The Comprehensive Care for Joint Replacement (CJR) program helped the University of Pittsburgh Medical Center Passavant reduce the percentage of total joint replacement patients who are discharged to a skilled nursing facility instead of home.

  • The program also helped to reduce the hospital’s length of stay among those patients.
  • Applying a case management/care continuum approach in handling total joint replacement surgery helps with both quality of care and cost-effectiveness.
  • Patients with diabetes, obesity, and comorbidities are referred to nutritional counseling and other programs to help them improve their health before surgery.

The role of orthopedic nurse navigator ramped up when CMS rolled out initiatives for total joint replacement.

Under the Trump Administration, the Comprehensive Care for Joint Replacement (CJR) initiative has been curtailed, decreasing the mandatory sites and canceling its expansion. However, changes in the process and patient focus have improved outcomes and collaboration across the care continuum, says Pamela A. Cupec, BSN, MS, RN, ONC, CRRN, ACM, orthopedic nurse navigator at the University of Pittsburgh Medical Center (UPMC) Passavant in Pittsburgh.

The program helped UPMC Passavant reduce the percentage of total joint replacement patients who are discharged to a skilled nursing facility (SNF) instead of home from about 35% to 22%, Cupec says.

“We have also reduced our LOS [length of stay],” Cupec adds. “Several years ago, a total hip or total knee replacement involved a four-day length of stay, and the team implemented several changes to decrease length of stay. Some of our hip replacement patients have been discharged safely to home the following day. On average, these patients return home after a two-to-three-day LOS.”

The LOS decline was due to the navigator program, as well as to changes made by physicians and surgeons, she notes.

Applying a case management/care continuum approach to handling total joint replacement surgery makes a great deal of sense from both a quality of care perspective and a cost of care perspective, Cupec says. “Total joint replacement is an expensive surgical procedure, with cost of care disparity across the nation. Part of the CJR initiative is to rein in costs while delivering high-quality outcomes and patient-focused care.”

One of the changes that the program promoted was deferring surgery when patients’ health might lead to poor outcomes.

Patients with diabetes, obesity, and comorbidities were referred to programs — such as nutritional counseling — that could help them improve their health before surgery.

The role of the orthopedic nurse navigator varies and can be practice-based or facility-based. Practice-based navigators assist patients prior to surgery, providing education related to surgery and post-op care.

“Some practices would have a navigator in the surgical office, who would meet with patients prior to scheduling surgery and give [them] education,” Cupec says. “I don’t have that luxury. I call patients before surgery and invite them to join a class and start to develop a discharge plan.”

During a phone call with the patient, the nurse navigator assesses the patient’s current support system, as well as the feasibility of the patient returning home after surgery and whether he or she will need a skilled nursing facility stay for post-acute care, she adds.

“The navigator, who may also have a strong case management background, can discover barriers to discharging patients home,” Cupec says. “They can start working with the patient in forming a discharge plan and alternatives, such as having a family member take off time, or perhaps move into a child’s home if they have a better home set up.”

For patients who are unable to attend a live class, navigators can review key points in educating that patient prior to surgery, leading to better understanding and preparation, she says.

Postponing surgery to give patients time to improve their health can result in fewer complications with infection, she adds.

The following is how the orthopedic nurse navigator works with total joint patients:

  • Before, and day of, surgery: The hospital case manager and Cupec work closely together. For instance, there might be a high-census, high-volume day in which TJR patients are kept in the recovery room longer than necessary because there are no hospital beds available. Cupec will try to use that time efficiently by sending a physical therapist to start a treatment session with a patient who is stable.

This helps with the hospital’s LOS because that patient won’t be delayed in discharge due to a late start to therapy. “If they go up to the unit late, they will miss their session of therapy until the next day,” Cupec explains. “If they don’t get in two sessions, then they have to stay in the hospital another day, and 
that doesn’t make anyone happy.”

For example, one staff nurse’s husband underwent knee surgery, and Cupec noticed he was walking around the unit when he should have been resting in the recovery room.

“I said, ‘Your husband is walking around the unit. Did they cancel the surgery?’” she says.

Post-surgery, he was working with a physical therapist within eight minutes of entering the recovery room.

This kind of solution helps. “It’s all part of case management, where you don’t back up people and extend the LOS, but you help keep that process moving,” Cupec says.

  • Post-surgery: The morning after surgery, Cupec gives patients her contact information and says, “I will be the person following you for the next couple of months.”

Having one person they can contact and rely on can help them feel less overwhelmed. “If they say they are having trouble getting therapy scheduled, it’s my job to intervene,” she says.

When Cupec sees patients, she discusses their discharge plans and asks how they’re doing.

“I say, ‘Hey, I hear you’re doing great,’” she says. “We talk about what kind of progress that patient has and whether there are medical complications.”

Cupec makes rounds every other day, and she’ll stop to speak with patients when she sees them in the hall, emphasizing that she is there for them.

  • Long-term follow-up: Cupec uses a spreadsheet to track patients post-surgery. She also checks therapy notes about them and reviews a daily list of those who return to the ED.

UPNC produced an app that sends information to physicians after hospital and ED visits. “If a patient comes to the ED with drainage in the leg, the app sends out an alert,” she says.

This triggers a request to the physician to determine whether the doctor could see the patient the next day to avoid admitting the patient to the hospital.

After 90 days, Cupec stops following patients.

“We reach out to patients in the last nine or 12 months to do a survey, and patients report outcomes,” Cupec says.