Fast track programs combine evidence-based clinical care with systematic organizational approaches (Husted 2012). To implement hip and knee replacement fast track programs, home health agencies will need protocols for efficiently and effectively meeting the needs of patients after discharge. Agencies will also need processes to assure referring physicians that the agency is prepared to manage hip and knee surgery patients and a measurement approach to ensure high quality outcomes.
Elements of a Home Health Fast Track Program
Pre-hospitalization assessment and initial plan
Post-surgery assessment and care plan
Post-acute clinical care at home, including therapy
Close physician / home care team communication and coordination
Patient and family engagement
Flexibility of plans to accommodate patient needs and wants
Collaboration between home care team and community supports
Coordinated transitions between levels of care
Continuous evaluation of patient experience, outcomes, and costs
Program Design Considerations
Clinical Features
Implement evidence-based clinical pathways integrated with training, documentation, and performance evaluation
Adopt evidence based physical therapy and nursing visits. Factors impacting frequency include type of surgery; patient condition and co-morbidities; time since surgery; type of discharging facility; availability of support at home; post-surgical pain and other symptoms
Innovate physical therapy (PT) approach: consider PT only visits, joint replacement protocols, frequency of visits based on patient function status, and protocol for transition to outpatient PT
Proactively manage pain. This includes planning for the transition from facility to home, coordinating transition to oral and then to non-narcotic medications, ensuring that the patient is prepared for pain management during PT, and educating the patient on non-pharmacologic pain management
Proactively prevent readmissions through pain management, infection prevention, patient education, emergency planning and proactive communication. For example Zone Tools can be used for patient education to identify risk of re-hospitalization
Develop protocols for medication management for joint replacement: medication reconciliation, anticoagulation; pain medication; bowel regimen
Plan your safety program: focus on falls risk assessment and prevention; anti-coagulation management; infection control
Administrative Features
Establish and communicate joint replacement program goals:
For patients, increase mobility, improve strength and balance, and prevent complications.
For payers and providers: prevent readmissions and emergency department (ED) use, manage costs, deliver good outcomes, and ensure patient satisfaction.
Ensure patient access to home care after inpatient discharge: make available evening and weekend visits and extended hours for start of care
Adopt tools to assist staff with assessments and patients with self-management
Align your electronic medical record program to prompt for quality indicators
Define roles and accountabilities of home care professionals to ensure comprehensive care, conduct required assessments, and submit essential documentation:
Nursing
Physical Therapy
Occupational Therapy
Aides
Develop referral pathways for social services, mental health, and transportation
Plan for coordinated handoffs to outpatient therapy
For fast track and same day programs, coordinate with inpatient PT to ensure smooth handoff to home care
For fast track and same day programs, coordinate with inpatient or community pharmacy to ensure patients have access to pain medications at discharge
Best Practice Tip: Have agency home care liaison meet with patients during pre-op teaching session at hospital or have physical therapy liaison meet regularly with discharge planners. (Ensure that this practice meets Medicare and State regulatory criteria.)
Quality Strategy
Measure program results and report to joint replacement partners
Evaluate opportunities for improvement, including cost savings and improvements in patient experience
When possible, use technology to manage workflow and to automate quality checks
Train staff to ensure consistency and accountability across all types of care givers
Review data monthly at agency and individual level
Telephone check in with patient within the first 2 weeks of care to ensure satisfaction
Marketing and Communications
Establish a communication program about availability of joint replacement services at home:
Target messages to hospitals, physicians, and patients
Participate in pre-op teaching workshops hosted by hospital or physician
Conduct pre-discharge visits
Develop program information for physicians and patients
Share your program cost and outcome results with hospital, ACO, managed care and physician partners
VNANE Best Practice Program Characteristics: 1) central referral and intake line: 2) dedicated customer relationship management team; 3) collaborative target population analysis, planning, and performance reviews; 4) customization of services to meet customer goals; 5) incentives to align organizational efforts with customer business imperatives
Intake
Before the Home Visit: Obtain the following information as part of the intake process at least 24 hours before the start of care:
H&P and discharge summary
Determine if patient is under a fast track protocol
Get information on the type of surgery, restrictions related to type of surgery, long-acting pain medications administered during surgery
Determine if patient may be a re-hospitalization or safety risk
Get discharge medication list including pain management meds
Get verbal orders for treatments, labs, wound care, etc.
Notify direct care providers of known risks.
Best Practice Tip: Intake often begins before discharge. Call or speak to the patient on day of discharge from the facility. Use a pre-visit phone script to improve consistency but empower staff to collect information using a conversational approach to make the interview go more smoothly. Many agencies believe a nurse or PT should make the call in order to assess patient need for a same-day visit. A clinician can ask follow up questions that help to understand patient needs and functional status more comprehensively.
