PROGRESS REPORT For the first 2 weeks after surgery, therapists visit patients for about 45 minutes every other day to make sure rehab is progressing properly and to keep physicians informed.

I've sent about 50 total knee patients home on the day of their surgeries, and not one has had to make an unscheduled return. No one has fallen, none have developed infections, and no one has ended up in the emergency room for any other reason. That's not just good luck, of course. To achieve and maintain that kind of success, we carefully mapped out the details of our outpatient total joint program, including all the obstacles patients potentially face once they're discharged to home. By working with a reliable home healthcare organization to address the following essential elements of recovery success, we know that patients will be safe during the crucial first 2 weeks after surgery.

1. Home assessment
What kind of home does the patient live in? Are there a lot of stairs? Is there a lot of clutter? Is there a caregiver who's up to the task? These and other questions need to be answered well before the day of surgery. You don't want to do a total joint and send a patient into an unsafe environment. So our evaluation starts with a pre-surgical visit by a therapist 2 to 3 weeks before surgery — someone who clearly understands what the patient is going to be going through those first days of recovery, and who can spot issues that a patient wouldn't necessarily recognize. Do pathways need to be widened? Is the bed on the same level as the bathroom? What kinds of stairs is the patient going to have to deal with, and how often?

We know our therapists will work with our patients and make good suggestions about improving the home setup — How about if we move this couch out of here, and move this bed into this room? That first visit is early enough to ensure that therapists have the time and opportunity to rearrange furniture or whatever else is needed to make the environment safe.

That initial home visit also plays a big part in our decision-making process. After we put in a referral, our agency visits the patient and reports back to us with a form that touches on all of the important variables. Our decision as to whether to do the surgery inpatient or outpatient is based not just on the patient's health history and comorbidities, but also on the therapist's feedback.

2. Welcoming care
The next important visit is on the day of surgery. We give the agency a heads-up when a patient is leaving our facility, and they send a therapist out to the home, to be there when the patient arrives. The therapist helps the patient get into the house, makes sure everything is sorted out, and answers any questions that hadn't come up previously. The therapist also begins working with the patient during this visit, easing him into some of the exercises he'll be doing for the next couple of weeks.

PHYSICAL THERAPY
The Changing Post-Surgical Rehab Landscape

ADDED EXPENSE Post-surgical rehab has become a target for cuts, with more patients being sent straight home after joint replacement, where they can get in-home nursing visits and go to outpatient physical therapy.

Post-surgical care of joint replacement patients is rapidly changing, with more rehab taking place at home and at the physical therapist's rather than at costly inpatient rehab facilities or nursing homes.

Surgical facilities didn't pay nearly as much attention to where joint replacement patients rehabbed before the advent of bundled payments, which pay facilities for an episode of care that begins before surgery and ends 30 to 90 days after. Providers share in savings if they bring expenses down. A typical stay in a nursing home after surgery can cost up to $15,000, nearly 4 times as much as an average home-care episode ($3,500) and a course of outpatient physical therapy ($700). Plus, studies have shown that joint replacement patients do no better with physical therapy than with daily activity.

Increasingly, inpatient rehab is reserved for the elderly with other medical problems, and for patients who don't have a good support system at home. Matthew S. Austin, MD, director of joint replacement services at the Rothman Institute at Thomas Jefferson University Hospital in Philadelphia, is among those who believe that you don't need to have a rigidly structured rehab program after joint replacement.

At Rothman, healthy, active total joint patients may choose to be in charge of their own therapy, using a computer program called Force Therapeutics, which guides them through exercises and tracks both compliance and pain. It's not for everybody, but the economic impact of the self-therapy route is significant.

"Post-discharge care can occupy a significant amount of the total cost of joint replacement — in some case up to 50%," says Dr. Austin. "We're trying to appropriately utilize services."

To help determine what their post-operative care will be, Rothman patients fill out a "risk-stratification form" with help from an allied health professional. A nurse navigator, who looks at the patient holistically, then reviews the forms.

"The traditional expectation would be that the patient would get home physical therapy for 2 weeks after surgery and then transition to an outpatient physical therapy environment," says Dr. Austin. "But we're trying to look at it differently. What does this patient really need to get back to what he was able to do? If you have an active person who's 55 years old, they may not need formal physical therapy afterward."

It's important to remember, says Dr. Austin, that while there's formal physical therapy, there are also other kinds of therapy. "It's not as if the patients aren't going to get any therapy whatsoever," he says. "You can get therapy doing your active daily living in some cases. Not every person is a round peg that needs to fit in a round hole."

— Jim Burger

3. Consistent support
Over those next 2 weeks, the therapist stops by the patient's house for about 45 minutes every other day to make sure the recovery is progressing the way it should, and to keep us informed. That last part is crucial. You don't want to have a patient return 3 or 4 weeks later and suddenly start discussing a problem you never heard anything about, despite the fact that you had a home health agency sending a therapist or nurse out every other day.

It helps when you can work with the same agency for every patient, since every agency has its own method of conveying information. We strive for that, but some of our patients come from outside the local area, or even from other states. When that happens, we'll see what's available in their areas, and our home health agency is happy to communicate with other agencies to let them know what our expectations are. That networking approach has worked out well.

4. Setting expectations
Patients have to know what to expect, too. We've worked with our home health caretakers on handouts that help clarify expectations after surgery. They're easy to read and color-coded, so if a reaction occurs that's in the green category, patients know it's nothing to worry about. If it's yellow, however, they should get in touch with the home health nurse; and if it's red, they need to make sure to call a doctor or 9-1-1.

Education is huge. In addition to joint class at the hospital, the pre-visit with the home physical therapist helps facilitate a comfort level before the surgery takes place. We don't want patients worrying after they're home that something bad is going to happen. Knowing what to expect gives them a better mindset going in.

5. Clear communication
When the idea of doing outpatient total joints first came up, I knew I wouldn't feel safe sending patients home without a safety net. So I sat down with our home health agency and told them what my expectations were and what I was going to need in order to have the comfort level to do it. We discussed all of my concerns and came up with a plan. Fortunately, we'd worked with this group before, when discharging inpatients, so it was a natural progression.

Good therapists are obviously a must, but it's equally important to have a company that communicates well, and that's responsive — one that can get somebody out to the home quickly, when needed. If you have all those elements in place, the last piece of the puzzle — proper home care — should fall into place. OSM