Hip and Knee Replacements - GTA Rehab Network · Guiding Principles ... Hospital or Private/Public...

Hip and Knee Replacements

Standardized Rehabilitation

Treatment Approaches

across the Continuum of Care

February 2014

3

Table of Contents

Acknowledgements ................................................................................................................. 4

Abbreviations and Definitions ................................................................................................... 5

Background & Introduction ....................................................................................................... 6

Guiding Principles ................................................................................................................... 7

Hip and Knee Replacement: Rehabilitation Pathway .................................................................. 8

Hip/Knee Joint Replacement Standard Rehabilitation Approaches .............................................. 9

Conservative Management Phase ................................................................................... 9

Pre-habilitation Phase .................................................................................................. 11

Inpatient Surgery Phase ............................................................................................... 14

Inpatient Rehabilitation Phase ....................................................................................... 17

Outpatient Rehabilitation – Hospital or Private/Public Physiotherapy Clinics ...................... 20

Community In–Home Rehabilitation Phase .................................................................... 23

Appendix A: Clinical Outcome Measures ................................................................................. 26

Appendix B: Champlain LHIN Orthopedic Physiotherapy Discharge Communication Report ........ 30

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Acknowledgements

This document is the result of extensive

consultation and collaboration with individuals

from the Champlain LHIN region who work in

organizations across the continuum of care and

have joint replacement knowledge and experience.

These organizations include:

Carleton Place & District Memorial Hospital

Champlain Community Care Access Centre

Champlain Orthopedic Program Planning

Initiative

Cornwall Community Hospital

Kemptville District Hospital

Montfort Hospital

Ontario Physiotherapy Association

Pembroke Regional Hospital

Queensway-Carleton Hospital

Rehabilitation Network of Champlain

The Arthritis Society

The Cochrane Collaboration

The Ottawa Hospital

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Abbreviations and Definitions

List of Abbreviations:

ADL: Activities of Daily Living

BBS (BERG): Berg Balance Scale

CCAC: Community Care Access Centre

COPPI: Champlain Orthopedic Program Planning

Initiative

CPM: Continuous Passive Motion

IM: Functional Independence Measure

IADL: Instrumental Activities of Daily Living

LEFS: Lower Extremity Functional Status

LHIN: Local Health Integration Network

LOS: Length of stay

M-HAQ: Modified Health Assessment

Questionnaire

MMSE : Mini Mental State Examination

MOCA : Montreal Cognitive Assessment

NRS: Numerical Rating Scale

OQS: Orthopaedic Quality Scorecard

RM&R: Resource Matching and Referral

RNOC: Rehabilitation Network of Champlain

ROM: Range of Motion

THR: Total Hip Replacement

TINETTI: Tinetti Balance Assessment Tool

TJAC: Total Joint Assessment Clinic

TKR: Total Knee Replacement

TUG: Timed Up and Go

VAS: Visual Analog Scale

WOMAC: Western Ontario and McMaster

Universities Osteoarthritis Index

Definitions:

Wait 1a: time from referral from primary care

provider to assessment at a Total Joint Assessment

Clinic

Wait 1b: time from assessment at a joint

assessment clinic to surgeon consultation

Wait 2: time from decision to treat (surgery) to

surgery date

Conservative Management is the episode of care

appropriate for patients with confirmed or suspected

hip or knee arthritis whose symptoms may be

managed non-surgically. This phase involves

individual and/or group evaluation and treatment.

Cryotherapy (or cold therapy) involves the

application of very low temperatures to the skin

surrounding an injury or surgical site. This can be

by means of bags of ice or specialized devices that

deliver cooled water to the area1.

Pre-habilitation is a program provided to assess

the client’s baseline functional capabilities and

safety, to provide patient education and self-

management, to maximize the client’s potential

recovering from surgery, and to optimize the

discharge process.

1 The Cochrane Collaboration. 2012. Cryotherapy following

total knee replacement (Review).

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Background & Introduction

The Champlain LHIN recognizes that the

development of a regional approach to service

delivery can make a significant contribution to

certain patient populations and as such, has focused

on sectors of the system that have the potential to

make the biggest impact.

Orthopedic care is a high volume, high cost service

that crosses multiple sectors - thereby providing

significant opportunities for system improvement.

More than 4000 hip and knee replacements are

completed annually in the Champlain LHIN at six

different acute care sites.

The rehabilitation associated with these procedures

is provided in a variety of settings and locations

throughout the LHIN. Patients who are candidates

for a hip or knee replacement typically are referred

by their primary care provider to the Regional Hip

and Knee Program via the Central Intake Clinic.