Pre-visit questions may include:
“Do you have written information on how to take care of yourself after the surgery?
“Who is helping you”?
“Were you able to obtain medications you need?”
“Have you needed pain medicine since you got home?”
“Do you understand how to take your pain medicine?”
“How are you getting to the bathroom (or other functional status question)”
“Have you noticed any changes or problems with your incision or bandage since you’ve been home?”
“Do you feel safe being home?”
“Are you having problems with any of your other health conditions?”
Responses to questions lead to a decision about making a same day visit. Responses should also be used to organize care before or during the first visit, for example arranging a family visit, bringing certain supplies, or assisting with DME arrangements.
For Fast Track or Same Day Discharges:
Try to meet with the patient prior to surgery. Some agencies participate in joint surgery classes offered by hospitals
Coordinate with hospital PT staff to ensure PT visit on day of discharge
Know what teaching and tools have been provided to the patient
Ensure that medications are in the home when patient arrives
Consider adding anxiety assessment to identify patient /caregiver capability to meet needs
Start of Care
Initial Start of Care Visit Includes:
Telephone call to confirm visit with the patient
Start or complete OASIS and a comprehensive therapy assessment
With the patient and caregivers, plan visit frequency and discuss the plan of care
Conduct general assessment of risk for rehospitalization
Conduct pain assessment. Use standard tool and assess at every visit. See tools in this section.
Physician contact regarding orders and medication reconciliation.
Initial self-management teaching: pain, bowel management, wound care, falls prevention, other safety teaching
Assess equipment or home modification needs, including grab bars
Initiate referrals as needed:
Refer to skilled nursing for medication teaching and INR blood draw if needed and RN required by state law
Refer to occupational therapy (OT) for assistance with ADL’s
Refer to MSW/psych RN if positive for anxiety or depression
Refer aide services for assistance with personal care
DME provider for any equipment required that is not in home (or obtain needed referrals).
Provide agency name and contact information and assurance of 24 hour response to calls—teach back with information
Verify that physician follow-up appointment is made (usually at 6 weeks)
Leave patient education and zone tools for patient use
Prevent Post-Surgical Complications
Surgical complications can be major or transient (Papayasiliou, 2012). Complications most commonly observed in the home health setting include thromboembolism or infection. Home health has an important role in preventing emergency visits and readmissions related to surgical complications as well as those related to exacerbation of chronic disease. Evidence suggests that readmissions can be positively impacted by reducing post-operative surgical complications (Keeney 2015) and carefully monitoring functional status (Shih 2015, Fisher 2015).
Thromboembolism – Venous thromboembolism (VTE) may manifest as a deep vein thrombosis (DVT) or as a life-threatening pulmonary embolism (PE). Predisposing factors include age older than 40, female sex, obesity, varicose veins, smoking, past history of DVT, diabetes and coronary artery disease.
VTE Prevention: The current evidence-based recommendation is for timely initiation of VTE preventive care postoperatively. Current prophylaxis methods include mechanical compression stocking or foot pumps (mechanical prophylaxis) as well as pharmaceutical agents such as low-dose warfarin, unfractionated heparin, low molecular weight heparin or aspirin (Autar 2011).
ACCP clinical practice guidelines recommend antithrombotic prophylaxis following total hip arthroplasty or total knee arthroplasty
Low-molecular-weight heparin (Lovenox and other brand names) is the preferred method of prophylaxis; Recommended alternatives are fondaparinux (Arixtra); dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto)
Apixaban (Eliquis)or dabigatran (Pradaxa) are the recommended alternative for patients who decline injectable LMWH
Anticoagulant prophylaxis is recommended for a minimum of 10-14 days following surgery and preferably for 35 days following surgery
Patients discharged on warfarin (Coumadin) need a plan for INR; note that warfarin is not the preferred anticoagulant
Compression therapy: Intermittent pneumatic compression device (IPCD) is recommended prior to discharge with or without anticoagulation therapy
Patients are frequently discharged with compression stockings or boots
Recommended use is 23 hours on and 1 hour off
Compression stockings are used until patient is fully ambulatory
Stockings can be handwashed and air dried.
VTE Assessment: check legs for redness, swelling (DVT); evaluate shortness of breath (PE)
VTE Patient/Family Education: educate on signs/symptoms of VTE, medications, importance of ambulating
Infection and Skin Integrity: higher rates of wound infections are associated with Rheumatoid arthritis, skin breakdown, prolonged wound drainage, previous knee surgery, obesity, steroid use, renal failure, DM, malignant disease. Infection around the prosthetic joint occur in approximately 1% of knee and hip joint replacements and are the leading cause of surgical revisions (Kapadia 2015, Lamagni 2014). Additionally, patients with limited mobility or cognitive impairments are at risk for pressure ulcers. Clinical interventions include prevention of infection at the surgical site and prevention of new or worsening pressure ulcers.
