At a Glance
- UVA is performing better than peer institutions when it comes to readmissions after joint replacement surgery.
- Success in this area is the result of thoughtful and continuing evaluation of pre-op and post-op procedures.
- Partnering with referring providers to ensure patients are medically optimized prior to surgery is key to preventing readmissions.
Between 2013 and 2015, UVA Health System cut readmission rates in half for joint replacement surgeries. Today, that downward trend continues thanks to a comprehensive strategy to continually evaluate readmissions and optimize processes to promptly implement change. Here are some of the steps UVA is taking to reduce readmissions after joint replacement surgery.
Engaging the Patient
Because a successful post-op begins with a thoughtful pre-op, UVA has adopted a multifaceted approach to preparing patients for joint replacement surgery.
Every patient scheduled for a knee or hip replacement meets with a designated nurse coordinator twice prior to surgery. These meetings immediately open the line of communication between the patient and the care team, involve the patient in his or her care and provide the patient with a reliable source of information. Nurse coordinators help set expectations for surgery, answer questions and walk the patient through the recovery process, which includes making a discharge plan after surgery.
Identifying Obstacles Sooner
As part of the discharge planning process, nurse coordinators screen patients to determine whether there are any barriers to recovery at home, including fall hazards or lack of support. If barriers exist, nurse coordinators communicate with the surgeons to determine if the procedure needs to be put on hold until those issues are resolved.
“Our surgeons respect our evaluation of the patient’s home situation,” says nurse coordinator Michele Duprey, RN. “Patients may need further medical optimization or a home safety evaluation before surgery. We work with the patient and providers to get those accomplished, and then we can schedule the surgery for the patient.”
With the rise in chronic conditions such as heart disease and diabetes, pre-op considerations for joint replacement surgery now must include not just the hip or knee, but also the patient’s overall health status. To acquire this comprehensive health assessment and ensure patients are optimized prior to surgery requires collaboration among the surgical team and referring providers.
“We are focused on the technical aspects of managing a patient’s orthopedic care, but that doesn’t happen in a vacuum,” says UVA orthopedic surgeon James Browne, MD. “We recognize now more than ever that we have to account for the patient’s overall wellbeing and get them healthy before we treat their joint problem. For this, we rely on referring providers. We need those experts in medical management to be a part of our team. Occasionally, we also need our specialty medical consultants here at UVA to get involved as well to ensure patients are medically optimized before proceeding with surgery.”
To initiate this collaborative effort, nurse coordinators screen patients for modifiable risk factors that may lead to readmissions or complications. Based on this screening, they will then draft a letter to a referring provider requesting additional lab work or information and to obtain clearance for surgery. This letter is given to the patient with instructions to share the document with his or her provider, who can return it easily via fax or via EpicCare Link.
“In these letters, we outline what we need before surgery can happen,” says Duprey. “Without this medical evaluation and intervention from referring providers, the patient’s surgery will be postponed. This is why timely medical optimization is so important.”
With a pre-approved discharge plan in hand, patients return home with clear expectations for recovery. Nurse coordinators make a post-op phone call to every patient two to four weeks after surgery to ensure their pain is managed effectively, healing is progressing and that they are continuing physical therapy. “Just by reaching out, we can often catch problems early on and get patients into clinic if needed,” says Duprey.
Patients are advised to make an appointment with their primary care provider two weeks after surgery to assess their recovery. They will be seen at UVA for a surgical follow-up after approximately six weeks. Nurse coordinators are a direct point of contact for the patient and his or her physician at any point. “They can call us if they have any questions about healing or recovery,” says Duprey.
In many instances, the cause of a hospital readmission may be beyond the control of a care team. By evaluating each case in which a readmission occurs, the UVA orthopedic surgery team gains a better understanding of the factors that contribute to readmission and which can be modified to prevent patients from returning to the hospital in the future.
A monthly Joint Council meeting brings together a large multidisciplinary team, including nurse managers, social workers, occupational therapists, surgeons, administrators and others to assess current readmission data, discuss new initiatives and processes and review specific cases in which readmissions occurred. “Everyone involved in a patient’s hospital stay gets together to review barriers and focus on the root cause of why he or she was readmitted,” says Browne.
In an effort to further improve patient safety, the surgical group also now meets monthly to review individual patients who are at high risk for readmission. “We discuss how to optimize a patient prior to elective surgery to ensure the best outcome,” says Browne.
Thanks to these initiatives and others, UVA has made great progress in reducing readmissions. However, this team is committed to push the dial even further. “When it comes to readmission rates, we are now performing better than many peer institutions,” says Browne. “Our ultimate goal continues to be improving quality of life and function, which means keeping them out of the hospital and engaged in their everyday activities. We’ll keep doing all we can to meet that goal.”