Referrals are triaged by Central Intake staff and

assigned to the appropriate Total Joint Assessment

Clinic, based on geography or patient choice. The

patient is assessed by a physiotherapist or advanced

practice nurse to determine surgical candidacy.

Education and information is provided during the

assessment.

Conservative management options are provided. If

surgery is the treatment of choice, the patient is

referred to a surgeon according to patient

preference, geographical area or wait time.

Conservative management patients are referred to

The Arthritis Society and surgical patients are

booked for a consultation with a surgeon.

Once the decision for surgery has been made by the

surgeon and patient, the patient is booked for the

pre-habilitation phase of rehabilitation during which

the patient and family receive education, an

exercise regimen, and support to prepare for

surgery.

Once surgery has been performed the patient

recovers for 2-4 days from the acute stage on a

surgical inpatient unit where post-operative

rehabilitation is provided.

On discharge from the surgical unit, the patient

proceeds to rehabilitation either in an inpatient

rehabilitation unit, in a hospital-based outpatient

clinic, in a community based outpatient clinic or is

discharged home with rehabilitation treatment

provided by CCAC.

Standardized rehabilitation treatment approaches

for hip/knee replacement patients have been

developed for the following rehabilitation phases:

conservative management, pre-habilitation, acute

care post-operative rehabilitation, inpatient

rehabilitation, outpatient rehabilitation and

community rehabilitation.

The guidelines in this document are a result of

regional collaboration that were first developed in

2005, updated in 2008 and again in 2014 under the

direction of the Champlain Regional Orthopedic

Program and the Rehabilitation Network of

Champlain.

These standardized guidelines are intended as a tool

for practitioners to ensure rehabilitation for hip &

knee replacement patients is high quality, accessible

and efficient.

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Guiding Principles

The rehabilitation standard approaches/guidelines

for each phase of care will:

Be patient centered

Be based on current Champlain LHIN

Rehabilitation for Hip/Knee Replacement

Framework

Be broad enough to address 80% of patients

Identify and address the rehabilitation needs of

the remaining 20%

Incorporate the following goals: access,

quality, and efficiency

Be evidenced based where there is available

evidence or based on the advice/consensus of

expert panels/practitioners

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Hip and Knee Replacement: Rehabilitation Pathway

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Hip/Knee Joint Replacement Standard Rehabilitation Approaches

Conservative Management Phase

Definition:

Episode of care suitable for patients with confirmed or suspected hip or knee arthritis whose symptoms may be managed

non-surgically. This phase involves individual evaluation and individual/group treatment.

Goal:

To provide education and exercise prescription for the purpose of symptom self-management/maintenance or improvement

of function.

In some cases early referral to a conservative management program may postpone or divert the need for surgery.

Criteria for Referral Patients with confirmed or suspected hip or knee arthritis

Referral sources may include Family Physician, Total Joint Assessment Clinic or Self-Referral

Services Provided Service may be provided by a physiotherapist, occupational therapist, rehabilitation aide,

kinesiologist or chiropractor and may be provided in different settings such as private/publicly-

funded physiotherapy clinics, The Arthritis Society, or Family Health Team setting.

Assessment and Screening

Initial assessment and screening is provided on an individual basis and includes:

Medical and joint history including pain level

Physical examination including gait speed, range of motion, strength, flexibility, muscle

imbalances, joint stability, balance, proprioception, functional activity

The assessor may make recommendation for appropriate care to family physician for referral to:

TJAC for surgical appropriateness

Rheumatologist or Sports Medicine for conservative medical management

CCAC for in-home services or home assessment

Other program e.g. for bracing and /or assistive devices,

Specialized community programs (e.g. geriatric day program)

GP, pharmacist regarding medication use

Other health care practitioners e.g. Psychologist, social worker

Treatment

Exercises for range of motion, strengthening, flexibility, balance, proprioception and functional

training

General Education

Principles of healthy lifestyles and active living are incorporated in the program. This may include

providing resources or referrals to available community resources (pool programs, falls program,

Arthritis Society, Eat Right Ontario)

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Education on the following topics should be provided:

Low impact fitness alternatives (swimming, cycling)

Pacing strategies

Gait aids, bracing, assistive devices, proper footwear

Use of heat/ice

Importance of weight control

Hurt vs. harm

Typical Duration Duration and frequency: variable and is patient-specific

Discharge Criteria Patient demonstrates knowledge and tolerance of prescribed exercises

Patient has been provided with self-management strategies

Appropriate referrals to other disciplines/programs have been completed

Performance

Indicators: Clinical

and Non-Clinical

Outcome Indicators

Clinical Outcome Indicators (Quality)

