As the number of total knee (TKA) and total hip (THA) replacement procedures grows each year, insurers push for lower costs and improved outcomes. Medicare and Accountable Care Organizations (ACOs) are beginning to link reimbursements with quality measures and patient outcomes. Controlling costs while maintaining high quality outcomes and reasonable reimbursements has led many hospitals to improve the continuum of care on total knee and hip patients.
By February 28th, 2015, the Total Joint Program at a hospital planned to reduce direct costs by 4% and reduce length of stays by 10%, by focusing on improved continuum of care by interdisciplinary collaboration, including:
A. Implementation of the Outcomes Manager (OM) Role for the TKA and THA patients and initiation of a pre-screening tool
B. Initiation of bi-weekly Collaborative Care team meetings
C. Completion of nutrition and pastoral care evaluations
D. Implementation of the health literacy, pharmacy, and depression screening tools
E. Implementation of the One Day Joint Program, pre-operative therapy (Pre-hab), and an early mobilization therapy protocol
In the USA, the demand for knee and hip total joint replacements continues to rise steadily. By 2030, the number of primary total hip arthroplasties is predicted to grow by 174% to 572,000 cases per year while primary total knee arthroplasties will grow by 673% to 3.48 million procedures.* This projected increase in demand will challenge hospitals and their financial resources. Efforts to improve patient costs while reducing length of stay are essential.
Through improved processes, increased awareness, and collaboration of the Outcomes Manager led interdisciplinary team, the hospital:
- Achieved a direct cost reduction of $240,881 between September 2014 and February 2015 for TKA and THA patients.
- Saved, in total, 178 patient days between September 2014 and February 2015 for TKA and THA patients.
*Kurtz S, Ong K, Lau E, Mowat F, Halpern M, Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J. Bone Jt. Surg. Am. 2007; 89: 780–5.
Patient and Family Centeredness Implications:
- The work of the interdisciplinary team has directly impacted the care of the patients by improving patient-provider communication, improving patient education, decreasing anxiety/stress by setting expectations prior to surgery, involving the patient in the coordination of his or her care, respecting the patient’s right to receive all pertinent information, and allowing the patient to participate in decisions about his or her own care.
- Care across the continuum (before, during, and after surgery) is the center focus of care which results in the patients being more involved in their own care with improved outcomes.
- Through evidence based practice, improved processes and heightened focus on patient centered care: The hospital improved overall patient satisfaction for the TKA and THA patients from September 2014 to February 2015 by 2.4% (overall standard mean).
Team prioritized 4 main issues to focus on based on the impact and frequency issue tool:
- Need for an Outcomes Manager Role (team care approach)
- Lack of a skilled healthcare professional to lead interdisciplinary team, to drive change, monitor outcomes, coordinate care across the continuum and collect and report data on a daily basis
- Need for identification of gaps in care and standardization of processes
- Lack of pre-screening tool, pre-op education, and coordination of care before/after surgery
- Need to utilize evidence based practice
- Lack of health literacy and depression screening tools, and nutrition and pastoral care evaluations
- Need for early mobilization therapy protocol
- Lack of one day joint process, lack of pre-hab, and lack of early mobility
- Patient Satisfaction
- % of patients with pastoral care and nutrition evaluations, prescreening, health literacy and depression screening completed
- % of patients seen day of surgery by therapy and involved in the One Day Joint Program
- Direct Cost for TKA and THA patients
- Length of stay for TKA and THA patients
- 30 day readmission rate for the TKA and THA patients who discharged home in one day was 0%.
Rapid Cycle Improvement: Cycle 1
Plan- Outcomes manager hired to lead interdisciplinary team and build a pre-screening tool to identify patient needs and meet bi-weekly. Team implemented a workflow process to provide nutrition and pastoral care evaluations.
Do- Outcomes manager utilized the pre-screening tool. Changes to the pre-screening tool were based on bi-weekly meetings and brainstorming sessions from the team’s fishbone diagram/prioritization matrix. Updates to the workflow process were made based on feedback from dietitians’ and chaplains’ involvement with patients.
Check- Compare the monthly raw data to the pre-screening forms to ensure accuracy (100% completion). Daily review of the nutrition and pastoral care evaluations to ensure completion.
Act- Continue to pre-screen all patients and make changes/adjustments to the nutrition and pastoral workflow processes. Gaps in care and the need for new screening tools and programs were identified thus the need for the team to engage in another rapid cycle improvement.
Rapid Cycle Improvement: Cycle 2
Plan- Team decided on a health literacy and depression screening tool. Screening tools and pharmacy process implemented and interventions provided based on results. Team built a One Day Joint program (pre-habilitation and day of surgery therapy).
Do- Outcomes manager screened all patients for health literacy and depression and nursing/social work provided interventions. Pharmacy screened all patients and contacted hospitalists for medication changes. One Day Joint Program and process was initiated. Patients attended pre-habilitation (1-3 sessions of therapy) prior to surgery. Patients began aggressive day of surgery therapy.
Check- Daily review and data collection were completed to provide timely feedback to the team via daily emails. They shared data monthly to all stakeholders.
Act- Refine the workflow processes, analyze data and make changes based on results, continue to examine processes for efficiencies, reward positive outcomes, and begin sustainment cycle.
- TKA decreased by 4.8% from July 13’-Dec. 13’ ($11,220) to Sept. 14’- Feb. 15’ ($10,681); surpassed goal of 4% reduction.*
- THA decreased by 8.7% from July 13’ – Dec. 13’ ($11,746) to Sept.14’- Feb.15’ ($10,726); surpassed goal of 4% reduction.*
Length of Stay
- TKA decreased by 20.9%; all months surpassed goal of 10% reduction.
- THA decreased by 16.2%; 5 out of 6 months surpassed goal of 10% reduction.
The team will continue to sustain improving costs and length of stay by:
- Sustaining overall metrics for 6 months following our last intervention by continuing to decrease direct cost and length of stay
- Collection of data and building screening tools electronically instead of the current manual process
- Increasing scope of processes to include other orthopedic patient populations with continuation of processes
- Continuation of bi-weekly taskforce meetings
- Continuation of collecting, analyzing, and sharing data monthly with all stakeholders (Physicians, Nursing staff, Social Work, Care Coordination, Nutrition, Pastoral Care, Pharmacy, and Nursing Leadership Team)
- Recognizing and rewarding performance and goal accomplishments with all disciplines
- Pilot completion, continuation of the One Day Joint Program, and add revisions and complex TKA and THA cases to the pilot.
- Build all screening tools in the electronic health record (EHR).
- Focus on 30 day readmissions with hospitalist group at the hospital.
- Utilizing a proactive vs. reactive approach and identifying gaps in care to drive operational improvements.
- Variation in care amongst surgeons, facilities, and organizations exists and standardization of protocols and processes are essential to success.
- Outliers due to medical complications or break in processes can increase direct cost and length of stay, thus continuous monitoring and coordination with the interdisciplinary team is the key to success.