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One of the largest drivers of patient dissatisfaction with joint replacement is the uncertainty as to what to expect at all points along the care pathways. The staff at Indian River Medical Center in Vero Beach, Florida, learned this the hard way. For many years, orthopedic surgery was performed at the hospital, but it wasn’t a service line. As a result, the hospital was losing market share. Patients were happy with their surgeon, but they were reporting a negative experience overall. Something had to change.

Medical examTwo years ago, Sarah K. Mondano took on the role of Director of Musculoskeletal Services at Indian River Medical Center. She was tasked with developing a comprehensive total joint program that spans the continuum of care. At the 2018 Musculoskeletal Leadership Summit, Mondano discussed how, in just two years, the staff developed a nurse-led initiative to improve the experience, outcomes, and value of the TJR program at the hospital.

In this two-part series, we’ll be sharing the key tactics Mondano and her team implemented to improve the patient experience and maximize financial benefit while maintaining quality outcomes.

Guiding Principles of Care Redesign

IRMC assembled a multidisciplinary team charged with the task of improving the TJR patient experience. At the beginning of the project, the team had difficulty envisioning an opportunity for improvement; everyone felt like they were doing a good job. That is until the patient experience became their viewing lens. “This really was an ah-ha moment for the staff,” Mondano says.

The team subsequently analyzed what they were doing and they came up with a plan for what they could change to not only improve the patient experience but also improve their outcomes. Of course, in order for standardized protocols to work, consensus and buy-in were critical. “This was achieved by involving the entire team – requiring lots of hours and lots of meetings to develop protocols and pathways together,” explains Mondano.

Pre-Op Care Redesign

IRMC focused on the following strategies to reduce variation across the TJR continuum of care:


  1. Evaluate patient selection and optimization. Don’t just clear patients for surgery. Clearing patients for surgery just a few days in advance only allows for the identification of their potential risks. It doesn’t give providers time to help patients improve the odds of successful surgery and fast recovery. Instead, proactively manage patient risk.


  1. Complete RAPT (Risk Assessment Prediction Tool) score pre-operatively. Don’t wait to start discharge planning. When patients don’t know what kind of care they’re going to need after surgery, they’re unable to plan for where they should go when it comes time to leave the hospital. This can stall discharge and drive up post-acute costs. Instead, help surgeons reliably predict discharge needs before surgery. In the last two years, IRMC has seen a 90% accuracy rate in predicting where patients are going to go post-acute.


  1. Engage patients in the episode. Don’t focus on the patient experience solely within the inpatient care setting. When the patient education focuses primarily on what to expect during the inpatient stay, patients may fail to take the right steps to ensure they are fully prepared. Instead, educate patients on what to expect before and after surgery, including recovery.


  1. Assess education materials and joint camp attendance. At IRMC two years ago, less than 10% of patients attended the weekly joint camp class. In the first quarter of 2018, that number now stands at over 90%. The team completely re-designed the curriculum for the joint camp class and made it mandatory that patients and their primary care partner attend. During this time, they focus on demystifying the surgical procedure, as well as identifying clear expectations for pain management and mobility after surgery. They also redesigned communication protocols to reinforce consistent messaging surrounding expectations throughout the episode of care.


  1. Consider patient navigation platform. The team at IRMC launched a web-based patient navigation platform designed to increase compliance and navigate all patients. Patients receive automated texts, phone calls and/or emails reminding patients to take their medications, do their exercises and attend appointments, in addition to having access to other educational materials.


  1. Evaluate PROs. IRMC collected PROMs during pre-admission testing and uploads the data to their web-based platform. This enables the staff to analyze PROMs in the aggregate or to analyze them by specific physicians. All of this data is collected in the pre-operative phase, before being passed on to the American Joint Replacement Registry.


  1. Perform case management assessment in PAT (Pre-Admission Testing). This allows case management to confirm the discharge plan, and complete the assessment pre-operatively rather than on post-op day one.


Tune in to part two of this series as we share the strategies IRMC implemented during the acute and post-acute care phases, and look at the ways the team measured success throughout this initiative.