For an outpatient bundled total joint surgery program, case managers play an important role in helping patients stay healthy post-surgery.

• Case managers were trained to work with a private insurance population that undergo total joint surgery in an outpatient setting where they are sent home instead of to a hospital bed after surgery.

• Outcomes show no infections or deep vein thrombosis issues, and a lower percentage of reoperations than the national average.

• Case managers start by assessing patients for inclusion in the outpatient surgery program.

Case managers are integral to two North Carolina bundled payment for total joint surgery programs, one of which is an outpatient program and another that is Medicare-based.

The outpatient bundled program established in August 2017 by Delta Joint Management of Greensboro, NC, has case managers coordinating care for patients with physical therapy and other appointments up to 90 days after surgery in an ambulatory surgery center. Its financial and health outcomes success is tied, in part, to case managers assisting with criteria assessment, communication, and coordination.

The organization’s case managers handle a Medicare bundled total joint program, so when the outpatient bundled program was launched, case managers were trained to work with this private insurance population, says Donna Garvey, CMPE, practice administrator of Sports Medicine and Joint Replacement in Greensboro and executive director of Delta Joint Management.

The program has worked very well for bundled ambulatory surgery total joint patients, with outcomes better than the national average: There were zero infections and deep vein thrombosis issues in the bundled program’s first nine months, and a 1.6% reoperation rate — less than half of the national rate. Hospital readmissions are zero, compared with 3.5 to 6.5% nationally, says Steve Lucey, MD, co-founder of Delta Joint Management.

Because of the positive health outcomes, the bundled payment strategy is financially feasible. The physician owners of Delta Joint Management pay for patients’ care from the day of surgery to 90 days after surgery. One negotiated payment per patient with a private payer covers everything required to ensure a successful surgery. If a patient’s surgical site became infected or some other problem arose, the physicians’ company would be responsible for covering those costs, up to a cap.

Patients pay 10 to 20% of the total amount in co-insurance. Their out-of-pocket costs are much less in the outpatient setting, Lucey says.

For the program to work financially, case managers must ensure patients and families are aware of their responsibilities.

“Our outpatient patients have done very well,” says Lisa Thornton, case manager at Sports Medicine and Joint Replacement. “We make sure patients have everything they need when they get home. They have prescriptions filled, any equipment they might need, outpatient physical therapy appointments scheduled, and we make sure a caregiver is there with them.”

This type of focused case management gives case managers more time to focus on what patients need and what the outcomes should be, says Renee Angiulli, RN, BSN, MHA, CCM, case manager at Southeastern Orthopaedic Specialists in Greensboro, NC.

“I think there’s more consistency when you focus on a population than when you work across the spectrum of patients,” Angiulli says. “You learn the nuances and tricks to keep those patients successful.”

Case management for the inpatient total joint Medicare population requires a little more creativity because they often have less household support, Angiulli says. (See story in this issue on case management with Medicare total joint program.)

Here’s how the program works:

• Case managers assess patients for inclusion in the outpatient total joint program. Patients must meet specific criteria to enter the program. Case managers use an assessment tool to ask patients about their health. Questions target risk behaviors, such as whether the patient has any of the following red flag issues:

- Does the patient take more than 10 mg of oxycodone a day?

- Is the patient’s A1c (blood glucose level) over 7.5?

- Is the patient morbidly obese?

- Does the patient experience serious psychiatric issues?

A “yes” answer to any of those questions could suggest it would be safer for the patient to undergo surgery in the hospital, where he or she could be monitored for a few days post-surgery.

“I do the risk assessment to make sure they’re truly healthy enough to do outpatient surgery at the center,” says Jill Lauer, registered nurse/case manager at Delta Joint Management.

After performing the risk assessment, case managers check the patients’ medical records for respiratory, cardiac, liver, and other conditions to see if anything stands out as a potential surgery risk. Checking the medical records can verify or correct patients’ recollections of their medical history, Lauer notes.

