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All Hands on Deck:The benefits of a team approach to

individualized patient care.Sharifa Coover, BSN, RN, ONC

Beth Gard, MSN, RN, ONC

DISCLOSURES

In compliance with continuing education requirements, all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled products or

products under investigational use.

OrthoNebraska’s Summer Symposium and the presenters for this seminar do not have financial or other associations with the manufacturers of commercial products, suppliers of

commercial services, or commercial supporters.

We hereby certify that, to the best of our knowledge, no aspect of our current personal or professional situation might reasonably be expected to affect significantly our views on the

subject on which we are presenting.

Objectives

Recognize ways to identify and implement patient care strategies that improve care.

Understand the role Quality Programs & Alternative Payment Models (APM) play within orthopedics.

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Nurse Navigation at OrthoNebraska

In the beginning…• Need was identified to move from “reactive” Case Management during patient’s

hospitalization to “proactive” Nurse Navigation• Focus initially was on education for both what to expect (Joint Class) as well as

discharge disposition• Pilot was started with three surgeons (one TKAs, one TKA/ THAs, one TSAs)• Promising pilot led to rollout of Nurse Navigation for all inpatients with majority of

surgeons buying in thanks to early results:

Decreased SNF &

HHC Usage

Increased Patient &

Staff Satisfaction

Decreased Number of Post-Op

Complications

The Patient Journey

Surgery Decision

Pre-Operative Nurse

Navigation

Patient Optimization Joint Class

Pre-Admission Call

(H&P/Specialty)

Surgery Hospital Stay

Discharge

Post-Op Patient Navigation

Clinic Collaboration

What gets discussed during the Nurse Navigation

phone call?

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Let’s talk…

• Joint Class. The patient’s learning needs are evaluated to determine if they need regular class, a web- based presentation emailed to them, a class done via phone, or a 1:1 in-person session.

• Pre-Operative Appointments. Navigators ensure that the patients have made their preoperative evaluation appointments.

• Risk Assessment. Risk assessment and patient optimization.• Discharge planning is thoroughly discussed.• Set up of Outpatient therapy is arranged or patient is encourage to do this

ASAP for the day after likely hospital discharge. • The Navigators provide the patient with their office number, which is one point of

direct contact for all things OrthoNebraska (med refills, billing questions, anxiety, education, etc…).

Discharge Planning

Started with RAPT What evolved from that experience

Case Study #1

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Joint Replacement Class

Main Objectives:1. Understanding Surgery https://www.orthonebraska.com/treatment/knee-replacement/#resource-video-1TimelineFamily/Friend Anticipations

2. Pain ManagementAnesthesiaRealistic ExpectationsMultimodal ApproachSide Effects

3. Preventing ComplicationsBlood ClotsInfectionsFall Prevention

4. Discharge PlanningHome EnvironmentTransportation

5. Safety After SurgeryOT/PTHome SafetyEquipmentPre & Post ExercisesPrecautions

6. Information Review Form“Test” Time

7. TourFamiliarity & Comfort

All hands on deck –The importance of a team approach for

successful outcomes.

What we do well during every phase of the patient journey.

Clinic Staff: Close collaboration between clinic nurses and hospital staff Create high level of availability with clinic access

Preadmissions: Ensure completion of patient optimization & patient’s preoperative clearance.Standardizing care- treating a pinky finger the same as a total joint. Standardized processes that become individualized based on the patient’s incoming info.

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Case Study #2

OR:• Turnover time less than 10 minutes- cascading schedule allows tech to get

room/ supplies ready for the next case quickly, supply chain personnel are experienced scrub techs who know the cases/ surgeon’s preferences

• Anesthesia support• Specialized ortho setting allows all staff to be experienced with all cases

Pre/ postop:• No downtime in preop, every moment is filled, so no patient time wasted• LOW nurse/ patient ratio allows for less anxiety/ more discussion with patient

(undivided attention)• PACU RN helps with quick OR turnover by getting their patients from the OR.

