Inpatient program a hit with physicians
Shorter LOS, low cost are among the advantages
By creating an accelerated inpatient rehabilitation program, Columbia St. David’s Rehabi-litation Center is treating joint replacement patients who would have bypassed rehab altogether in the past few years.
The rehabilitation center, on the campus of St. David’s Medical Center in Austin, TX, developed its Progressive Orthopedic Program (POP) as a way of providing rehab services to joint replacement patients who were being transferred from the acute care hospital to home with home health or to a skilled nursing facility after their surgery.
The POP is a high-intensity program designed for high-level joint replacement patients. It follows a critical pathway that calls for four days in the acute hospital, followed by three to five days in rehab. The cost of the rehab stay is $1,000 a day. (For details on how the program works, see p. 32, right column.)
Reduce the acute care stay
A rehab stay for joint replacement patients at St. David’s has been as much as $1,300 a day in the past, says Laura Halliday, LMSW/ACP supervisor of the orthopedic program in rehab.
However, Halliday points out, in the past, many patients in the POP would have stayed seven days or longer in the acute care hospital and been discharged to home. Acute hospital costs are much higher because of the overhead and staffing costs, she adds.
"The reduced length of stay is the selling point. Because we can get them through the acute stay and rehab in seven to nine days, the entire episode of care costs less," she says.
The hospital developed the POP after the staff observed that a number of orthopedic patients reported during follow-up visits that they were having difficulties with tub transfers and other activities of daily living, says Donna Young, PT, clinical supervisor of the physical medicine department.
"There was a real need for the patient to receive and a real opportunity for us to provide the full benefits of rehab services and in a short period of time," Young says.
The program includes basic rehab services physical therapy, occupational therapy, and therapeutic recreation. "They may come out with the same outcomes as in a traditional rehab program, but it takes less time," Young says.
Patients in a more traditional program may stay in acute care as long as seven to nine days and in rehab up to two weeks, depending on their condition, their physician’s orders, and the willingness of their insurance companies to pay for a lengthy stay.
The program focuses on helping patients with the real-life skills they need to function at home alone. For instance, one component helps patients negotiate architectural barriers, such as doors, stairs, and entryways, so they can go back to the doctor’s office.
Patients go on outings, take the bus to the grocery store, and practice getting around in the community. The hospital has a large number of patients from rural areas that don’t have services such as home-delivered meals. These patients have to run their own errands and stand in the kitchen and prepare meals when they return home, Young says.
Before designing the program, staff talked to orthopedic surgeons and physiatrists to find out what their needs were and what they thought would make the program successful, Halliday says. (For details on how staff work with physicians, see p. 32, left column.)
"We tried to create a program that would be efficient in time but would give the patients all the benefits of acute care and rehabilitation so they could return to the least restrictive environment possible," she says.
To keep costs down, staff have eliminated re-evaluations for the new rehab patients. Instead, the transitional assessment done in the acute care phase carries over to the rehab stay. The program makes heavy use of group therapy and provides an intensive rehab program.
"We are really careful with our length of stay because that is how you save costs. We make sure we are not dragging out what could be done in four to five days over a longer period of time," Young says.
Only healthy patients with high levels of function are accepted into the POP. Frail, elderly patients or those with other medical diagnoses can’t handle the intense schedule, Young says. For instance, a knee replacement patient with cardiac problems who may have to stop and rest after walking would not be appropriate for the POP.
The pathway helps keep things moving along, Young says. "The staff need to think this is day three, and I need to make sure this and this have happened,’" she says.
Clinicians make final decisions
However, she emphasizes that the pathway is only a guideline. Physicians may decide a patient needs an extra day in acute care, for instance.
If surgeons indicate on the postoperative orders they want patients to be in the POP, the therapists make a thorough evaluation. If patients have lost blood or have cardiac problems that would make them inappropriate candidates, staff identify that early on and discuss it with the physicians.
One patient initially set up on the POP developed unexpected medical complications, for example, and had to stay a couple more days in the acute hospital. "He may stay less than seven days in rehab, but he won’t be a primary POP candidate because he has slowed down in progress," Halliday says. The patient will be two days behind on the pathway and may not be able to keep up with POP momentum, she adds.
The number of patients is limited only by the criterion that they be at a high level of functioning, Young points out, adding that some borderline patients have progressed well in the program.
In 1998, orthopedic patients will go through a pre-surgery education program to accelerate their progress and help them learn what will happen after surgery so they can be better prepared, Young says.
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