A win-win… discharging total joint patients to their homes |

A win-win… discharging total joint patients to their homes


NYU Langone Reduces Referrals to Rehab Facilities, Decreases Costs

They dreamt: “Just what would the ideal patient experience look like?” And then they got down to work. The team at NYU Langone Medical Center set out to create a long-term care plan for their hip and knee replacement patients…one that would drive down postop referrals to acute care facilities. Joseph Zuckerman, M.D., the Walter A.L. Thompson Professor of Orthopaedic Surgery and chair of the department of orthopaedic surgery at NYU Langone, told OTW, “We knew there must be a way to reduce the number of patients who were discharged to acute care facilities. In 2012 (when it was voluntary), we began participating in the Medicare Bundled Payment for Care Improvement program. NYU Langone put together the necessary resources and created not just a 2-3 day in-hospital plan but a 90 day care plan for our joint replacement patients.”

So what did they come up with as their ideal? “Patients were prepared ahead of time for surgery and rehabilitation. They were actively supported before surgery by our clinical care coordinators (CCCs). Working with our surgeons, the CCCs developed comprehensive care plans with the goal of discharge to home with appropriate home care services. In the past, due to the nature of healthcare in New York, many patients were discharged to other health care facilities. One of the problems with this is that when patients are in your facility you can control the quality, but when they go elsewhere you have no control. We began working closely with a few carefully selected home care services and instituted a program in which a physical therapist visits the patient four to six times a week and the nurse twice a week. This is a true extension of our high quality hospital care.”

The results, which appear in the November 23 edition of JAMA Internal Medicine, were great news for patients, says Dr. Zuckerman. “We were thrilled to see that we achieved a drop of 34 percentage points for those undergoing lower extremity joint replacement surgery—and with no increase in readmission rates. These patients were able to recuperate in the comfort and familiarity of their own homes with no increased risk of medical complications.”

Asked about the particular challenges of implementing their program, Dr. Zuckerman told OTW, “There are many situations where patients with significant medical issues require more care, but not necessarily acute care. Ours is no longer a country of extended families and social issues are a factor. To address this, patients are contacted ahead of time by a clinical care coordinator, they are assessed for readmission and if they score below the threshold then we do plan on discharge to a rehabilitation facility for a shot stay in order to minimize the risk of readmission.”

This kind of preparation must start from the initial meeting with the patient, says Dr. Zuckerman. “From the very first visit I tell my patients that they will be in the hospital for two days and then they will go home. They are often surprised because they assume they will have to go to a sub-acute facility. I tell them, ‘That’s just another hospital. And our goal is to get you out of the hospital and back home’ It is important that they get the message that they can go home directly from their physician.”

“My key message to administrators is that you must have physician/institutional alignment in order for a program like ours to succeed. If you attempt to implement such a program without this alignment, then it will not be successful because it will lack the through and through support it requires. One way to look at this program is that it expands the ‘care umbrella’ of the doctor. This way you can be confident that the care you deliver and expect continues once the patient is out of your direct contact. We have essentially established a 90 day care umbrella.”