Patient Self Report Outcome Measures (pre and post):

WOMAC

LEFS * (recommended)

VAS or NRS *(recommended)

M-HAQ

Patient Satisfaction

Clinical Objective Outcome Measures (pre and post):

Gait Speed (3 vs. 4 meter test)

range of motion

strength

flexibility

balance (BBS or TINETTI)

functional activity (TUG, Stairs)

cognition (MOCA, MMSE)

Non-clinical Indicators (Access)

access to publicly funded conservative management program (Target: 2 - 4wks)

Non-clinical Indicators (Efficiency)

number of visits per episode of care (Target: 2-8 visits)* short term focused on teaching

self-management

*Recommendation – no standard available in literature

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Pre-habilitation Phase

Definition:

Pre-habilitation phase is defined as the period between the decision for surgery and the date of surgery.

Goal:

To assess the client’s baseline functional capabilities and safety, to provide patient education and self-management, to

maximize the client’s potential recovering from surgery, and to optimize the discharge process

Pre-habilitation includes the following elements:

An assessment/screening of the home environment for equipment and safety needs;

Education and the demonstration of exercises.

Screening for core issues which may delay recovery or timely hospital discharge

Expectation/goal setting for the pre-habilitation phase

Criteria for Referral All patients booked for hip/knee (primary or revision) are automatically referred for pre-habilitation

The referral is made as soon as consent for surgery is signed

Services Provided The pre-habilitation program is provided by a physiotherapist and/or an occupational therapist.

Additional disciplines are added as required and available eg. pharmacist, dietitian, nurse.


Complete the hospital specific pre-habilitation tool to establish the bench-mark for client progress

and achievement of functional outcomes.

Screen to identify:

1. barriers to discharge home

2. potential post-op or discharge issues

General Education

Education on the following topics is provided:

the surgical procedure and hospital stay

precautions and joint protection post-operatively, energy conservation and pain

management techniques

assistive devices and home equipment required for the post-operative period; resources

and supply options available

demonstration of standardized exercises specific to THR and TKR with a home program

of exercises to be continued either at a gym facility or at home.

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A client/patient information package is provided to standardize and consolidate information, to

facilitate communication for the client and health care providers, and to foster a sense of client

participation in outcomes achieved.

Goal setting and expectations are reviewed and documented.

Typical Duration Pre-habilitation takes place after decision for surgery is made and is provided in two components

one of which is in a group education format and the second component is individual based.

Component 1: 1 – 2 hour group session by a multidisciplinary team (up to 30 clients)

Component 2: 1:1 with Physiotherapist or Occupational Therapist or Social Worker

Key Activities Key Components: Total Hip or Knee Replacement

Key Activities:

General education about joint replacement surgery

Patient role and responsibility explained

Hospital specific THR or TKR clinical pathway explanation

Specific equipment requirements reviewed

Individual patient assessment completed

Instruction of exercise program for appropriate joint replacement

Pain management techniques, importance of joint protection reviewed

Lower Extremity Function Scale tool filled in by patient

List of contacts at hospital, hospital specific processes

Home care, convalescent and short term inpatient rehabilitation needs identified

Discussion & education re: equipment requirements and importance of procuring the

equipment emphasized

Home environment questionnaire completed

Review joint protection precautions

ADL assessment

MMSE as required

Outcomes:

Patient understands the type of surgery and pathways for their specific joint replacement

Patient understands their role and responsibility in the process and as part of the team.

Patient understands pain management and joint protection

Patient receives instruction in joint replacement specific exercises and understand the

need to practice these exercises before surgery

Potential post-operative rehabilitation needs identified and providers alerted

Equipment, home management, home environment plans are discussed and patient’s

individual plan for care is initiated and discussed as needed

Cognitive status evaluated as indicated

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Discharge Criteria Patient attended program

Performance


and Non-Clinical

Outcome Indicators


Patient Self Report Outcome Measures:

WOMAC



Patient Satisfaction

Clinical Objective Outcome Measures :

range of motion* (recommended)

strength* (recommended)

functional activity (TUG, Stairs)


Non-Clinical Indicators (Access)

% of patients first joint specific surgery participation in pre-habilitation (Access) Target: 95%*

Non-Clinical Performance Indicators (Efficiency)

None


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Inpatient Surgery Phase

Definition:

Episode of rehabilitative care associated with the immediate post-operative period ranging from day of surgery until

discharge from acute surgical care.

