after surgery.” Patients also meet with a case manager in the surgeon’s office or during their pre-operative clearance visit who reinforces the home discharge message. The case manager asks, “How can we help you go home after your discharge from the hospital?” The scheduler says the same thing. We convey this consistent message through all clinic visits and the inpatient stay.
If discharge to home is an appropriate goal after surgery, all care providers should communicate this clearly to patients and their loved ones right from the beginning of their joint replacement journey. Conveying this idea starts with the surgeon, and all other care providers who interact with the patient should reinforce the same message.
- Share the plan with the family and the inpatient team
Everyone in a position to help the patient after surgery and discharge should also know the plan. Make every attempt to include a family member (or other appropriate friend or loved one) in the discharge-to-home planning discussions. Tell the inpatient team about the home discharge plan, which helps the physical therapist incorporate the plan into their work with the patient. In our hospital, we also post a sign at the head of every joint patient’s bed so that any person who comes in the room can see the plan — for example, that the patient will go home with home health care services on Wednesday.
- Anticipate and address barriers to home discharge
To deal with potential barriers, the care team must find out well in advance what might get in the way of a home discharge and do some pre-emptive problem solving. For patients who live alone, for example, providers should ask them who is going to stay with them for three to five days. For a patient who normally sleeps in an upstairs bedroom, it’s important to talk about preparing a room downstairs they can use for a few days.
For all patients, anticipating obstacles means asking about their post-surgical expectations. If patients or their relatives have had a previous joint surgery with us, a home discharge plan doesn’t surprise them. If, however, they know someone who went to a skilled nursing facility for two weeks post-discharge, they’re more inclined to think that’s the norm.
There’s a big psychological component to the success of a home discharge plan. Patients or their families may initially assume they can’t go home without going to inpatient rehab first. They may not know they’re capable of going directly home unless they hear it from their care team. Our goal is to do all we can to help patients get home, and we expect that patients are going to do well. We’ve seen a shortened average length of stay for our joints patients, and I have to wonder if some of that is because we really want patients to go home because we believe they’ll have better outcomes, and we do everything we can to support that plan.
- Engage patients through dialogue
It’s important to approach the discussion about a home discharge plan as a dialogue. It’s not a one-way lecture.
Take the example of a 68-year-old woman who is preparing for a knee replacement. We learn from talking with her that she assumes that she’s going to an inpatient rehab facility after surgery because that’s what her sister did. After further discussion, we discover that she believes she’ll do better in rehab.
This conversation gives us the opportunity to explain that her post-surgery progress is up to her, not a rehab facility. “Wherever you are — at home or in a facility,” we tell her, “you’ll be the one to do the work. Your progress is up to you.” It also gives us a chance to explain that she’s likely to have fewer complications, such as infections, if she goes directly home.
By opening up this dialogue and meeting patients where they are, we can help them solve problems, address misunderstandings, and understand their role in their recovery. We encourage them to be active participants rather than passive recipients of care. Asking patients, “How will you go home?” instead of, “Will you go home?” sets the expectation for home discharge, a choice patients may not realize they can attain.
Effective communication is vital to improving the joint replacement discharge process. By engaging all the key care team members — especially the patient and family — early and throughout the patient’s journey, we can enhance the care experience, improve the health of this population of patients, and help maintain better control over costs.
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