Joint Replacement


Home health agencies frequently care for patients after Total Hip Replacement (THR) or Total Knee Replacement (TKR) surgery. Home health agencies have the opportunity to demonstrate their value to providers and patients by adopting practices that result in good outcomes combined with high patient satisfaction.

The demand for total joint replacement is steadily increasing. There was a 101% increase in yearly hospitalizations for hip and knee replacements between the years 1997-2007. (Pereira, 2015) The average hospital length of stay after joint replacement has decreased from several weeks to between three to six days (Gulotta,2011), and is expected to continue decreasing.

Patients are seen at home much earlier in their recovery. “Fast track” programs are being implemented in many hospitals to reduce hospital stays after joint replacement and return patients home rather than a post-acute care facility (Kehlet 2013, Husted 2012). Fast Track programs reduce hospital stays to around two days in a safe and effective manner (Raphael 2011). Many home health agencies are reporting an increase in same-day discharges as well as two-day fast track discharges

Medicare is strongly encouraging providers to improve efficiency of joint replacement procedures, and to improve outcomes. The CMS Comprehensive Care for Joint Replacement program will increase use of fast track programs and increase the number of patients discharged to home. Home health agencies can add value for hospital and physician partners and patients by implementing evidence-based, streamlined programs to prevent complications and promote healing and increased mobility.
 
Acknowledgements: This Blueprint module was developed in collaboration with the Visiting Nurse Associations of New England. 
 
Elements of a Home Health Fast Track Program
  • Pre-hospitalization assessment and initial plan
  • Post-surgery assessment and care plan
  • Post-acute clinical care at home, including therapy
  • Close physician / home care team communication and coordination
  • Patient and family engagement
  • Flexibility of plans to accommodate patient needs and wants
  • Collaboration between home care team and community supports
  • Coordinated transitions between levels of care
  • Continuous evaluation of patient experience, outcomes, and costs

Goal: Establish effective Joint Replacement Program with proactive clinical management
Fast track programs combine evidence-based clinical care with systematic organizational approaches (Husted 2012). To implement hip and knee replacement fast track programs, home health agencies will need protocols for efficiently and effectively meeting the needs of patients after discharge. Agencies will also need processes to assure referring physicians that the agency is prepared to manage hip and knee surgery patients and a measurement approach to ensure high quality outcomes.
Best Practice Interventions:
  • Implement evidence-based clinical pathways integrated with training, documentation, and performance evaluation
  • Adopt evidence based physical therapy and nursing visits.  Factors impacting frequency include type of surgery; patient condition and co-morbidities; time since surgery; type of discharging facility; availability of support at home; post-surgical pain and other symptoms
  • Innovate physical therapy (PT) approach: consider PT only visits, joint replacement protocols, frequency of visits based on patient function status, and protocol for transition to outpatient PT
  • Proactively manage pain.  This includes planning for the transition from facility to home, coordinating transition to oral and then to non-narcotic medications, ensuring that the patient is prepared for pain management during PT, and educating the patient on non-pharmacologic pain management
  • Proactively prevent readmissions through pain management, infection prevention, patient education, emergency planning and proactive communication.  For example Zone Tools can be used for patient education to identify risk of re-hospitalization
  • Develop protocols for medication management for joint replacement: medication reconciliation, anticoagulation; pain medication; bowel regimen
  • Plan your safety program: focus on falls risk assessment and prevention; anti-coagulation management; infection control
Goal: Establish and communicate joint replacement program goals that are meaningful to patients, payers, referral sources, and the community.
Best Practice Interventions:
  • For patients, goals will be to increase mobility, improve strength and balance, and prevent complications. 
  • For payers and providers goals to address and communicate are: prevent readmissions and emergency department (ED) use, manage costs, deliver good outcomes, and ensure patient satisfaction.
  • Measure program results and report to joint replacement partners
  • Evaluate opportunities for improvement, including cost savings and improvements in patient experience
  • When possible, use technology to manage workflow and to automate quality checks
  • Train staff to ensure consistency and accountability across all types of care givers
  • Review data monthly at agency and individual level
  • Telephone check in with patient within the first 2 weeks of care to ensure satisfaction
Goal: develop effective systems for managing patient care, information, and coordinating with partners
Best Practice Interventions: 
  • Ensure patient access to home care after inpatient discharge: make available evening and weekend visits and extended hours for start of care
  • Adopt tools to assist staff with assessments and patients with self-management
  • Align your electronic medical record program to prompt for quality indicators
  • Define roles and accountabilities of home care professionals to ensure comprehensive care, conduct required assessments, and submit essential documentation: Nursing, Physical Therapy, Occupational Therapy, Aides
  • Develop referral pathways for social services, mental health, and transportation
  • Plan for coordinated handoffs to outpatient therapy
  • For fast track and same day programs, coordinate with inpatient PT to ensure smooth handoff to home care
  • For fast track and same day programs, coordinate with inpatient or community pharmacy to ensure patients have access to pain medications at discharge
Best Practice Tip: Have agency home care liaison meet with patients during pre-op teaching session at hospital or have physical therapy liaison meet regularly with discharge planners. (Ensure that this practice meets Medicare and State regulatory criteria.)
 
