Ortho program cuts LOS, boosts satisfaction
But will recent hospital re-engineering hurt?
Sometimes less is indeed more at least at Heartland Home Health and Hospice in Lincoln, NE, where a four-year-old orthopedic program has not only reduced lengths of stay at hospitals, but it also has increased patient satisfaction.
Part of St. Elizabeth Community Health Center, Heartland started in 1992 by offering home care for patients who had undergone total knee replacement. About eight months later, according to Heartland director Phyllis Rizzo, services were expanded to offer care for total joint replacement patients.
"We see a lot of patients with total hip replacements and shoulder replacements," says Rizzo. Heartland now is developing a similar program for microdissection laminectomy patients.
Rizzo reports that when the program began four years ago, the lengths of hospital stays for patients with total knee replacements took a dramatic drop from 11.2 days to 4.1 days. Overall, the lengths of stays for the other surgeries were reduced from seven to five days, she says.
Rizzo says cost savings were significant, although she didn’t have current figures.
Patient satisfaction surveys were conducted for the first year and a half, she says, with no fall-outs or any dissatisfaction reported. Scores were consistently high. "They all were very pleased, so we stopped doing them." Rizzo estimates that between 120 and 150 patients a year have used the program.
She credits home health nurse Judy Pierce, RN, who has had extensive orthopedic experience, with developing Heartland’s program, although the hospital’s current re-engineering program has forced changes in the original model.
Care originally was designed to begin with preadmission. A home health nurse would meet a patient at the hospital the day before surgery for preadmission testing, then both would tour the orthopedic unit, the nurse explaining to the patient what to expect.
The home care nurse next would visit the patient in the hospital to see that "the care plan or patient care map was being followed. Any deviation from it [the care map] we would report to the physician," says Rizzo. "We would see the patient prior to surgery, throughout the hospital stay, then at home."
Care begins at preadmission
Now hospital patient care coordinators carry out preadmission testing and in-hospital visits. The result is unknown at this point, Rizzo says.
Re-engineering has "been frustrating for our nurses," she acknowledges, "but on the whole, the program has served the patient very well. [Re-engineering] began in July, and we haven’t had enough history with it yet to see if it’s affected the length of stay."
Under the old system, Rizzo says, "patients liked it because they liked seeing the same nurse, and the docs liked it because they knew who to contact."
Another concern, of course, is how all this will affect the continuity of care that had been established by the home health nurse. "There may be some lost continuity, but we’re still looking at what we can do. We’re just sort of biding our time."
Patients are still kept informed all along the way about what to expect, Rizzo explains, from pain management following surgery to mobilization. Only now, home health nurses and patient care coordinators must communicate closely to maintain patient satisfaction.
"Following patients got us on top of things, and it’s still going OK, I think, if you use patient care coordinators."
The home orthopedic unit is composed of one primary orthopedic nurse to head the program and three other nurses to assist. "All nurses can do case management," Rizzo says. The program also includes one physical therapist from the hospital and two from home health.
"The main thing," adds Rizzo, "is to get staff with orthopedic training."
Other problems encountered during the earlier stage of the development process were patients either missing appointments or arriving late and the agency losing prospective patients to rehab facilities. "We ended up following patients who didn’t need home care, so we spent a lot of time up front without getting the patient in the end," notes Rizzo.
That happened in cases where a family was unequipped to deal with the patient’s rehabilitation, she explains, or when patients developed complications, such as phlebitis, which required moving them into a facility.
Incidents that caused nurses’ time to be lost or misused occurred because of a lack of communication between the home health agency and the patient. "A preadmission testing patient was supposed to be coming to the hospital, and our nurse would drop everything to meet the patient at the hospital only to find out the patient was late or the surgery had been cancelled. It was frustrating, but we learned to check those things ahead of time."
Rizzo says they began calling patients to remind them of appointments and make sure "every thing was on track." Sometimes, she adds, nurses call the doctor’s office.
"You have to kind of learn those things the hard way."
One learning experience that didn’t come the hard way was the information booklet Heartland developed and gave to every patient. It has proved very popular among patients.
Its 25 pages, which include illustrations, cover such topics as exercise, diet, pain management, and "what to expect through the whole process," says Rizzo. "We revised it and revamped it, and we even had a group of people at the hospital look at it from a consumer’s point of view to be sure it appealed to the general public."
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