Recovering at home

Atrius Health

Newton, Mass.

To improve surgical outcomes, save costs and enhance patient satisfaction, Atrius Health nurses launched a program to ensure most joint replacement patients recovered from surgery in their own homes rather than in costly skilled-nursing facilities.

Collaborating with nurses in Atrius' home health unit VNA Care and with hospital case managers, the nurses initiated a team-based approach that puts the patient's needs at the center of care from the start of pre-op visits to well after the patient is discharged from the hospital.

“It's very coordinated from the time of the surgery right down to the post-op visit, and it's very concise and timed for these patients,” said Michael Costa, the program's nurse team leader.

Once a patient is identified as a joint replacement candidate, nurses work with the patient to discuss post-operative issues, alleviate fears or concerns, and set expectations to recover at home after the surgery. The nurse also pinpoints any barriers that could make recovering at home difficult and would disqualify the patient from the program, and relates those issues to the home health team.

Next, VNA Care nurses and physical therapists arrange a pre-operative home visit a couple of weeks ahead of surgery to troubleshoot any barriers to safe recovery and coach the patient about self-managing their care.

Once the surgery is complete and the patient is sent home, a physical therapist pays a home visit to start therapy and discuss post-op care within 24 hours. Atrius utilization management nurses are on the phone with patients soon after.

Before launching the program, nearly 67% of Atrius' joint replacement patients were discharged to a nursing home after surgery in 2013. In 2015, just 29% of patients went directly to a nursing home.

For those patients who were necessarily discharged to a skilled-nursing facility, the hands-on care helped shorten their stay by an average of two days. As a result, cost savings from the program totaled about $665,700 in 2016.

Just as important: patients are happier. The program “promotes a higher quality and lower cost of care for the patients, and better patient experience overall,” Costa said.

—Shelby Livingston

PHOTO: The team: (Back row, from left) Michael Costa, RN, BSN, associate nursing director of specialties, Atrius Health; Jacque Anderson, RN, referral center manager, VNA Care; Judy Walsh, MS, PT, director of rehabilitative services, VNA Care; Jim Noonan, LPN, nurse liaison, VNA Care; Gael Varsa, RN, BSN, manager of utilization management programs, Atrius; Karen Chirsky, RN, BSN, vice president of transitional care/business development, VNA Care; (Front row, from left) Karen Fitch, RN, BSN, nurse case manager, Atrius; Dorene Gillis, RN, BSN, utilization management coordinator, Atrius.