“It’s a lot of communication between schedulers and physicians and case managers,” Angiulli says. “I call the patient and go through the check-off questions, and then I put it in and say ‘This is a good candidate for outpatient surgery.’”

• Physicians conduct pre-surgery physical. Patients who meet criteria are scheduled for surgery. A few weeks before surgery, patients visit the surgeon for a physical and medical history.

“They are potentially diving even deeper than I do,” Lauer says. “They go over medications and make sure any health conditions are controlled. They discuss the surgery in detail and answer any questions patients might have.”

Then a case manager meets with patients to make sure they have someone who can be with them for at least three days after surgery.

“We ask how many steps they have at the house and how many stories. What kind of equipment do they need? What kind of therapy will they have after surgery?” Lauer explains. “Then I set them up for the therapy appointment and coordinate that.”

• Develop a care plan. “As case managers with Dr. Lucey’s practice, we started several years ago treating total joints and partial knee replacements,” Thornton says. “As a case manager, I speak with a patient prior to surgery, and we design the patient’s care plan.”

Case managers determine whether the patient needs home health or outpatient physical therapy.

“We make sure they have a caregiver to stay with them for at least 72 hours when they’re discharged from the surgical facility,” Thornton says. “We make sure they have transportation lined up, and we’re the first contact point for our patients.”

Case managers also tell patients how to keep their legs elevated properly after surgery. “We tell them to keep their toes above their noses and go over icing protocols, giving them a folder of frequently asked questions,” Lauer says.

• Contact patients one day post-surgery. “We talk to patients the day they’re discharged from the facility,” Thornton says.

Case managers call patients to ensure they have filled their prescriptions. “We call to make sure the pain meds are controlling their pain,” she says.

“If they will be using a CPM [continuous passive motion] machine, we make arrangements for it to be delivered,” Thornton adds. “We also make sure they know when the home health physical therapist is scheduled to come in for the first visit.”

Case managers encourage patients to ask questions. Some common patient questions include:

- When do I take my medications?

- When can I take a shower?

- What do I do about drainage from the bandage?

- How should I take muscle relaxers?

Patients have a lot of questions about pain, Thornton notes.

“Our physician assistant is good about explaining prior to surgery that they’re going to feel pain,” she explains.

“Often, they’ve had a nerve block in the hospital and it hasn’t worn off, so when they leave the hospital they haven’t been feeling the pain, but they’ll start to feel it once they are at home,” she adds.

Case managers should prepare knee replacement patients for the pain they’ll experience, Lauer says.

“We have a protocol in place for pain management, but a lot of people get concerned that the pain isn’t normal,” she says. “We reassure them that the pain is normal.”

• Call at one week and 30 days post-discharge. At one week after surgery, case managers call to make sure patients have attended their outpatient physical therapy.

This phone call is proactive, helping to reduce the volume of phone calls patients make to the physician’s front office, Thornton says.

The calls also might prevent a hospitalization. For example, one patient developed a significant hematoma. Instead of going to the ED, he called Lauer and texted a picture of his knee.

“I sent that photo to Dr. Lucey, and we got the patient on antibiotics and had him see the doctor the next business day,” Lauer recalls. “He had to have a wash-out procedure, but otherwise he would have ended up in the ER.”

At two weeks post-discharge, patients visit the doctor’s office. Case managers usually do not call patients between one and four weeks post-surgery unless patients are experiencing considerable pain, Lauer notes.

At 30 days post-surgery, case managers check in on patients to see how they’re doing with their pain and physical therapy sessions. Patients experiencing excessive pain or other issues are called more frequently. Those who have had this surgery before might not need much guidance, Lauer says.

Total joint surgery requires a well-trained team, and case managers are the contact people between the team’s surgeon, physician assistant, patients, physical therapists, and others, Thornton notes. “I think our roles are very important in the successful outcomes of our patients.”