Goal:

To optimize patient’s capacity which will allow the patient to be discharged to the most appropriate care setting by:

assisting patient to mobilize post operatively

reinforcing post-operative exercise regimen

preparing patient for discharge by assessing knowledge and confirming that safety needs are addressed,

ensuring that a longer term rehabilitation plan is in place post hospital discharge

Criteria for Referral All patients undergoing hip or knee replacement (partial or total/primary or revision) will receive

post-operative rehabilitation. Each patient will have identifiable rehabilitative goals according to the

clinical pathway.

Services Provided Assessment and Screening:

standard physiotherapy assessment for post-operative care

focused assessment to determine breadth of deficits and intensity of rehabilitation required

assessment of function and ADL management with appropriate intervention as required

assess for barriers to discharge (review Pre-habilitation Assessment)

confirm equipment for discharge is in place/ready

Treatment:

Activity:

By post-operative day 1:

Patient is up in chair, is up to ambulate with assistance and mobility aid

ROM exercises and strengthening exercises have begun (For Knee Replacements, CPM is

at the discretion of Physiotherapy for exceptional cases only)2

Cryotherapy is used at the discretion of the physiotherapist3

By discharge day (Day 0, 1, 2 or 3 dependent on type of surgery):

Patient is safely mobilizing and transferring with aids as required (no specific walking

distance)

Patient is safe to ambulate on stairs if required at home

2 Mac JC, Fransen M, Jennings M, March L, Mittal R, Harris IA. Evidence-based review for patients undergoing elective hip and knee

replacement. ANZ J Surg. 2013 Mar 15. doi: 10.111/ans.12109. (Epub ahead of print); Waddell, JP, Frank C, Editors. Hip and knee

replacement surgery toolkit. Bone and Joint Canada; 2009 April 30 (coted 2013). Available from:

http://www.gov.pe.ca/photos/original/BJ_toolkit.pdf

3 Adie S, Kwan A, Naylor JM, Harris IA, Mittal R. (2012) Cryotherapy following total knee replacement (Review). The Cochrane

Collaboration. The Cochrane Library 2012, Issue

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Exercise and General Education:

review post-operative exercises, progression of exercise program and related education

review home safety precautions

Hip Replacement – hip precaution education reviewed

Discharge Planning

An Orthopedic Physiotherapy Discharge Communication Report (Appendix B) is completed and

forwarded to service provider if patient is discharged to a provider other than the hospital where the

surgery was performed (e.g. CCAC, Private Clinic)

Ensure “key contacts” for post discharge are provided

Typical Duration Initiation: Therapy provided by rehabilitation professional is initiated post-operative Day 1.

Rehabilitation activities are supplemented by other members of the team (e.g. Nursing).

Duration: Target LOS is 2 – 3 days if patient is expected to move to inpatient rehabilitation unit and

1-3 days if patient is expected to return home

Frequency: Frequency of therapy post-operatively varies, but at a minimum, staffing levels should

be sufficient to support provision of therapy at least once per day

Discharge Criteria Criteria for discharge home:

Patient ambulates and transfers safely with mobility devices

Patient able to do stairs if needed

Home exercise/education program has been provided to patient and/or caregiver

Rehabilitation plan in place (Outpatient, CCAC)

If criteria for discharge not met, consider alternate levels of care e.g. Convalescent care,

Inpatient Rehabilitation Unit.

Performance


and Non-Clinical

Outcome Indicators




Satisfaction Survey *(recommended)

Clinical Objective Outcome Measures :

range of motion* (recommended)

strength * (recommended)

functional activity (TUG, Stairs) * (Stairs assessment is recommended if needed)

Non-Clinical Indicators (Quality)

Readmission Rates (within 30 days) Target: <3.1 % (provincial average - no target)**

Non-Clinical Indicators (Efficiency)

LOS acute care Target: 3 days (Local) Source: OQS

4.4 days (Provincial)

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% Discharged Home - Target: 90% (provincial) Source: OQS


**Based on the provincial average reported on Orthopedic Quality Scorecard – changes quarterly

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Inpatient Rehabilitation Phase

Definition:

Episode of rehabilitative care provided by a rehabilitation team on a mixed or dedicated population Rehabilitation Unit in

acute care or rehabilitation hospitals. This level of rehabilitation is suitable for patients in need of an interprofessional

rehabilitation program who also cannot be safely discharged home.

