Same Day Surgery Live Webcast

Same Day Surgery Live Webcast

Overview History of Advanced Center for Surgery in Altoona, PA Establishing a Same Day Joint protocol Getting Started Aligning Goals across care teams Preparing and Implementing protocols Care Pathway Assessments Anesthesiologist Home Health Services Surgery featuring VISIONAIRE and JOURNEY II BCS Patient arrival Intraoperative care Patient discharge Patient Testimonial Panel of experts Anesthesiologist: Dave Berkheimer Home Health Care Services: Amy Hancock and Sheena Henry Reimbursement expert, CEO UOC and Director of the ACS: Dave Davies WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Advanced Center for Surgery First TKA performed December 2012 126 TJA performed with measured outcomes 55 THA and 71 TKA FREESTANDING SURGICAL CENTER 0.125 Stay NOT 23hr program Home in 3-4 hours from surgery Highly advanced protocols Patient Demographics Age 22-72 BMI less than 50 68 Female and 58 Male ASA Classification 1 and 2 only 1 st Revision Discharge No OTHER option, all d/c straight home Requires excellent communication between all providers Care Pathway management This is accountable care at its highest level WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Where to start? Understand your Practice and Patient Demographics Referral Base Assess team s clinical capabilities Surgical Anesthesia PT Evaluate service line resources PT Home Nursing Home Pharmacy Negotiate payer contracts in advance Understand costs and necessary resources Facilities Instruments Staffing Implement a Joint Coordinator Identify Team Leaders WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Communication Communication begins with the first office visit Patient Education Cloud Based Care Pathway Multi-disciplinary contact Direct and Rapid Electronic Communication Open communication amongst all providers Vital to ensure safe and successful joint program Care is protocol driven Changes in patient status, care or condition is communicated to all providers Protocol changes are implemented at Joint Team Board level and communicated WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Preparation Educate referral base of new improved patient options Educate office staff and care teams Care Pathway and Implementation Home Nursing Physical Therapy Home Pharmacy Educate surgical team Anesthesia Protocol Procedure Care Pathway Implementation Train, Practice, Discuss! Surgical Run Through Equipment/Supplies Pharmaceuticals Data collection PI with Care Pathway Process in place WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Implementation Office Visit Patient Complaint- Pain/Arthritis/Avascular Necrosis Alternatives to Total Joint Replacement have not aided patient complaints Severity of Disease-Requires Surgical Intervention Patient Surgical Candidate Motivated Wants to avoid inpatient stay Same Day Joint Replacement Candidate Meets selection Criteria Patient Education Identify and understand Home Care Needs Patient Responsibilities Initiate Care Pathway through Joint Coordinator WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Preoperative Evaluation Home Health Execute Care Pathway Process Referral received 3-4 weeks in advance Insurance verified Potential out-of-pocket expenses identified PT schedules Home Assessment 1-2 weeks in advance Home Assessment checklist completed Patient home assessed for safety and areas of concern Post op teaching tools provided Baseline vitals obtained S.A.F.E- Risk stratification tool will be completed Review of medications Pre-operative functional ability Home environment and support system assessed Project appropriate level of assistance needed upon discharge Communicate home assessment results with all providers Call patient Monday of surgery to address final questions WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Day of Surgery Home Health Communication day of surgery Advanced Center for Surgery updates Home Health with patient s progression 30 minutes prior to discharge Home Health notified Allows nurse to be at home when patient arrives Discharge instructions include last does of antibiotic, IV pain medication, etc. Nurse and PT meet patient at their home Assist patient out of the car and into home If clinician worried about safety during assessment, a third clinician will be at home WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Day of Surgery Home Health Nurse completes admission assessment and education Hemovac drain (knees) or Q-pump (hips) Pain medications, side effects, use of ice, S& S of infection, DVT, fall prevention, TEDhose and pneumatic compression device Administer IV antibiotic approximately 8 hours after first dose in Pre-op pain medications as needed Ensure patient has all medications ordered Physical Therapy completes evaluation Supine AROM TKA exercises Measure AROM/AAROM WWW.SAMEDAYJOINTS.COM 2013 Same Day Joints, All rights reserved.