Goal: Establish a communication program about availability of joint replacement services at home
Best Practice Interventions:
  • Target messages to hospitals, physicians, and patients
  • Participate in pre-op teaching workshops hosted by hospital or physician
  • Conduct pre-discharge visits
  • Develop program information for physicians and patients
  • Share your program cost and outcome results with hospital, ACO, managed care and physician partners 
VNANE Best Practice Program Characteristics: 1) central referral and intake line: 2) dedicated customer relationship management team; 3) collaborative target population analysis, planning, and performance reviews; 4) customization of services to meet customer goals; 5) incentives to align organizational efforts with customer business imperatives
 
Joint Replacement and Home Health: Summary of Clinical and Process Recommendations
Before the Home Visit: 
Obtain the following information as part of the intake process at least 24 hours before the start of care:
  • H&P and discharge summary
  • Determine if patient is under a fast track protocol
  • Get information on the type of surgery, restrictions related to type of surgery, long-acting pain medications administered during surgery
  • Determine if patient may be a re-hospitalization or safety risk
  • Get discharge medication list including pain management meds
  • Get verbal orders for treatments, labs, wound care, etc.
  • Notify direct care providers of known risks.
Pre-visit communications
Responses to questions lead to a decision about making a same day visit. Responses should also be used to organize care before or during the first visit, for example arranging a family visit, bringing certain supplies, or assisting with DME arrangements. Pre-visit questions may include:
  • “Do you have written information on how to take care of yourself after the surgery?  
  • “Who is helping you”?
  • “Were you able to obtain medications you need?”
  • “Have you needed pain medicine since you got home?”
  • “Do you understand how to take your pain medicine?”
  • “How are you getting to the bathroom (or other functional status question)”
  • “Have you noticed any changes or problems with your incision or bandage since you’ve been home?”
  • “Do you feel safe being home?”
  • “Are you having problems with any of your other health conditions?”
For Fast Track or Same Day Discharges:
  • Try to meet with the patient prior to surgery.  Some agencies participate in joint surgery classes offered by hospitals
  • Coordinate with hospital PT staff  to ensure PT visit on day of discharge
  • Know what teaching and tools have been provided to the patient
  • Ensure that medications are in the home when patient arrives
  • Consider adding anxiety assessment to identify patient /caregiver capability to meet needs
Start of Care Visit Includes: (See also 'For All Patients' content on the Blueprint for Excellence)
  • Telephone call to confirm visit with the patient
  • Start or complete OASIS and a comprehensive therapy assessment
  • With the patient and caregivers, plan visit frequency and discuss the plan of care
  • Conduct general assessment of risk for rehospitalization
  • Conduct pain assessment. Use standard tool and assess at every visit.  See tools in this section.
  • Conduct home safety assessment including falls risk and emergency preparedness
  • Conduct medication reconciliation
  • Assess medications specific to joint replacement: pain management and anticoagulation
  • Conduct depression assessment
  • Physician contact regarding orders and medication reconciliation.
  • Initial self-management teaching: pain, bowel management, wound care, falls prevention, other safety teaching
  • Assess equipment or home modification needs, including grab bars
  • Initiate referrals as needed:
    • Refer to skilled nursing for medication teaching and INR blood draw if needed and RN required by state law
    • Refer to occupational therapy (OT) for assistance with ADL’s
    • Refer to MSW/psych RN if positive for anxiety or depression
    • Refer aide services for assistance with personal care
    • DME provider for any equipment required that is not in home (or obtain needed referrals).
  • Provide agency name and contact information and assurance of 24 hour response to calls—teach back with information
  • Verify that physician follow-up appointment is made (usually at 6 weeks)
  • Leave patient education and zone tools for patient use
 Plan of Care: Determine number of contacts/week based on:
  • Length of rehab stay prior to home care (if any)
  • In home support
  • Co-morbidities
  • Surgical complications
  • Patient ability to adhere to plan
  • Fast track status
  • Any physician specific protocols
  • Accessibility to outpatient rehab
On-going care includes:
  • Assess for pain at each visit using rating scale and transition to non-narcotic as soon as possible
  • Take vital signs pre and post exercise and assess for edema
  • Check medication status: ask patient if on any new medications, changes in dosage, problems/issues experiencing. See "For all patients" information in the Blueprint for Excellence
  • Evaluate surgical wound: Remove staples or change dressing as ordered by physician
  • Monitor for surgical complications: Thromboembolism or DVT, infection and stiffness
  • Request and implement physical therapy, occupational therapy and other referrals as needed
Transitional Care Planning should include:
  • Identify any follow up home care services needed
  • Refer to outpatient rehab and coordinated handoff
  • Hand off up to date medication list and care plan to next providers of care
  • Discharge summary to physician if requested/required
  • Patient able to describe the plan for follow up care, including physician visits and rehabilitation
 