Inpatient rehabilitation should not be the first choice for the typical patient with a primary, elective total hip or knee

replacement. It is expected that no more than 10% of hip/knee replacement patients will require inpatient rehabilitation4

(OQS)

Goal:

To optimize the patient’s capacity which will allow discharge to the most appropriate care setting by:

Assisting the patient to mobilize post operatively

reinforcing post-operative exercise regimen

preparing the patient for discharge by assessing knowledge and confirming that safety needs are addressed

ensuring that a longer term rehabilitation plan is in place post discharge

Criteria for Referral Unsafe for discharge to a home environment and has the potential to improve functional status

Patients will not be excluded from admission on the basis of a mild/moderate cognitive impairment.

Services Provided Assessment and Screening

Assessment and development of an individualized therapy plan (1:1 or group setting)

Assessment of functional outcome status (Functional Independence Measure - FIM) on

admission and at discharge to document progress and guide treatment selection

Treatment

Rehab services are provided 5 days per week at a minimum.

Frequency of therapy (Occupational and/or Physiotherapy) varies but at a minimum, staffing levels

should be sufficient to support provision of therapy at least twice per day. Rehabilitation activities are

supplemented by other members of the team (e.g. Nursing).

Therapeutic interventions include:

Exercises for ROM and strength, including home exercises

Functional training (e.g. gait, stairs, balance, transfers) including any applicable precautions

Activities of Daily Living (ADL)/Instrumental Activities of Daily Living (IADL) assessment

and training

4 Orthopedic Quality Scorecard. Released quarterly by Ministry of Health and Long Term Care

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General Education

Principles of healthy lifestyles and active living are included in the rehabilitation program. This may

include providing resources or referrals to external programs (eg. Arthritis Society)

There is a mechanism to assess the patient’s learning needs. Education on all of the following topics

is available and reviewed with patient/family as appropriate:

Caregiver training

Safe activity resumption

Mobility

Expected progress

Discharge Planning

Review therapy goals, treatment expectations and discharge criteria with client

Referral to outpatient or community service as needed when patient is ready for discharge.

Complete the Orthopedic Physiotherapy Discharge Communication Report (Appendix B) if the

patient is discharged to any provider other than the hospital where surgery was performed.

Typical Duration Average length of stay is typically 2 weeks (range of 7 – 21 days) however the length of stay is not

constrained by a maximum duration but is guided by patient need and goals of rehabilitation.

Discharge Criteria Criteria for discharge home:

Ambulates and transfers safely with mobility devices

Able to do stairs if needed

Able to perform safe/supported ADLs with or without assistive devices

Home exercise/education program has been provided to patient and/or caregiver

Rehabilitation plan in place (Outpatient, Community)

If criteria for discharge not met, consider alternate levels of care.

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Performance


and Non-Clinical

Outcome

Indicators




WOMAC

Satisfaction Survey

Clinical Objective Outcome Measures:

range of motion *(recommended)

strength *(recommended)

balance (BERG or TINETTI)

functional activity (Gait Speed)

functional activity (TUG, Stairs) *(recommended)

functional activity (FIM) (mandatory)



% admitted from acute care Target: 10% or less**

Wait time for admission from acute care Target: 1 – 2 days ***

(Administrative) Performance Indicators (Efficiency)

Average Length of Stay Target: 14 days***


**Orthopedic Quality Scorecard

***Local Target set by consensus Ortho-Rehab Working Group

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Outpatient Rehabilitation – Hospital or Private/Public Physiotherapy Clinics

Definition:

Episode of care suitable for individuals who are in need of an outpatient rehabilitation service in a single specialty

area/profession. Services include assessment and treatment. Treatment may be provided in group or individual format.

Goal:

To optimize patient’s functional capacity in order to maximize normal function.

Criteria for Referral Patients reside in the community and have been discharged either from an acute surgery unit, an

inpatient rehabilitation unit, another outpatient rehabilitation program or from a community in-home

rehabilitation program

Referral from a physician for hospital outpatient clinic (majority of hospital outpatient clinics accept

referrals from physicians with privileges in that hospital only)

Able to get to the clinic

Able to actively participate either independently or with support (eg. family member)

Services Provided

Assessments and treatment are focused on patient safety at home as well as physical and functional

abilities necessary for daily activities

Treatment is provided by a combination of physiotherapist and rehabilitation assistant for group

sessions; group size is dependent on space & staffing but typically group size ranges between 5 and

15 clients. Knee post discharge rehabilitation is most efficiently provided in a group setting.


initial focused assessment is 1:1 with a physiotherapist to determine breadth of deficits and

intensity of rehabilitation required

assessment of function and ADL management with appropriate intervention as required

assessment for and development of individualized therapy plans (eg. 1:1 or group settings)

Treatment

exercises for ROM and strength, including home exercises

functional training (eg. gait, stairs, balance, transfers) including home exercises

hands on therapy as required

pain management

General Education

Principles of healthy lifestyles and active living are incorporated in the rehabilitation program. This

may include providing resources or referrals to external programs

There is a mechanism in place to assess the patient’s learning needs. Education on all of the

following topics is available:

Caregiver training


Mobility and precautions if applicable

Expected progress

Sources of help

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Discharge Planning

Review therapy goals, treatment expectations and discharge criteria with client

Communication to Orthopedic Surgeon only as needed.

