Total joint replacement patients need care coordination, too

Many are older, with comorbidities

Case managers shouldn’t be complacent about patients receiving total knee and total hip replacement surgery and think that their chances of being readmitted are low, says Brian Pisarsky, RN, MHA, ACM, senior managing consultant at Berkeley Research Group and Centers for Medicare & Medicaid Services (CMS) alumni faculty for the Community-based Care Transitions Program (CCTP).

"I see data that shows that readmissions for total hips and knees are pretty high. Some are coming back because they didn’t get adequate therapy after discharge or they didn’t do well with therapy. Others come back because of comorbidities, surgical-site infections, deep venous thrombosis, or because they didn’t follow their treatment plan," he says.

Pisarsky cited statistics that show that 5.5% of total knee and total hip replacement patients come back within 30 days.¹

The readmission rates may not seem high compared to other diagnoses such as congestive heart failure or pneumonia, Pisarsky points out. "However, hospitals and case managers are surprised when they look at their internal data and find that their perceived very low rate is higher than the published CMS overall rate," he says.

Joint replacement patients frequently are older, sicker individuals who have multiple comorbidities and are readmitted from a skilled nursing facility or assisted living facility during their initial recovery, Pisarsky says. Many times, it’s the medical comorbidities, not the joint replacement that brings them back, he adds.

"One problem is that joint replacement patients are often admitted and managed by their orthopedic surgeon without medical consultation. However, they may have medical comorbidities such as diabetes, heart failure, or hypertension that need medical management," he says.

According to Pisarsky, the best practice is to place triggers for medical consultation either in the patient’s clinical pathway or postoperative order sets. "This hopefully will prevent readmissions because of medical comorbidities," he says.

Look at the entire picture of the patient and not just the surgery, Pisarsky advises. If the patient has chronic conditions, take that into consideration when you anticipate the patient’s needs after discharge.

Timely follow-up with a primary care physician as well as their surgeon is important for joint replacement patients, he says. Try to get these appointments made prior to discharge from the hospital, he adds.

Call joint replacement patients a few days after discharge to find out how they are doing and if they are following their treatment plan. Ask if they have started therapy and if they have a follow-up appointment with their surgeon and with their primary care physician, Pisarsky says

If their doctor ordered a passive range of motion machine, find out if it has arrived and if they are using it, he says. Make sure they are taking whatever medication their doctor prescribed for deep vein thrombosis. If their physician ordered compression hose, make sure they have gotten them and are wearing them as directed.

"Sometimes patients don’t participate in physical therapy postoperatively and many times complications can arise causing readmissions. It is part of the case manager’s role to encourage them to complete their entire treatment regimen and follow their discharge plan," he says.

Reference

1. Procedure Specific Readmission Measures Updates and Specifications Report: Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty. Version 3.0. http://www.qualitynet.org.