Hip Today Home Tomorrow:

Transcription

1 Hip Today Home Tomorrow: A Collaborative Effort between an Orthopedic Practice and a Hospital to Create an Innovative Outpatient Total Hip Replacement Program Kimberley Murray RN MS CNS-CNOR Kelly Keenan RN MS CNS Overview Crouse Hospital 506 bed not for profit hospital Non teaching Performs 4000 musculoskeletal procedures/year 7 separate orthopedic/spine practice groups SOS 30 surgeon practice Perform surgery at 3 hospitals in Syracuse 11 surgeons that perform procedures at Crouse 40% of SOS joint replacements are performed at Crouse Environment for Collaboration Hospital Established Orthopedic/Spine Service line Co-Management Agreement with physician groups Dedicated orthopedic resources Administrative support Nursing Expertise Dedicated CNS Excellus Blue Distinction Designation for Hip & Knee Replacement SOS 11 joint replacement surgeons 5 fellowship trained 50% perform joint replacement surgery at Crouse Regional leader in orthopedics Total Orthopedic Care 9 offices 7 PT sites ASC 2 MRIs 2 Urgent Care Centers SOS shop Injection Clinic ~5000 joint replacements/year 3 rd highest volume joint replacement procedures in NYS Hip registry demonstrating exceptional patient outcomes Physician Champion SOS partner Orthopedic Department Chairman Co-Medical Director for Co-Management Fellowship trained joint replacement surgeon 27 years at Crouse Vision for an outpatient hip program Independent data collection for 1 year prior to idea launch Hip Joint Registry Report

2 Making the Case Growth and Financial Outlook Orthopedics a Top Volume Contributor 6 Dr. Izant s Informal Data Collection 30 cases over Surgical technique advancement and industry trend toward outpatient joint replacement Crouse hospital s commitment to innovation, programmatic development, & physician partnerships Opportunity for collaboration with shared risk/reward General Medicine Cardiac Services Obstetrics Neonatology General Surgery Orthopedics Neurology Oncology/Hematology Spine Vascular Services 2.6 M 2.4 M 1.6 M 1.1 M 907 K 775 K 4.6 M 4.3 M 4.0 M Service Lines by Volume Inpatient, 2013 Outpatient, M Cardiology Orthopedics ENT Gastroenterology Podiatry Neurology Gynecology Vascular Pain Management Spine 12.3 M 12.0 M 10.6 M 10.6 M 8.1 M 1.0 M Poised for Growth: 10-year Volume Forecasts 15% 28% Inpatient Outpatient Orthopedics Orthopedics 26.9 M 21.9 M 65.9 M 80.7 M 2014 The Advisory Board Company advisory.com Source: Advisory Board Inpatient and Outpatient Market Estimator tools. Growth and Financial Outlook Growth Largely Concentrated in Outpatient Setting Five-Year Orthopedic Growth Trajectories All-Payer Volume Growth Projections Orthopedic Services 15.4% 5.1% Outpatient 2014 The Advisory Board Company advisory.com Spine Services 22.9% Inpatient (0.1%) 157% Expected five-year growth of outpatient joint replacements Volume Growth Projections by Key Sub-Service Lines Spine Injections & Blocks 15% Sports Medicine 13% Hand 12% Joint Replacement 9% Foot 8% Fracture/Dislocation Treatment 4% Other Surgical Spine 2% Fusion 2% 0% Orthopedic Trauma -1% Sports Medicine -7% Medical Spine Outpatient Inpatient 169K Projected volume of outpatient joint replacements in % Source: Advisory Board Inpatient and Outpatient Market Estimator tools. 7 Care Pathway Development and Planning Comprehensive Product Packaging a Differentiator 2014 The Advisory Board Company advisory.com Components of a Comprehensive Joint Program s Continuum of Care Patient Intake Pre-operative Planning Post-operative Care Elevating Awareness Easy-Intake Joint Pain Seminars Advanced Technology Promotion Alumni Development Enhancing Patient Satisfaction Patient Education Pre-surgery Screening Hip and Knee Hotel Model Decreasing Length of Stay, Readmissions Rapid Recovery Protocols Next-Generation Pain Management Family Coaching Group Rehabilitation Organized Discharge Planning and Post-Acute Relationships Source: Service Line Strategy Advisor research and analysis 8 2

