Synchronized Care: Speeding Recovery From Surgery to Rehab

Discharge from acute care is no longer the endpoint of a healthcare provider’s patient care responsibilities. As hospitals and accountable care organizations participate in bundled payment models, they are at increased financial risk and are looking to post-acute care (PAC) providers to help meet cost, healthcare quality, and patient satisfaction goals.

Choosing the right PAC provider is particularly critical for patients who have undergone orthopedic surgery. By 2020, the number of orthopedic surgeries in the US—from joint replacements to spine, hand, shoulder, elbow, ankle, and foot surgery—is expected to reach 6.6 million, corresponding to growth in the aging population. Orthopedic patients typically have a period of post-acute recovery that requires physical therapy, rehabilitation, and ongoing care.

Driving wide-scale change

In 2016, many hospitals became accountable for all costs of hip and knee replacements—beginning at admission to 90 days after patient discharge from the hospital. Under the Comprehensive Care for Joint Replacement model (CJR), hospitals are rewarded if patients recover quickly and penalized if patients have complications or require lengthy rehabilitation.

“CJR and other bundled payment initiatives are driving wide-scale change across the care continuum,” says Stephen Littlejohn, MD, a leading orthopedic surgeon in Longview, Texas. “In today’s healthcare environment you have to be financially prudent, and this includes staying on top of both inpatient treatment and recovery in rehab.”

Delivering better patient outcomes

“When care is not coordinated, the result is random outcomes,” Dr. Littlejohn says. “Acute care providers today are highly motivated to send patients to PAC providers who deliver synchronized care and the best outcomes for payer dollars.”

Dr. Littlejohn is affiliated with several hospitals in the area, including CHRISTUS Good Shepherd Medical Center, the third program in the nation to receive the Joint Commission’s Gold Seal of Approval® for Advanced Certification for Total Hip and Total Knee Replacement. “At Good Shepherd, we direct our patients to where we believe is the best site for post-operative care. This proactive guidance is one reason why Good Shepherd received this prestigious level of certification.”

It used to be, he explains, that case management was more haphazard. “The nurse or social worker on duty the day of discharge decided where to send the patient, often with little evidence on outcomes. As a physician, I am now directly involved, along with the patient and family, in discharge decision-making.”

CLICK HERE to learn more about the benefits of leveraging multi-disciplinary care teams with clinical competency to deliver continuity of care for patient well-being.

Directing patients to the right PAC facility

“Not all post-acute care facilities are created equal,” Dr. Littlejohn notes. “When my patients require a PAC facility, I look for where they will receive the best care experience and the best results.” A preferred PAC provider is Treviso Transitional Care, a new 140-bed facility in Longview.

One of StoneGate Senior Living’s 43 facilities in Texas, Oklahoma, and Colorado, Treviso provides short-term care and rehabilitation services to patients covered by Medicare and managed care plans. The goal is to help patients recover as quickly as possible and transition seamlessly back to their lives.

“The most important part of patient recovery is continuity of care and teamwork. When we’re all pulling in the same direction, the patient gets a better outcome. I know that at Treviso, my patients will receive holistic, as opposed to fragmented, care. The care team regularly communicates with me and keeps me informed of each patient’s status.”

Continuity of care begins with patient education, he notes. His joint replacement patients, for example, are thoroughly versed on what to expect throughout their treatment. “Before surgery, they meet with our orthopedic nurse coordinator, who’s also the first person they see after surgery. She gets them up and walking. If the plan is to discharge them to a PAC facility, as opposed to home, they know in advance which facility that will be. They realize it’s a short stop before returning to home—and this understanding alleviates any fear and increases motivation to move toward a full recovery.”

Doing unto others

According to Dr. Littlejohn, the ideal PAC facility goes beyond providing excellence in clinical care to considering all aspects of patient well-being. “In considering the patient experience, the Golden Rule sums it up. Treat patients as you would want to be treated—from being kind and encouraging to making sure the food you’re serving them tastes good and their loved ones are well-informed. Treviso staff strive to understand what will make each patient happy and to consistently deliver a positive and restorative experience.”

To learn how value-focused delivery systems are creating positive clinical outcomes while reducing unnecessary healthcare costs and meeting patient satisfaction goals, CONTACT US.