A Medicare bundled total joint program has case managers help patients transition from the hospital to a post-acute care or home setting.

“We follow patients long-term — up to 90 days, or longer if they need to reach out to me,” says Renee Angiulli, RN, BSN, MHA, CCM, case manager at Southeastern Orthopaedic Specialists in Greensboro, NC.

Case management starts a few days before the surgery. The case manager visits the nursing home to make sure it’s an appropriate plan for when the patient leaves the hospital, she says.

“For 90 days after the hospital discharge, I call the patient weekly, tapering off to bi-weekly for up to 12 weeks,” Angiulli says. “Then I call at six months and a year. We really follow up to make sure they don’t fall through the cracks.”

With the Medicare population, case managers must be creative. There sometimes are difficult situations, such as cases where the patient’s family lives in another state and the patient has no one to care for him or her after the surgery, she says.

Even when a caregiver is available for the first few days post-discharge, the caregiver might have difficulty handling the job.

“Sometimes I have to call these patients every day, including weekends,” she says. “Maybe the patient is confused or had a bad reaction to medication, and they can’t handle it.”

Help at home is essential for elderly patients, and it’s important that caregivers stay with the patient as outlined in the care plan, says Lisa Thornton, case manager at Sports Medicine and Joint Replacement in Greensboro.

“We had an incident with an inpatient Medicare patient where the patient had a family member lined up to stay with them,” Thornton recalls. “After the patient was discharged, the family member got up the next day and went to work.”

The elderly patient was left alone on pain medications. The woman took her medications incorrectly, which placed her at risk of a fall. In situations like this, a case manager might move the patient to a skilled nursing facility for a week, she adds.