Postoperative Home Health POD1 Nursing Completes full assessment Assesses Hemovac drainage (knees) or On-Q pump (Hips) Administers last IV dose of antibiotics and discontinues IV lock. Obtains a CBC Therapy Start seated AROM exercises Continue supine AROM Measure AAROM

Postoperative Home Health POD 2 Nursing Completes full assessment Removes Hemovac drain (knees) or On-Qpump (hips) Obtains CBC only if day 1 Hg <10.5 or excessive drainage from incision Ace bandage removed Silver lon dressing (if used) left on for 7 days and then removed Therapy Start standing exercises with walker Continue with all others Start stair training if able POD3 Therapy Increase all exercises difficulty (repetit ions) depending on tolerance

Post-Op Daily Assessments Home Health Nursing Educate patient and family members Fall prevention, pain control, S&S of infection and DVT Importance of regular bowel movements Medication and their side effects Importance of ice/ elevation Complete full system assessment Check incision Edema measurements Document findings on communication sheet in folder Allows subsequent clinician visits has an established baseline.

Post-Op Daily Process Home Health Patient responsibility Instructed to complete exercises three times a day Ice and elevate with heel prop after each session Ambulate once an hour Therapy Each session includes bed mobility, gait training and transfer training Focusing on safety using muscular strength and normalization to avoid compensatory techniques. Progress patient to SPCfrom WW and eventually to no AD when gait is with minimal or no pain. Progress patient to exercises with Theraband when appropriate.

Advantage Home Health Risk Assessment Overview Same Day Surgery Outcomes Hips Average Average Ave SN Ave Therapy LOS Age Visits Visits 28.3 56 9 14.3 Knees Average Average Ave SN Ave Therapy LOS Age Visits Visits 17.3 59.6 6.3 9.5 Hospital 30 days 60 days READMISSIONS 0% 0%

Preoperative Evaluation - Anesthesia Execute Care Pathway Process Physical Evaluation of the patients Is a MUST-7-10 days out Pre-Operative Testing Coexisting Diseases Airway, Airway, Airway Anesthetic Technique Considerations Post Op Pain Control Educate Patients and Family

Intra-operative Implement Care Pathway OR Preparation Surgical Equipment Disposables, Implants Staff Standard operating procedures implemented Proper patient identifiers Time Outs Positioning preparation Anesthetize patient surgical prepping Reduction in OR traffic Infection Control Reduction Hemostasis considerations and techniques Minimize operative insult and duration Minimally Invasive Efficiency

Postoperative Implement Care pathway Rapid and Safe recovery from anesthesia discharge under 4 hours Phase I/II Nursing Staff Trained in Rapid TJR Discharge Early Ambulation and Gait Training/ Transfers Post Op Pain Management Post Op N/V Management Educate Patient, Family and Home Health of Special Needs Home Pharmaceuticals in place

Reimbursement Same Day TJR Payer Limitations Medicare Exclusions Inpatient Only procedure; ASC Covered procedures Commercial payers dependent on Medicare coverage policies Licensing Restrictions Approved procedure exclusions of Total Joint Codes Participating Payers Highmark Blue Cross/Blue Shield ACS Facility Reimbursement Negotiated Fee for Service (Procedure Based) plus Cost carve outs for Implants Physician Reimbursement Incentive Based Fee for Service (Procedure based payment increases based on Episode Quality and Cost Performance) Under Development Retail Bundled Pricing

Cost Per Episode ASC v. Hospital Clinical advancements and cost efficient protocols are generally portable and can be applied in a hospital based setting. Hospitals conceptually recognize the need to adapt and share with consumers lower unit costs Convincing Hospitals to pass cost savings to the consumer in terms of lower pricing or out of pocket expenses remains a challenge

Partnering with Payers It s like bringing Moneyball to health care - Brett Morris, President of Health Net of Arizona Health Insurers recognize that narrow networks improve cost and quality performance predictability Desirable networks include physicians who practice evidence based medicine AND utilize cost effective facilities The gateway to earning payment incentives for physicians is quality, and the means for insurance companies to fund the incentives is lower facility cost. Physicians practicing quality medicine in high cost venues will end up in those network tiers that will require the patient to pay an increased cost to access them Today, low costs and high value trump provider choice

Same Day Surgery Recipe for Success Featuring VISIONAIRE and JOURNEY II BCS Dr. Chris McClellan and Dr. Ken Cherry Advanced Center for Surgery Altoona, PA

JOURNEY II BCS A Rationale for Guided Motion

Performance to patient expectations Only 14% were satisfied with squatting 2 Arms (TKA v Normal Knee) 243 TKA Patients v 257 individuals Age and Gender matched arms Performance to expectations was poor Clin Orthop Relat Res. 2005 Feb;431:157-165: Noble PC, Gordon MJ Mathis KB

