Jersey City Medical Center shared governance enabled an interprofessional team to increase total joint replacement discharges to home from 29% to 84%, improving patient outcomes and reducing costs.
Best Practice: Patients with Total Joint Replacements Discharged to Home, Jersey City Medical Center, Jersey City, NJ
Jennyfer Morel-Carvajal, MPA, BSN, RN, CCCTM, is the Orthopedic Institute Nurse Manager Navigator at Jersey City Medical Center, Jersey City, NJ, one of the few hospitals that is fully accredited in shared governance by the Forum for Shared Governance.
Background: The Orthopedic Institute
The Orthopedic Institute (TOI) at Jersey City Medical Center was founded in late 2014. The Institute’s main focus was to provide services covering the continuum of care from pre-hospitalization to post-acute care. These services included the coordination of preadmission testing, weekly prehospitalization patient education classes, patient navigation (starting preoperatively) throughout hospital stay, and post-discharge follow-up aimed at optimal outcomes and reduced readmissions.
Despite all these initiatives, higher utilization of services persisted because the majority of patients were being discharged to a facility post-op. However, literature supports the safe discharge of patients to home with physical therapy (PT) instead of using PT services in inhouse acute rehabilitation and skilled nursing facilities.
The Case for Home Discharge
PT provided in the home setting allows patients to complete their activities of daily living in their customary environment. As a result, this approach has the potential to reduce length of stay, improve recovery time, and reduce costs. With the Centers for Medicare and Medicaid Services’ bundled payment system in place for total hip and knee replacements, strategies need to promote the best discharge disposition for patients while achieving the best cost of care delivery.
Using 2015 data as a baseline, the team set a goal for 2017 and 2018: to raise the percentage of total joint replacement (TJR) patients discharged to home from 29% in 2015 to 85% in 2018. The aim was to reduce length of stay, improve recovery time, and minimize the cost of care delivery.
Strategies for Improvement
The team reviewed the current process and identified areas for improvement. First, they focused on educating the team and improving patient education by partnering with physician offices to ensure their staff understood the benefits of home discharge. This partnership also ensured that staff discussed home disposition as surgery was being planned with each patient.
Second, the team revised the preadmission testing process and reserved every Thursday specifically for orthopedic patients scheduled for a TJR with the TOI. They also organized a comprehensive two-hour preoperative course for patients, their coaches, and family members. The course provided patients with data supporting home discharge with PT services vs inhouse rehab. In addition, it covered surgical preparations, expectations, safety measures, infection prevention, rehabilitation modalities, home assessments, and the discharge process.
The third step involved standardizing clinical pathways, protocols, and early mobility strategies. Enhanced and early collaboration between the orthopedic nurse manager and case management regarding final disposition and resource allocation made this possible. The team also completed a home assessment checklist that allowed early evaluation by an interprofessional team to ensure patient needs were met in a timely manner. Furthermore, RNs and PTs collaborated to achieve early mobilization and created a standard schedule for mobilization milestones — for instance, dangling on the first postop day, out of bed to chair the next day, and ambulation twice per day by PT/occupational therapists.
Improving communication and process with case management was also vital, as it allowed a coordinated and efficient discharge practice. The last step involved strengthening collaboration with visiting nurse association (VNA) agencies to ensure a continuation of skilled nursing service and PT at home for those who qualified. As a result, for the year 2018, the team sent 84% of patients to home versus 29% discharged home in 2015.
Additional 2018 Initiatives
Other initiatives that the orthopedic nurse manager navigator implemented during 2018 included:
1. Sending welcome packets to patients as soon as they were booked for surgery. The purpose of the packet was to establish an early connection with patients. Each packet contained a welcome letter, a flyer invitation to the preoperative patient education course, an educational video through Emmi Solutions related to the procedure and fall precautions, and a home assessment checklist.
2. Revising current patient education materials and program brochures.
3. Creating wound care supply kits. Collaboration with VNA allowed the team to improve a home care protocol during the year. One of the issues identified in early 2018 was the lack of supplies carried by the VNA team on the first visit. In response, the protocol was revised and the VNA team agreed to provide a trunk supply of wound care items to their nurses for timely and efficient wound care. Additionally, the nurse manager navigator created a wound care supply kit for patients being discharged home so they could have backup supplies available. The revision of the protocol and the implementation of the wound care supply kit increased patient satisfaction.
4. Instituting quarterly office visits to ensure continuity of care and services.
Recognition and Certification
In 2018, TOI received recognition during the 11th Annual RWJBarnabas Health Quality and Patient Safety Forum for its contribution to the advancement of quality and safety at RWJBarnabas Health, particularly for its work on “Increased TJR Discharged to Home.” A poster that addressed this was selected as one of the top four amongst 10 presenters at Jersey City Medical Center. It was displayed during the annual Quality Fair and Patient Safety Forum on November 6, 2018, as well as during the New Jersey Council of Magnet Organizations, Inc., annual meeting in early November 2018. Moreover, in March 2019, TOI earned certification as a hip and knee replacement program by the centers of excellence through DNV GL Healthcare, which validated the important work done by the team.
Goals for 2019
Goals for 2019 include reducing surgical site infection (SSI) cases from 11 during 2018 to four in 2019 by collaborating with the infection control team in the Orthopedic SSI Reduction Taskforce. The team also aims to improve class attendance from 47% in 2018 to 54% in 2019 by continuing to send welcome packets, expanding TJR courses for Spanish-speaking patients, and providing an online version of the class. Through the shared governance model, the team has collaborated with interprofessional teams, both internal and external, to ensure patients are educated and able to make informed decisions. This approach has led to a stellar increase in patient satisfaction.