Typical Duration KNEE REPLACEMENT

Initiation: Treatment begins in a timely manner for all patients based on individual needs.

Specifically, treatment for patients referred from acute care should begin within 2 weeks*** of acute

care discharge.

Duration: The typical duration is 5-6 weeks

Frequency: Up to twice per week for a full knee replacement and once per week for a partial knee

replacement.

HIP REPLACEMENT

Initiation: Treatment begins in a timely manner for all patients based on individual needs.

Specifically, treatment for patients referred from acute care should begin at the 3 week mark for

assessment and review/progression of home exercise program.

Duration: The typical duration is 4-6 weeks after initial assessment.

Frequency: Frequency of treatment depends on achievement of goals, typically no more than once

per week.


Discharge Criteria

Functional active ROM (consider pre-op status and lifestyle)

Extension 0 degrees (hip); 0-5 degrees (knee)

Flexion minimum 90 degrees (hip); 110 degrees (knee)

Functional Strength (consider pre-op status and lifestyle)

Hip: Grade 4/5 hip flexion and extension

Grade 3/5 hip abduction

Knee: Grade 4/5 or functional control of the knee

Independent ambulation (indoors and outdoors, with/without ambulation aid as required –

consider pre-op status)

Safe transfers as required (home, vehicle)

Safe use of stairs if required

Swelling resolved or self-managed; wound healed or self-managed; pain self-managed

with/without medications

Long-term equipment needs identified; vendors, funding and safe use understood

Patients are discharged when they have achieved their discharge goals or they have reached a

plateau (showing no improvement for 2 weeks) rather than based on a maximum number of visits.

If client’s personal goals exceed the program goals above, a home exercise program or referral to a

private clinic may be arranged.

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Performance

Indicators Clinical

and Non-Clinical

Outcome

Indicators



WOMAC



M-HAQ

Satisfaction Survey




functional activity (TUG, GAIT)

functional activity (Stairs) *(recommended)

balance (TINETTI or BERG)


Wait time to access publicly funded outpatient rehabilitation program Target: 2 weeks (knees)***

3 weeks (hips)***

Non-Clinical Indicators (Efficiency)

Number of Visits per patient Target: 10-12 visits (full knee replacement)***

6 - 8 visits (partial knee replacement)***

6 – 8 visits (hip replacement)***



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Community In–Home Rehabilitation Phase

Definition:

Episode of care suitable for individuals who are in need of rehabilitation service by a Physiotherapist and/or Occupational

Therapist but are unable to access (temporarily or permanently) an outpatient clinic setting. Services include assessment

and treatment. Services may be provided during a one time visit or multiple visits. Treatment is usually in an individual

format but could be in group format. Service is provided in the home by Community Care Access providers.

Goal:

To optimize patient’s functional capacity by providing treatment until the patient is able to access therapy in an outpatient

setting or has attained discharge goals.

Criteria for Referral Patients reside in the community and have been discharged either from an acute surgery unit or an

inpatient rehabilitation unit

Patients are unable to access outpatient services because of co-morbidities, medical status, social

supports, or non-availability of outpatient resources within local area (eg. excessive travel distance –

greater than 30 minutes)

Referrals are accepted from any healthcare professional

Services Provided Assessments and treatment are focused on patient safety at home as well as physical and functional

abilities necessary for daily activities

A mechanism is in place to refer for further medical management and/or rehabilitation services as

needed

Service is provided by physiotherapist; other disciplines such as Occupational Therapist are added

as required


focused assessment to determine breadth of deficits and intensity of rehabilitation required

assessment of function and ADL management and fall risk with appropriate intervention as

required

assessment for and development of individualized therapy plan

Treatment

home exercise program for ROM and strength

functional training (e.g. gait, stairs, balance, transfers)

hands on therapy as required

pain management

General Education

Principles of healthy lifestyles and active living are incorporated in the rehabilitation program. This

may include providing resources or referrals to external programs

Reinforcement of the benefits of ongoing independent participation in exercise

24

There is a mechanism in place to assess the patient’s learning needs. Education on all of the

following topics is available:

Caregiver training


Mobility and precautions if applicable

Expected progress

Discharge Planning

Communication to attending physician is established if required because of complications or lack of

progress

Referral to outpatient physiotherapy as needed when patient is ready for discharge from community

program; copy of original medical referral plus a new Orthopedic Physiotherapy Discharge

Communication Report (Appendix A) must be completed and sent to provider

Typical Duration Initiation:

Patient care as defined by delivery of direct services by PT and/or OT (NOT including CCAC Care

Coordinator assessment or equipment delivery) should be started within 1 week of discharge. High

risk patients should be identified as per normal hospital process for earlier initiation of service.

