A case management report: a collaborative perioperative surgical home paradigm and the reduction of total joint arthroplasty readmissions - PubMed (original) (raw)

A case management report: a collaborative perioperative surgical home paradigm and the reduction of total joint arthroplasty readmissions

Navid Alem et al. Perioper Med (Lond). 2016.

Abstract

Background: Efforts to mitigate costs while improving surgical care quality have received much scrutiny. This includes the challenging issue of readmission subsequent to hospital discharge. Initiatives attempting to preclude readmission after surgery require planned and unified efforts extending throughout the perioperative continuum. Patient optimization prior to discharge, enhanced disease monitoring, and seamless coordination of care between hospitals and community providers is integral to this process. The perioperative surgical home (PSH) has been proposed as a model to improve the delivery of perioperative healthcare via patient-centered risk stratification strategies that emphasize value and evidence-based processes.

Results: This case report seeks to specifically describe implementation of readmission reduction strategies via a PSH paradigm during total joint arthroplasty (TJA) procedures at the University of California Irvine (UCI) Health. An orthopedic surgeon open to collaborate within a PSH paradigm for TJA procedures was recruited to UCI Health in October of 2012. Institution specific data was then prospectively collected for 2 years post implementation of the novel program. A total of 328 unilateral, elective primary TJA (120 hip, 208 knee) procedures were collectively performed. Demographic analysis reveals the following: mean age of 64 ± 12; BMI of 28.5 ± 6.2; ASA Score distribution of 0.3 % class 1, 23 % class 2, 72 % class 3, and 4.3 % class 4; and 62.5 % female patients. In all, a 30-day unplanned readmission rate of 2.1 % (95 % CI 0.4-3.8) was observed during the study period. As a limitation of this case report, this reported rate does not reflect readmissions that may have occurred at facilities outside UCI Health.

Conclusions: As healthcare evolves to emphasize value over volume, it is integral to invest efforts in longitudinal patient outcomes including patient disposition subsequent to hospital discharge. As outlined by this case management report, the PSH provides an institution-led means to implement a series of care initiatives that optimize the important metric of readmission following TJA, potentially adding further value to patients, surgical colleagues, and health systems.

Keywords: Anesthesia; Hospital discharge; Perioperative medicine; Perioperative surgical home (PSH); Readmission reduction; Surgical readmissions; Total joint arthroplasty (TJA).

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Figures

Fig. 1

Fig. 1

Members of the rounding PSH team dynamically work in concert with other key providers to proactively preclude factors that may contribute to a readmission. Note: The fellow is an anesthesiology graduate conducting a perioperative medicine fellowship and the resident is an anesthesiology resident conducting an innovative PSH rotation

Fig. 2

Fig. 2

The PSH team strives for continuous care transitions between the community and hospital period with relevant information clearly relayed

Fig. 3

Fig. 3

Discharge readiness checklist to be reviewed with the patient by the PSH team prior to discharge

Fig. 4

Fig. 4

Standardized list of post-discharge questions during nurse follow-up calls

Fig. 5

Fig. 5

This standardized discharge note prepared by the PSH team is replete with information regarding the patient’s perioperative medical care. It is integrated into the electronic medical record and sent to the patient’s community primary care provider on the day of discharge

Fig. 6

Fig. 6

Meta-analysis of UCI readmission results in comparison to previously reported results. Forest plot and statistics for nine previously reported readmission rates in studies of TKA and THA patients and comparison to the UCI data set from 2013 to 2014. CI confidence interval, W weight of study in meta-analysis (Bosco et al. ; Clement et al. ; Cram et al. ; Cullen et al. ; Issa et al. ; Schairer et al. ; Schairer et al. ; Vorhies et al. ; Vorhies et al. 2012)

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