Best Practice Tip: Intake often begins before discharge. Call or speak to the patient on day of discharge from the facility. Use a pre-visit phone script to improve consistency but empower staff to collect information using a conversational approach to make the interview go more smoothly. Many agencies believe a nurse or PT should make the call in order to assess patient need for a same-day visit. A clinician can ask follow up questions that help to understand patient needs and functional status more comprehensively.
 
Know the Risks In Joint Replacement

Thromboembolism – Venous thromboembolism (VTE) may manifest as a deep vein thrombosis (DVT) or as a life-threatening pulmonary embolism (PE). Predisposing factors include age older than 40, female sex, obesity, varicose veins, smoking, past history of DVT, diabetes and coronary artery disease.
VTE Prevention: The current evidence-based recommendation is for timely initiation of VTE preventive care postoperatively. Current prophylaxis methods include mechanical compression stocking or foot pumps (mechanical prophylaxis) as well as pharmaceutical agents such as low-dose warfarin, unfractionated heparin, low molecular weight heparin or aspirin (Autar 2011).
Anticoagulant therapy:  The American College of Chest Physicians (ACCP) 2012 guideline on anticoagulation therapy after orthopedic surgery addresses evidence based anticoagulation therapy:
  • ACCP clinical practice guidelines recommend antithrombotic prophylaxis following total hip arthroplasty or total knee arthroplasty
  • Low-molecular-weight heparin (Lovenox and other brand names) is the preferred method of prophylaxis; Recommended alternatives are fondaparinux (Arixtra); dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto)
  • Apixaban (Eliquis)or dabigatran (Pradaxa) are the recommended alternative for patients who decline injectable LMWH
  • Anticoagulant prophylaxis is recommended for a minimum of 10-14 days following surgery and preferably for 35 days following surgery
  • Patients discharged on warfarin (Coumadin) need a plan for INR; note that warfarin is not the preferred anticoagulant
Compression therapy: Intermittent pneumatic compression device (IPCD) is recommended prior to discharge with or without anticoagulation therapy
  • Patients are frequently discharged with compression stockings or boots
  • Recommended use is 23 hours on and 1 hour off
  • Compression stockings are used until patient is fully ambulatory
  • Stockings can be handwashed and air dried
Infection and Skin Integrity: higher rates of wound infections are associated with Rheumatoid arthritis, skin breakdown, prolonged wound drainage, previous knee surgery, obesity, steroid use, renal failure, DM, malignant disease. Infection around the prosthetic joint occur in approximately 1% of knee and hip joint replacements and are the leading cause of surgical revisions (Kapadia 2015, Lamagni 2014). Additionally, patients with limited mobility or cognitive impairments are at risk for pressure ulcers. Clinical interventions include prevention of infection at the surgical site and prevention of new or worsening pressure ulcers.Infection Prevention: There is no single standard of care for surgical wound dressings (Dumville 2014). Some patients may need surgical wound care while other patients may be discharged with sterile occlusive dressings, which are not changed for 10-14 days. Home health provides wound care or dressing changes as needed; otherwise patient teaching is key to prevention and early detection.

