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.
The Orthopedic Institute (TOI) at Jersey City Medical Center was founded in late 2014. The Institute’s main focus was to provide services that covered 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 of all these initiatives, a higher utilization of services persisted as the majority of the patients were being discharged to a facility post-op. However, literature exists that 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.
PT provided in the home setting allows patients to complete their activities of daily living in their customary home setting with a 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 be implemented that promote the best discharge disposition for patients, while achieving the best cost of care delivery. For the years 2017 and 2018, our team focused on strategies that used discharges to home versus facility environments. In the year 2018 and using 2015 data as a baseline, our goal was to raise the percentage of total joint replacement (TJR) patients discharged to home from 29% in 2015 to 85% in 2018 with the aim of reducing length of stay, improving recovery time, and minimizing the cost of care delivery.
We reviewed the current process and identified areas for improvement that allowed us to achieve our goals. First, we focused on educating the team and improving patient education by partnering with the physician offices to ensure their staff understood the benefits of discharging to homes, and also to ensure they were discussing disposition to home as surgery was being planned with the patient. Second, we revised the preadmission testing process and reserved every Thursday specifically for orthopedic patients scheduled for a TJR with the TOI and also organized a comprehensive two-hour preoperative course for the patients and their coaches and family members. The course content provided patients with data supporting home discharge with PT services vs inhouse rehab, in addition to focusing on surgical preparations, expectations, safety measures, infection prevention, rehabilitation modalities, home assessments, and discharge process. The third step was to standardize clinical pathways, protocols, and early mobility strategies. This was made possible by enhanced and early collaboration between the orthopedic nurse manager and case management regarding final disposition and resource allocation, and completion of a home assessment checklist that allowed early evaluation by an interprofessional team to ensure patient needs are met timely. Also, by having RNs and PTs collaborate to achieve early mobilization and creating a standard schedule for mobilization milestones, for instance, dangling on the first postop day, and out of bed to chair, the next day, with ambulation twice per day by PT/occupational therapists. Improving communication and process with case management was also vital, as this allowed a coordinated and efficient discharged practice. The last step was to strengthen collaboration with visiting nurse association (VNA) agencies to ensure that a continuation of skilled nursing service and PT at home for those who quality. As a result, for the year 2018, we were able to send 84% of our patients to home versus 29% discharged home in 2015.
Other initiatives that were implemented by the orthopedic nurse manager navigator during 2018 included:
1. Sending welcome packets to the patients as soon as they were booked for surgery. The purpose of the packet is to establish an early connection to the patients. In this packet the patient received 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 has allowed to improve a home care protocol during the year. One of the issues identified by the team in early 2018 was the lack of supplies carried by the VNA team on the first visit. The protocol was revised and the VNA team agreed to provide a trunk supply of wound care items to their nurses to allow timely and efficient wound care. Also, the nurse manager navigator created a wound care supply kit for patients being discharged home, so they could have backup supplies available at home. 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.
In 2018, TIO was recognized 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 and was displayed during the annual Quality Fair and Patient Safety Forum on November 6, 2018. The poster was also displayed during the New Jersey Council of Magnet Organizations, Inc., an annual meeting early November 2018. And in March 2019, TOI was certified as a hip and knee replacement program, by the centers of excellence by DNV GL Healthcare, which validated the important work done by the team.
Our 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 and to improve class attendance from 47% attendance in 2018 to 54% in 2019 by continuing to send welcome packets, expanding TJR courses for Spanish-speaking patients, and by providing an online version of the class. Using our model for shared governance, we have been able to collaborate with interprofessional teams, both internal and external, to make sure our patients are educated and able to make informed decisions that has led to a stellar increase in patient satisfaction.