Infection Prevention: There is no single standard of care for surgical wound dressings (Dumville 2014). Some patients may need surgical wound care while other patients may be discharged with sterile occlusive dressings, which are not changed for 10-14 days. Home health provides wound care or dressing changes as needed; otherwise patient teaching is key to prevention and early detection.
Infection Assessment: check wound area for intact dressing; if assessable, evaluate redness, swelling, pain or drainage at wound site. Routine temperature check. Use a standard assessment tool such as the Braden scale for pressure ulcer risk assessment.
Infection Patient/Family Education: signs and symptoms of infection, showering / bathing protocols with the dressing, daily temp monitoring and call agency if temperature is above established set point. Use a Zone Tool for patient education and self-management.
Stiff knee after TKR: Approximately 1-5% of patients experience ongoing stiff knee following surgery, defined as a flexion contracture of ≥15° and/or <75° of flexion. Risk factors for reduced range of motion (ROM) include younger age, post-traumatic arthritis, prior knee surgeries or pre-existing stiffness. Post-operatively stiffness can be caused by infection, inadequate pain management, or other pathology limiting knee motion. Patients with continued stiff knee after 2 months should be referred for further evaluation. (Husain 2011)
Prevention: pain management, physical therapy
Assessment: range of motion and pain scales, edema assessment
Patient / Family Education: pain management, exercise program, exercise program.
Rehabilitation Therapy
Rehabilitation services are an integral component of fast track joint replacement programs (Quack, 2015, den Hertog 2012) Physical therapy is an integral part ofa core service in home-based joint replacement care. Some joint replacement cases are PT only, meaning that PT clinicians must document all clinical and functional limitations and ensure that improvements are documented. Although patient-related factors such as age, weight, and prior functional status impact the recommended rehabilitation prescription, there is expert consensus around many aspects of rehabilitation care (Westby 2014, Health Quality Ontario, 2005).
Start of Care: (In addition to start of care activities previously described)
Determine physician prescription for weight bearing, joint precautions or positioning
Assess functional status and mobility
Assess pain level, noting that pain management is essential to enable the patient to engage in PT activities
Goal Setting: Implement physical therapy plan with emphasis on:
Walking, balance, stairs
Fall prevention, safety
Flexion, extension and range of motion to prevent stiff knee
Patient-identified goals relating to function or pain
Therapy: Provide therapy interventions/treatments based on initial assessment including:
Gait training on various surfaces
Range of motion (ROM) and Strength
Practice ADLs (sit, stand, toileting, bathing, stairs)
Exercises for balance in different positions – supine, prone, sit, side, stand
Site specific rehabilitation exercises
Hip Exercises*
Knee Exercises
Quad Sets
Glut Sets
Ankle Pumps
Hip & Knee Flexion (Heel Slide)
Hip Abduction
Knee Extension (Long Arc Quad)
Short Arc Quad
Standing Hip Flexion
Squats
Ankle pumps
Quad sets
Short arc quads
Heel slides
Long arc quad
Straight leg raises
Occupational Therapy (OT)
OT may be consulted for patient training and education on functional bathroom transfers with use of DME as needed
OT can recommend equipment such as: reacher, sock aid, stocking aid, long handled shoe horn, dressing stick, hand held shower, grab bars, shower chair, raised toilet seat
OT will provide teaching and training for ADL skills while maintaining joint precautions
OT teaching and training on adaptive devices will allow for greater independence while following surgical precautions.
OT will assess for Home Health Aide needs and develop a care plan.
OT will educate, train and teach patient on positioning strategies for pain management.
Physical Therapy Teaching
Pain management--emphasize the importance of medicating before PT and use of heat or cold therapy
Exercises for the patient to do on his/her own with caregiver
Correct crutch, walker or cane usage on flat surfaces and stairs
Joint precautions (such as not crossing legs and standing techniques) and weight bearing limitations
Recommended ROM limitations or goals for specific functional tasks
Provide and review patient education and information (may be developed by the agency or are publicly available. See for example Mass General's Patient Rehabilitation materials.
PT Objective Tests And Measures
Objective tests and measures should be performed at initial evaluation to obtain baseline. These should be performed again for comparison at reassessment and discharge. The physician should receive PT evaluation and discharge summary and also be updated as appropriate and needed on the patient’s progress throughout the plan of care (Clarkson 2005).