Stiff knee after TKR: Approximately 1-5% of patients experience ongoing stiff knee following surgery, defined as a flexion contracture of ≥15° and/or <75° of flexion. Risk factors for reduced range of motion (ROM) include younger age, post-traumatic arthritis, prior knee surgeries or pre-existing stiffness. Post-operatively stiffness can be caused by infection, inadequate pain management, or other pathology limiting knee motion. Patients with continued stiff knee after 2 months should be referred for further evaluation. (Husain 2011)

Goal: Prevent Post-Surgical complications, including thromboembolism, infection, loss of function
Home health has an important role in preventing emergency visits and readmissions related to surgical complications as well as those related to exacerbation of chronic disease. Evidence suggests that readmissions can be positively impacted by reducing post-operative surgical complications (Keeney 2015) and carefully monitoring functional status (Shih 2015, Fisher 2015).
Best Practice Interventions: 
  • VTE Assessment: check legs for redness, swelling (DVT); evaluate shortness of breath (PE)
  • VTE Patient/Family Education: educate on signs/symptoms of VTE, medications, importance of ambulating
  • Infection Assessment: check wound area for intact dressing; if assessable, evaluate redness, swelling, pain or drainage at wound site. Routine temperature check. Use a standard assessment tool such as the Braden scale for pressure ulcer risk assessment.
  • Educate patient and family on signs and symptoms of infection, showering / bathing protocols with wound dressing. Implement daily temp monitoring with 'call agency' if temperature is above an established set point. Use a Zone Tool for patient education and self-management.
  • Proactively manage pain
Goal: implement rehabilitation therapy
Rehabilitation services are an integral component of fast track joint replacement programs (Quack, 2015, den Hertog 2012) Physical therapy is an integral part of a core service in home-based joint replacement care.  Some joint replacement cases are PT only, meaning that PT clinicians must document all clinical and functional limitations and ensure that improvements are documented.
Best Practice Interventions:
  • Have PT staff conduct a thorough assessment: 
    • Determine physician prescription for weight bearing, joint precautions or positioning
    • Assess functional status and mobility
    • Assess pain level, noting that pain management is essential to enable the patient to engage in PT activities
  • Implement physical therapy plan that incorporates patient goals with emphasis on:
    • Walking, balance, stairs
    • Fall prevention, safety
    • Flexion, extension and range of motion to prevent stiff knee
    • Patient-identified goals relating to function or pain
  • Provide therapy interventions/treatments based on initial assessment including:
    • Gait training on various surfaces
    • Range of motion (ROM) and Strength
    • Practice ADLs (sit, stand, toileting, bathing, stairs)
    • Exercises for balance in different positions – supine, prone, sit, side, stand
    • Site specific rehabilitation exercises: Hip Exercises*; Knee Exercises; Quad Sets; Glut Sets; Ankle Pumps; Hip & Knee Flexion (Heel Slide); Hip Abduction; Knee Extension (Long Arc Quad); Short Arc Quad; Standing Hip Flexion; Squats; Ankle pumps; Straight leg raises
    • Incorporate PT teaching and assess for patient understanding
      • Pain management--emphasize the importance of medicating before PT and use of heat or cold therapy
      • Exercises for the patient to do on his/her own with caregiver
      • Correct crutch, walker or cane usage on flat surfaces and stairs
      • Joint precautions (such as not crossing legs and standing techniques) and weight bearing limitations
      • Recommended ROM limitations or goals for specific functional tasks
      • Provide and review patient education and information (may be developed by the agency or are publicly available. See for example Mass General Hospital Rehabilitation Tools: Patient Education Following Hip and Knee Replacement
Goal: Engage Occupational Therapy (OT) as needed to promote functional status goals
Best Practice Interventions:
  • OT may be consulted for patient training and education on functional bathroom transfers with use of DME as needed
  • OT can recommend equipment such as: reacher, sock aid, stocking aid, long handled shoe horn, dressing stick, hand held shower, grab bars, shower chair, raised toilet seat
  • OT will provide teaching and training for ADL skills while maintaining joint precautions
  • OT teaching and training on adaptive devices will allow for greater independence while following surgical precautions.
  • OT will assess for Home Health Aide needs and develop a care plan.
  • OT will educate, train and teach patient on positioning strategies for pain management.
PT Objective Tests And Measures
Objective tests and measures should be performed at initial evaluation to obtain baseline. These should be performed again for comparison at reassessment and discharge. The physician should receive PT evaluation and discharge summary and also be updated as appropriate and needed on the patient’s progress throughout the plan of care (Clarkson 2005).