Inpatient:• Extremely low falls due to PI project (“Call, Don’t Fall”) and adequate staffing• Patient satisfaction scores consistently in the 90th percentile• Strong daily Interdisciplinary Rounds with high expectation of attendance

Therapy/ DME:• POD #0 PT session • Total Shoulder in-person patient education class• “Prehab” for patients identified to have increased post-discharge needs• Close collaboration with Nurse Navigation for discharge planning (our offices are

next door to each other)

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Interdisciplinary Team Rounds

Lead Nurse

����������� �

Therapy

Pharmacy

Hospitalist

Bedside RN

Case Study #3

Post-Discharge Navigation

First call the morning after discharge• How did the ride home/ overnight go?• Prescriptions?• Review postop instructions related to pain medication/ management, swelling, nausea/

vomiting, constipation, any other questions/ concerns that come up.• How does the incision look?• Reminder of how to get ahold of Nurse Navigation or after-hours line for on-call practitioner.

Second call one week after surgery• Another review of pain medication/ management, swelling, nausea/ vomiting, constipation,

any other questions/ concerns that come up.• Need any refills?• How does the incision look?• Usually some cheerleading during this call

Additional Calls as needed

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Case Study #4

So how’s thatworking for you…?

To Standardize or Individualize

When Standardization matters (reduce variations to achieve lower cost and improve efficiencies)• Surgeon Specialty Meetings- total

joint surgeons meet up to work toward best practice

• Surgeons on the “same page” for discharge expectations

• Intra-operative joint injections with proven results

• Postop care (dressing changes, anticoagulation, pain management, therapy progression).

• Preop optimization- education/ support

When Individualization matters (modifications made to the standard care process to achieve improved patient care)• Same day discharge for total joints

• More robust education• Earlier OR start time• Medications

• Patient falls outside the norm, but able to be accommodated (cardiac or bleeding history needing plan with hospitalist/ specialist collaboration)

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The Joint CommissionDisease SpecificCare Certification

Disease Specific Care Certification “DSC”

Joint Commission Certification Program that launched in 2002 to allow accredited organization to seek specialty certification for a chronic disease or condition. (7)

Evaluates clinical programs across continuum of care through onsite surveys and continual process improvement review via measure submission.

Allows national experts to come in an evaluate your program and help share best practices.

Requires a consistent team approach to patient care across the continuum.

OrthoNebraska’s DSC Journey

2010

Initial Certification

2012

Recertification2014

Recertification2016

Recertification

2018

Recertification

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Our DSC Team

• Physician Champion*• Inpatient• Nurse Navigation• Physical & Occupational Therapy • Perioperative Services• Pharmacy• Surgical Services• Anesthesia

• Orthopedic Physician Assistant• Nursing Executive• Human Resources• Access• Education• Analytics• Quality & Accreditation• Physicians Clinic

Clinical Practice Guidelines

“Clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” –AAFP.org (4)

Total Hip Replacement

1. AAOS Recommendation for the Use of Intravenous Antibiotic Prophylaxis in Primary Total Joint Arthroplasty (AAOS Information Statement 1027)

2. An Investigation of the Effects of Preoperative Interdisciplinary Patient Education on Understanding of Postoperative Expectations Following a Total Joint Arthroplasty.

3. American Society of PeriAnesthesia Nurses Clinical Guideline for Pain and Comfort

4. AAOS Clinical Practice Guideline on preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty.

Total Knee Replacement

1. AAOS Recommendation for the Use of Intravenous Antibiotic Prophylaxis in Primary Total Joint Arthroplasty (AAOS Information Statement 1027)

2. An Investigation of the Effects of Preoperative Interdisciplinary Patient Education on Understanding of Postoperative Expectations Following a Total Joint Arthroplasty.

3. American Society of PeriAnesthesia Nurses Clinical Guideline for Pain and Comfort

4. A comprehensive joint replacement program for total knee arthroplasty: a descriptive study

5. AAOS Clinical Practice Guideline on preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty.

Performance Measures

1. Percent of patients who identify a specific post-operative goal

2. Percent of clinical staff attending DSC specific educational sessions monthly

3. Percent of patients that are able to complete teach back on their pain management plan

4. Percent of patients that are evaluated by therapy post-operatively on day of surgery

Focus on items that you can improve ACROSS

your care team!