Performance/Satisfaction of TKA s v THA? Post THA: sports activities increased from 36% to 52% Post TKA: sports activities decreased from 42% to 34% The Ulm Osteoarthritis Study- K Huch Up to 20% of patients are not satisfied with the outcome following total knee replacement Only 82% to 89% of primary TKA patients are satisfied J Bone Joint Surg Br. 2010 Sep;92(9): Scott CE, Howie CR, MacDonald D, Biant LC Clin Orthop Relat Res. 2010 Jan;468(1):57-63: Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD

Conventional TKA limitations Non-anatomic (abnormal) motion yields muscular inefficiencies Paradoxical motion (anterior sliding) Limited external rotation (hinge) Normal Knee Conventional Knee - Fixe

Conventional TKA limitations Non-anatomic shapes and position yields poor kinematics Abnormal proprioception Promotes paradoxical motion Symmetric jointline to manage inventory (left/right inserts) Posterior sulcus position to gain deep flexion

PHYSIOLOGICAL MATCHING : Normal motion Improve Kinematics to Boost Performance

PHYSIOLOGICAL MATCHING Restoring anatomy and motion Normal convexity Medial: Prominent posterior medial Restores anatomic 3 varus joint line Normal A/P sulcus position JOURNEY II TKA Conventional TKA

PHYSIOLOGICAL MATCHING : Stability Throughout a Range of Motion 0 0-20 20-60 - 155 60 Mid-line Sulcus Anterior Cam Posterior Medial Lip/Horn Posterior Cam Confidential For internal use only by Smith & Nephew employees and sales force. Do not publicly distribute. Trademark of Smith & Nephew. Certain marks Reg. US Pat. & TM Off. All Trademarks acknowledged.

JOURNEY II TKA: A Complete System BCS 10 AP Sizes Femur/Tibia Same AP Box Kinematic Options Bailout Options C R Revisio n Seamless Primary -> Revision 9 proven anatomic sizes (L/R) 8 sizes (L/R) Primary Stem Options Revision Stem Options

First Patient Enrolled: June 21, 2012 High-Level Experience First Period of Implantation: Dec. 2011 Total Implantations to Date: 7,606 (US) Total Implantations beyond 3 mos: 5,342 Total Implantations beyond 6 mos: 4,141 Total Implantations beyond 1 year: 1,856

Hospital Stats Personal Experiences Personal Clinical Experience Happiest post-op patients I ve ever had in my 20 year career Cases to date: 473 (715 Group) 1 st Case: December 2011 > 1 year follow-up = 171 Avg length of stay 1.6 days (20 last 3 months as outpatient) Avg. ROM @ discharge 107 Total PT sessions = 8.2 (ROM > 110 & independent ambulation) Complications: - ITB Pain 0 - Dislocation - 0 - Manipulation - 1

VISIONAIRE Cutting Guides Disposable TKA cutting guides designed to match the patient s anatomy Utilizes preoperative MRI and full-leg X-Ray Based off the gold standard of mechanical axis alignment

VISIONAIRE Instrumentation v standard TKA Reduces OR time by eliminating a number of steps in the surgical technique* Alignment, sizing, and rotation are included in cutting guides Improves alignment and sizing by using computer generated images of the patient s anatomy to determine bone cuts, and implant positioning preoperatively Eliminates need to violate the IM canal, reducing blood loss and complications from fat emboli Reduces sterilization due to less instruments required for surgery Standard TKA VISIONAIRE instrumentation

VISIONAIRE My Experience Pre-op plan allows me to know exactly what to expect with every surgery Less invasive to patients (No IM rod, Less Ligament releases) Better patient outcomes More efficient OR (Less trays & instruments) S&N has reduced the instruments and implant sets at my hospital It makes me a better surgeon

VISIONAIRE Surgeon Benefits Know exactly what to expect with each case Can anticipate intra-op problems before they happen Ability to customize each plan specific to patient s anatomy Dedicated engineer Reduced instrumentation in the OR OR Staff loves it My patients are happier (Increases patients confidence)

VISIONAIRE Patient Benefits Patients have: Less pain Shorter hospital length of stay Less physical therapy Less blood loss Preop X-Ray Post-op X-Ray Post-op 1 Month

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