Assessing Body Structure and Function:
Strength testing- manual muscle testing, observation of function if unable to perform manual muscle testing
Goniometric measurement of ROM
Normal Hip ROM: Flexion 0-120°; Extension 0-30°; Abduction 0-45°; Adduction 0-30°; IR 0-45°; ER 0-45°
Average hip ROM required for: Sitting in a standard height chair ~84°; Sit to stand from a chair typically requires at least 90° hip flexion but this varies based on chair height; Squatting to pick up an object from the floor 110-120° hip flexion; Tying a shoe with foot flat on floor ~120°; Ambulation 30° hip flexion and 10-20° hip extension; Stair ascent 67° hip flexion; Stair descent 36° hip flexion;
Normal Knee ROM: Extension/Flexion 0-135°
Average knee flexion required for: Sitting 93°; Tying shoes 106°; Level ambulation 60°; Stair ascent 83-105° (varies based on stair dimensions/height); Stair descent 83-107° (varies based on stair dimensions/height); Squatting to pick up an object 117°
Assessing Activity:
Balance
Transfers
Ambulation
Stair negotiation
Ongoing Care and Self-Management Teaching
Patient and Caregiver Engagement: Engage patients and caregivers in planning and managing their own care plans with goal of providing smooth transitions, reducing anxiety, improving knowledge of progress and care expectations, confidence in ability to self-manage care for more rapid return to normal living.
Make sure patient knows when to expect services. Case manager writes agency specific visit schedule for each discipline. Post on refrigerator or other central location
Communicate - any changes in schedule should be communicated to patients in a timely manner
Educate patient and caregiver on when to alert agency staff
Plan for emergencies – make sure the patient and care givers know how to contact Agency, PCP/orthopedist and 911.
Plan of Care: Determine number of contacts/week based on:
Length of rehab stay prior to home care (if any)
In home support
Co-morbidities
Surgical complications
Patient ability to adhere to plan
Fast track status
Any physician specific protocols
Accessibility to outpatient rehab
On-going care includes:
Assess for pain at each visit using rating scale and transition to non-narcotic as soon as possible
Take vital signs pre and post exercise
Assess for edema
Check medication status: ask patient if on any new medications, changes in dosage, problems/issues experiencing. See VNAA BLUEPRINT
Evaluate surgical wound: Remove staples or change dressing as ordered by physician
Monitor for surgical complications:
Thromboembolism or DVT
Infection
Stiffness
Physical therapy, Occupational therapy and other referrals as needed
Self-Management Teaching:
Patient/caregiver teaching should include:
Signs and symptoms of surgical wound infection, VTE
Pharmacologic pain management – narcotic and non-narcotic
Non-pharmacological pain management including ice and positioning for comfort.
Bed mobility
Transfers (bed, toilet, chair, shower, care, floor)
ADL/IADL skills
Edema management
Urgent and emergent response
Utilize teach back and demonstration methods to verify learning
Patient and caregiver should be able to:
Demonstrate ability to take medications correctly including pain, anticoagulants and bowel regimen
Verbalize medication actions/ side effects to report/administration schedule
Demonstrate mobility skills
Verbalize plan for emergencies
Leave behind patient education materials and tools
Best Practice Tip: Make a check in call after the first few visits with an open ended question such as “What else can we do for you?” This helps to manage the patient experience and identify any gaps in the agency’s performance.
Transitional Planning: Care transitional planning should include:
Identify any follow up home care services needed
Refer to outpatient rehab and coordinated handoff
Hand off up to date medication list and care plan to next providers of care
Discharge summary to physician if requested/required
Patient able to describe the plan for follow up care, including physician visits and rehabilitation
Tools for Hip and Knee Management
TOOLS – See Hip and Knee Replacement Resources Page
A variety of assessment tools are available to guide rehabilitation priorities. Assessment tools cover a variety of functional areas, and are important both for evaluating improvement of OASIS functional status measures and joint replacement outcomes.Clinicians may also use tools to address mental status changes that could impact recovery, including cognitive impairments or depression. A baseline assessment is needed for any patient at risk of or with reported cognitive changes.
Key areas to be assessed after joint surgery include:
Verbal Descriptor Scale - This scale consists of six possible suggestions describing the intensity of pain, ranging from “no pain” to “worst possible pain”.
10 Point Scale - The 10 point scale is a vertical or horizontal line numbered 0-10. 0 is labeled “no pain”, and 10 is labeled “worst possible pain.”
Wong-Baker FACES Pain Scale (patient visual) - used for children or limited-English speakers
Brief Pain Inventory (BPI) (verbal descriptor) - captures additional information on pain characteristics.
The resources and links above were evaluated by the VNAA Best Practices Work Group. All are resources are publicly available on the Internet. Please retain all logos and citations where authors/originators are listed on these resources. For questions or comments about these resources, contact us.
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