ROOM TO RECOVER Beginning their rehabilitation at home gives outpatient joint patients additional motivation.

Following knee or hip replacement surgery, patients will be recovering and rehabilitating primarily at home, something that's easy to forget when you're focused solely on the treatment delivered during the perioperative process. But an outpatient total joint replacement program without a coordinated home care component is doomed to failure. These patients demand consistent monitoring, in-home nursing and physical therapy in the days and weeks that follow surgery, care that same-day discharges and non-clinician caregivers can't guarantee. Here's what you need to know about this sometimes overlooked aspect of total joint surgery.

Why home recovery makes sense
Discharging total joint patients within hours of their surgeries and, by association, having them start their recoveries at home, offers advantages on both economical and clinical fronts.

One of the chief aims of the Affordable Care Act — and of Medicare's recently proposed Comprehensive Care for Joint Replacement payment model, slated to take effect in select markets in January — is promoting high-quality health care while reducing the costs of that care. One cost-effective tactic that frequently delivers value is shortening the lengths of hospital stays, when possible.

A hospital stay can cost roughly $2,500 to $3,500 per day, and sometimes insurers dictate a hospital stay, but if not, every day earlier that you can safely discharge a patient saves a substantial sum of money. Certainly you could refer patients to a skilled nursing facility, which is a comparative bargain at about $414 per day, but an adequate home recovery model can cost about $62 per day.

Home recovery also carries benefits for patient outcomes. Studies show that the longer a patient stays in the hospital, the higher the risk of surgical site infection, so speedy discharge and at-home care might actually reduce the risk of post-op complications as well as hospital readmissions.

It's providing them with an encouraging shot of motivation, too. It stands to reason that outpatient total joints programs are seeing such great results because patients aren't staying in the hospital, they're resting comfortably at home. After the rigors of surgery, that's where patients want to be. By bringing the therapy to the patient, there is a higher level of compliance and carry-over of the treatment sessions.

STEPS TOWARD THE DOOR Patients — and their insurers — don't want hospital stays to be longer than absolutely necessary.

The key to consistency
In addition, home recovery can provide a uniform post-op care regimen to patients who are spending the critical first few days following their joint surgeries outside the strictly prescribed environment of the hospital. Which is why 2 physicians with whom our nursing service works have made it a standard part of their outpatient joints program.

When Ken Cherry, MD, and Christopher McClellan, DO, saw the quality of results they were achieving with advanced implants and targeted anesthesia, they began to forgo the average 3-day hospital stay in favor of sending patients home 3 hours after their surgeries. (See "Yes, You Can Do Same-Day Hips" in Outpatient Surgery Magazine's March 2014 issue.) Their practice, Same Day Joints in Altoona, Pa., now consults with ASCs and hospitals looking to bring outpatient hips and knees to their own ORs.

During their early efforts, though, the stellar surgical results would occasionally fall on inconsistent outcomes after their patients were discharged. The doctors determined that there were gaps in the post-op care the patients received — sometimes they got good home care, sometimes they didn't, sometimes they were compliant with post-op rehabilitation schedules, sometimes not — and these gaps created complications. Clearly their same-day joints service needed to incorporate a consistent post-op home recovery program.

WALK THE WALK Visits from nurses as well as physical therapists approximates the hospital post-op experience.

Steps to success
A post-op checkup at home by a visiting nurse making the rounds has long played a role in the orthopedic surgery process, as a follow-up to the care received during an inpatient stay. Outpatient total joints, however, benefit from a more coordinated, more collaborative home recovery program than the standard nurse drop-in arrangements. A program that addresses the following factors can help to deliver high-quality outcomes.

• Ortho experience. Traditionally, home care agency nurses are jacks-of-all-trades who deliver a wide range of general services. A specialty-trained team can provide appropriate care, prioritize the interventions and ultimately reduce the length of stay by making every visit count. For same-day joint patients, it's better to send nurses who are trained in and have experience with orthopedic care, and who can recognize and handle specific musculoskeletal comorbidities such as osteoarthritis. Supplementing their care routine with visits from physical and occupational therapists adds convenience and boosts compliance.
• Coordinated care. It can't be expected that a nurse or therapist would be able to visit a patient and administer high-quality care without knowing anything about the case. That's why it's critical for home recovery caregivers to coordinate care pathways with the physician performing the surgery in advance of the surgery. This can take some time to plan, but a sit-down consultation with the physician can build the patient's recovery care on the physician's standing orders, protocols and expectations for each post-surgical day. With this collaborative approach, nurses and therapists can practically take the hospital model of care into the patient's home.
• Pre-op assessment. For patients who will be doing their joint replacement recoveries at home, pre-surgical education and preparation should include an assessment of their living situation in order to determine the potential for successful or risk-laden outcomes. Home recovery nurses who visit patients 2 weeks before surgery can scope out the accessibility of the environment, particularly entryways, steps, and bedroom and bathroom locations. They can identify potential barriers to recovery, such as a patient's body-mass index, medications, pets, or even the weather. They can help to develop workarounds and report the patient's level of complication risk back to the physician ahead of the surgery.
• Daily and in-depth. Patients who have been cleared for outpatient joint replacement surgery tend to be healthier patients. On average, the ones we've seen are about 57 years old. But that doesn't mean they won't require the thoroughness of care that inpatient joint patients receive. On the first day of home recovery, our nurses visit twice, once with the physical therapist and once to check in later in the day. After that, both nurse and therapist visit once a day, at different times, staggering the care to emulate that of a hospital stay.

In addition to administering the physician's prescribed care pathways, our nurses are also collecting data: daily pain scores, whether the patient is constipated or nauseated, the existence of edema. The physical therapists are rating joint function, range of motion and the use of mobility assist devices. These "scorecards" are reported back to the physician, the surgical facility and insurers. Also, the availability of electronic monitoring devices means that an attention to detail doesn't have to wait for a scheduled visit from the caregiver.

Results to report
Physicians from all over are intrigued by Dr. Cherry's and Dr. McClellan's same-day joint outcomes. They're the result of a four-part collaboration among anesthesia and their regional cocktail, which stays ahead of the pain; surgeons and their skilled approaches to the hips and knees; advanced implant and instrument technology; and home recovery efforts, which the physicians have credited as a game-changer.

Consider this: over a 2-year period, their outpatient joint patients who have received appropriate home care have seen zero hospital readmissions and an emergency department visit rate of 0.7%. All told, 90% don't require additional outpatient care following the 14-day home recovery program. Two weeks, and they're done. It's thrilling to be a part of surgical innovation, especially when the results are this good.