Assessing Body Structure and Function:
  • Strength testing- manual muscle testing, observation of function if unable to perform manual muscle testing
  • Goniometric measurement of ROM
  • Normal Hip ROM: Flexion 0-120°; Extension 0-30°; Abduction 0-45°; Adduction 0-30°; IR 0-45°; ER 0-45°
  • Average hip ROM required for: Sitting in a standard height chair ~84°; Sit to stand from a chair typically requires at least 90° hip flexion but this varies based on chair height; Squatting to pick up an object from the floor 110-120° hip flexion; Tying a shoe with foot flat on floor ~120°; Ambulation 30° hip flexion and 10-20° hip extension; Stair ascent 67° hip flexion; Stair descent 36° hip flexion;
  • Normal Knee ROM: Extension/Flexion 0-135°
  • Average knee flexion required for: Sitting 93°; Tying shoes 106°; Level ambulation 60°; Stair ascent 83-105° (varies based on stair dimensions/height); Stair descent 83-107° (varies based on stair dimensions/height); Squatting to pick up an object 117°

Goal: Educate patients and caregivers on ongoing care and self-management during and after the episode
Engage patients and caregivers in planning and managing their own care plans with goal of providing smooth transitions, reducing anxiety, improving knowledge of progress and care expectations, confidence in ability to self-manage care for more rapid return to normal living.
Best Practice Interventions: 
  • Make sure patient knows when to expect services. Case manager writes agency specific visit schedule for each discipline. Post on refrigerator or other central location
  • Communicate - any changes in schedule should be communicated to patients in a timely manner
  • Educate patient and caregiver on when to alert agency staff
  • Plan for emergencies – make sure the patient and care givers know how to contact Agency, PCP/orthopedist and 911
  • Patient/caregiver teaching should include:
    • Signs and symptoms of surgical wound infection, VTE
    • Pharmacologic pain management – narcotic and non-narcotic
    • Non-pharmacological pain management including ice and positioning for comfort.
    • Bed mobility
    • Transfers (bed, toilet, chair, shower, care, floor)
    • ADL/IADL skills
    • Edema management
    • Urgent and emergent response
  • Utilize teach back and demonstration methods to verify learning. Verify that patient and caregiver can:  
    • Demonstrate ability to take medications correctly including pain, anticoagulants and bowel regimen
    • Verbalize medication actions/ side effects to report/administration schedule
    • Demonstrate mobility skills
    • Verbalize plan for emergencies
  • Leave behind patient education materials and tools
Best Practice Tip:  Make a check in call after the first few visits with an open ended question such as “What else can we do for you?” This helps to manage the patient experience and identify any gaps in the agency’s performance.
Partner with referring clinicians and hospitals to develop programs and strategies to improve health outcomes and patient experience, and to help them meet accountability goals.  
By effectively engaging patients and caregivers as partners in care, home-based care organizations improve experience, activation, and ultimately, outcomes.
Educate payers on opportunity to improve outcomes by more effectively care for people in their homes. Drive smarter spending by preventing admissions and avoidable ED use.
Drive better outcomes by supporting practitioners to practice at the top of their license, training for excellence, and recognizing achievement.