3 Polling Question #1 Key Players Do any of the participants currently have a formal outpatient or fast track program for hip or knee replacement? A. Yes B. No Multidisciplinary Team Physician Champion Director of Care Coordination Director of Physical Therapy Service line Manager Director of Surgical Services Chief Nursing Officer CNS Director of Clinical Integration and Strategic Development from SOS Anesthesia VP of Communications and Governmental Affairs Director of Patient Placement Manager of Marketing and Outreach from SOS Consultative Participants SOS Nurse Navigator Orthopedic Nurse Manager Bedside RN Homecare Partner Core Elements Safety and reliability Effectiveness Efficiency The patient and family experience of care Communication during care transition Key Programmatic Components Patient selection criteria Standardized patient pathway across the continuum of care Patient coach/support person Standardized patient education materials Comprehensive perioperative anesthesia protocol Minimally invasive surgical technique Unique and distinct geographic care location Staff skilled in outpatient progression (vs. inpatient) Early day surgical times PT beginning within 4hours of return to unit & 2 sessions prior to discharge on POD#1 Comprehensive PT/rehab plans of care Commitment to continuous improvement Outcome monitoring and course correction as indicated Innovative strategies Materials that are distinct from the inpatient joint replacement program Patient contract/shared decision making Unique messaging for the patient, staff, and community Garb/clothing that is distinctive Patient pathways Nurse navigator case management Branding and program marketing Comprehensive launch plan/timeline 3

4 Patient Selection Criteria Standardized Patient Pathway Patient anticipated to be able to be safely discharged the day following surgery (POD #1) Surgical procedure to be scheduled for the AM BMI <40 No history of chronic pain management issues Single arthritic joint patient and/or without multijoint mobility issues Able to be discharged on standard VTE prophylaxis protocol Preoperative Sugical Visit Preoperative Preparation & Planning Post Discharge Care & Rehab Preparation, Operation, & PACU Surgical Stay & Discharge 4

5 Patient Education Online & Printed Class Schedule SOS/Surgeon Preadmission Class** Patient Folder Coaching materials Patient itinerary** Physical therapy exercises Home care Information Nurse navigator role General materials Day of Surgery Post Acute Patient Itinerary GETTING YOU HOME SAFELY: THE ESSENTIALS 5

6 Polling Question #2 Staff Education For those of you who have a preop joint class, is it mandatory (meaning surgery would be cancelled or delayed by failure to attend)? A. Yes, it is mandatory B. No, it is not mandatory Staff Education Continued Staff Education Continued 6

7 Developing A Unique Brand Branding and Marketing: MD News Branding work group Design specialist Securing the web domain Developing materials Protecting the brand Branding and Marketing Community Materials 7

8 Branding and Marketing Dedicated Landing Page on SOS Website and Crouse Website Program Launch Single Surgeon Pilot Patient Rollout to additional Surgeons Dedicated Hip Today Home Tomorrow Phone Line Contact Us Monitoring the Program Improving the Process Post Implementation PACU Time (Hours) NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Prior to program launch identified key operational & quality indicators to ensure accurate measurement and monitoring of the program s success (scorecard) Goal: identify potential problems & pitfalls early in the process for course correction purposes PACU Time -The amount of time the patient spent in the PACU. This was a key operational component as it impacted downstream processes such as patient flow & Physical Therapy assessing & intervening ont the patient on POD #0. Early in the project identified that delay in discharge was impacting PT on DOS goal and PACU discharge protocol amended to safely allow target to be met 8

9 Polling Question #3 Impact on Overall Total Hip Replacement LOS Total Hip Replacement - Average Length of Stay ALOS UCL +2 Sigma +1 Sigma Average -1 Sigma -2 Sigma LCL What is the average length of stay for your total hip replacement patients? A. <2.0 days B days C days D. >4.0 days RATE Jan-14 Feb-14 Mar-14 Apr May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Date Lessons Learned/Re-Group Prehab appointment mandatory Second set of eyes and assessment Geographic Placement Issues Patient Identification Implications of veering off established pathway References Berger, R., Sanders, S., Thill, E., Sporer, S., & Valle, C. (2009). NewerAnesthesiaand Rehabilitation Protocols Enable Outpatient Hp Replacement in Selected Patients. Clinical Orthopaedics and Related Reseach, 467, DiGioia, A., Greenhouse, K., & Levison, T. (2007). Patient and Family-centered Collaborative Care- An Orthopaedic Model. Clinical Orthopaedics and Related Research, 463, Mahomed, N., Davis, A., Hawker, G., Badley, E., Davey, R., Syed, K., Coyte, P., Gandhi, R., & Wright, J. (2008). Inpatient Compared with Home-Based Rehabilitation following Primary Unilateral Total Hip or Knee Replacement: A Randomized Controlled Trial. Journal of Bone and Joint Surgery(American edition), 90, Stowers, M., Manuopangai, L., Hill, A., Gray, J., Coleman, B. & Munro, J. (2016). Enhanced Recovery After Surgery in Elective Hp and Knee Arthroplasty Reduces Length of Hospital Stay. Journal of Orthopaedic Surgery, 22(3),

10 For more information/questions 10