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DMAIC

DMAIC is a data-driven, structured problem-solving framework. It builds on learnings from previous phases to arrive at solutions. Its discipline discourages a team from skipping crucial steps and increases the chances of a successful project. Define will tell the team what to measure. Measure will tell the team what to analyze. Analyze will tell the team what to improve. And Improve will tell the team what to Control and how to continuously monitor and analyze the improvement results to ensure sustainment.

Click to edit Master title style

What else?

• Discharge Disposition • Length of Stay • Flexion & Extension ROM upon

therapy evaluation to inpatient and at discharge

• Smoking Status• BMI • OR Time • Infection Rate • Anesthesia Type• Pain Rating by day• Proportion of patients attending Joint

Class on-site • Readmissions

• Stair Goals• Hip Precaution Education• Therapy Evaluation Time• Throughput • CPM usage• TXA use• PCA Use• IV Pain Medication Usage• Opioid prescribing practices• Tourniquet time• VTE Prophylaxis• Antibiotic usage• Demographics• Many, Many Others

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It’s not information overload.It’s filter failure.

Clay Shirkey

“ “

WECREATEMAGIC.

WEEMBRACETHE JOURNEY.

You treat a disease. You win, you lose.You treat a person,

I guarantee you win –no matter the outcome.

Patch Adams

“ “

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Orthopaedic Quality Programs& Alternative Payment Models

Comprehensive Care for Joint Replacement Model (CJR)

What is CJR? The CJR is a five-year model with the goal of improving quality of care and cost efficiency in hip and knee procedures through bundled payments and quality measurement for Medicare beneficiaries. (1)

Episode Types

The model began on April 1, 2016 and will run through December 31, 2020

Image source: https://accelerohealth.com/wp-content/uploads/2015/06/CJR_Episode-1024x212.jpg

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Bundled Payment Care Initiative – Advanced (BPCI-A)

What is BPCI-A? This is a voluntary bundled payment initiative through Medicare that seeks to improve the quality of care delivered and reduce healthcare spending.

“The Model aims to support healthcare providers who invest in practice innovation and care redesign to better coordinate care, improve quality of care, and reduce expenditures, while improving the quality of care for Medicare beneficiaries. BPCI Advanced will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.” (2)

“90 day bundle” program that encompasses all healthcare spend

Source: https://hbr.org/resources/images/article_assets/2017/10/oct17-13-604028956-rozelt-iStock.png

Participation

Quality Programs

Focus on:• The Triple Aim• Patient Engagement • Value Based Care

Types:• Centers of Excellence• Institutes of Quality• Performance Networks• APMs

Image Source: http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx

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Other Hot Topics

Thank you!

References

1. A study of cost variations for knee and hip replacement surgeries in the U.S. (n.d.). Retrieved June 1, 2019, from https://www.bcbs.com/the-health-of-america/reports/study-of-cost-variations-knee-and-hip-replacement-surgeries-the-us 2. BPCI Advanced. Retrieved June 1, 2019, from https://innovation.cms.gov/initiatives/BPCI-Advanced/ 3. Bundled Payments. Retrieved June 1, 2019, from https://accelerohealth.com/bundled-payments/4. Clinical Practice Guideline Manual. Retrieved June 1, 2019, from https://www.aafp.org/patient-care/clinical-recommendations/cpg-manual.html 5. Comprehensive Care for Joint Replacement Model. (n.d.). Retrieved June 1, 2019, from https://innovation.cms.gov/initiatives/cjr 6. The IHI Triple Aim. Retrieved June 1, 2019, from http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx 7. The Joint Commission DSC Orthopedic. Retrieved June 1, 2019, from https://www.jointcommission.org/certification/dsc_orthopedic.aspx

*Image references included within slides