Duration:

Knee Replacement: the typical maximum duration of therapy is 8 – 12 weeks if patient is unable to

access outpatient clinic.

Hip Replacement: the typical maximum duration of therapy is 12 weeks if patient is unable to access

outpatient clinic

Frequency:

Typical number of visits is once per week for both hip and knee patients

Discharge Criteria Patients are discharged when they are able to access appropriate community resources (eg.

outpatient services) or have achieved their discharge outcome (functional goals) or they have

reached a plateau (showing no improvement in 2 weeks) in any of the following conditions (strength,

range of motion, pain or swelling) rather than based on a maximum number of visits

If the patient’s in-home community rehabilitation is temporary, the discharge criteria is:

Patient is able to get in and out of home and vehicle safely to attend outpatient clinic

If the patient’s entire post-acute rehabilitation is provided in the community in a home

environment, the discharge criteria are:

1. Functional active ROM (consider pre-op status and lifestyle)

Extension 0 degrees (hip); 0-5 degrees (knee)

Flexion minimum 90 degrees (hip); 90-110 degrees (knee)

2. Functional Strength (consider pre-op status and lifestyle)

Grade 4/5 hip flexion and extension

Grade 3/5 hip abduction OR

Grade 4/5 or functional control of the knee

25

3. Independent ambulation (indoors and outdoors, with/without ambulation aid as required –

consider pre-op status)

4. Safe transfers as required (home, vehicle)

5. Safe use of stairs if required

6. Swelling resolved or self-managed; wound healed or self-managed; pain self-managed

with/without medications

7. Long-term equipment needs identified; vendors, funding and safe use understood

If patient’s personal goals exceed the program goals above, a home exercise program or referral to

a private in-home or outpatient clinic may be arranged.

Performance


and Non-Clinical

Outcome

Indicators



WOMAC



M-HAQ

Satisfaction Survey




functional activity (GAIT)

functional activity (TUG, Stairs) *(recommended)

balance (BERG or TINETTI)


Non-Clinical Indicators (Access and Efficiency)

Wait time to access Community in-home physiotherapy: Target: 1 week or less***

Length of Time receiving CCAC Therapy: (days/weeks): Target: 12 weeks or less***

Readmission Rates (within 30 days) Target: <3.1 % (provincial average - no target)**



26

Appendix A: Clinical Outcome Measures

Outcome Tool Acronym Description of Tool

Rehabilitation Phase appropriate for Use of Tool

√ = Appropriate for use

R = Recommended for use

TJAC Cons

Mgmt

Pre-

hab

Inpt

Acute

Inpt

Rehab

Outpt Comm

BERG BALANCE

SCALE

BBS Measures Balance and functional mobility

(Objective performance measure)

√ √ √

FUNCTIONAL

INDEPENDENCE

MEASURE

FIM Provides a uniform system of measurement for disability

based on the International Classification of Impairment,

Disabilities and Handicaps ; measures the level of a

patient’s disability and indicates how much assistance is

required for the individual to carry out activities of daily

living. Contains 18 items composed of 13 motor tasks and 5

cognitive tasks. Scores range from 18 (lowest) to 126

(highest). Scores generally rated at admission & discharge5

√

(manda

ted by

MoH)

GAIT SPEED

TESTING

GAIT Measures walking speed as an indicator of functional ability;

in conjunction with other measures can be predictive;

examples include 4 Meter Walk Test


√ √ √ √

Lower Extremity

Functional Scale

LEFS The LEFS is a self-report questionnaire. Patients answer the

question "Today, do you or would you have any difficulty at

all with:" in regards to twenty different activities. Patients

select an answer from the following scale for each activity

listed:

√ √/R √/R √/R √/R

5 Rehab Measures: Functional Independence Measure. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=889

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TJAC Cons

Mgmt

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hab

Inpt

Acute

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Outpt Comm

0. Extreme Difficulty or Unable to Perform Activity

Quite a Bit of Difficulty

Moderate Difficulty

A Little Bit of Difficulty

No Difficulty

The patient's score is tallied at the bottom of the page. The

maximum possible score is 80 points, indicating very high

function. The minimum possible score is 0 points, indicating

very low function.6

(self-report outcome measure)

Modified Health

Assessment

Questionnaire

M-HAQ The Health Assessment Questionnaire (HAQ) is one of the

most widely used self-assessment instruments for

measuring functional disability in patients. The HAQ is a

generic questionnaire in the sense that it does not

differentiate between disability caused by arthritis and that

caused by other disease conditions.7


√ √ √

MINI MENTAL

STATE

EXAMINATION

MMSE The Mini-Mental State Examination (MMSE) is a 10-minute

bedside measure of impaired thinking. The summed score

of the individual items indicates the current severity of

√ √ √ √

6 www.physio-pedia.com/Lower_Extremity_Functional_Scale 7 Krishnan, E., Sokka, T., Häkkinen, A., Hubert, H. and Hannonen, P. (2004), Normative values for the Health Assessment Questionnaire Disability Index: Benchmarking disability in the general

population. Arthritis & Rheumatism, 50: 953–960. doi: 10.1002/art.20048

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cognitive impairment.

Deterioration in cognition is indicated by decreasing scores

of repeated tests8

MONTREAL

COGNITIVE

ASSESSMENT

MOCA The MoCA is a brief cognitive screening tool with high

sensitivity and specificity for detecting MCI as currently

conceptualized in patients performing in the normal range

on the MMSE.9

√ √ √ √

NUMERICAL

RATING SCALE

OR

NRS The Numeric Rating Scale (NRS-11) is an 11–point scale for

patient self-reporting of pain. It is for adults and children 10

years old or older


√/R √/R √/R √/R √/R √/R √/R

VISUAL ANALOG

TOOL FOR PAIN

VAS The visual analog scale (VAS) is a tool used to measure

pain10 (self-report outcome measure)

√/R √/R √/R √/R √/R √/R √/R

PATIENT

SATISFACTION

SURVEY

Specific questionnaire according to organization √ √ √ √ √ √ √

8 Principles and Practice of Geriatric Psychiatry. Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. Blazer. Copyright & 2002 John Wiley & Sons Ltd

Print ISBN 0-471-98197-4 Online ISBN 0-470-84641-0

9 Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L. and Chertkow, H. (2005), The Montreal Cognitive Assessment, MoCA: A Brief

Screening Tool For Mild Cognitive Impairment. Journal of the American Geriatrics Society, 53: 695–699. doi: 10.1111/j.1532-5415.2005.53221.x

10 Myles, Paul S. MBBS, MPH, MD, FFARCSI, FANZCA; Troedel, Sally MBBS; Boquest, Michael MBBS; Reeves, Mark MBBS. The Pain Visual Analog Scale: Is It Linear or Nonlinear?

Anesthesia & Analgesia:

December 1999 - Volume 89 - Issue 6 - p 1517 doi: 10.1213/00000539-199912000-00038

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TINETTI BALANCE

ASSESSMENT

TOOL 11

TINETTI A falls risk index for elderly patients based on number of

chronic disabilities; one section measures balance sitting

and standing and is scored out of 16; a second section

measures GAIT at usual speed and at a rapid pace and is

scored out of 12. Risk of Fall: ≤18 = high risk, 19-23 =

moderate risk, ≥24 low risk


√ √ √ √

TIMED UP AND GO TUG The TUG measures limited aspects of balance and

therefore, risk of falls; has been used to measure

responsiveness to change in patients who receive physical

therapy

Measurement of the time in seconds for a person to rise

from sitting from a standard arm chair, walk 3 meters , turn,

walk back to the chair, and sit down. The person uses

regular and customary walk aid.12


√ √ √ √ √ √

Western Ontario

and McMaster

Universities

Osteoarthritis

Index -Physical

function subscale

WOMAC Measures the individual’s perspective of his/her own level of

mobility (licensing fee)

(Self-report outcome measure)

√ √ √ √ √ √

11 Tinetti ME, Williams TF, Mayewski R, Fall Risk Index for elderly patients based on number of chronic disabilities. Am J Med 1986:80:429-434 12 Deborah M Kennedy, Paul W Stratford, Jean Wessel, Jeffrey D Gollish and Dianne Penney . Assessing stability and change of four performance measures: a longitudinal study evaluating

outcome following total hip and knee arthroplasty. BMC Musculoskeletal Disorders 2005, 6:3 doi:10.1186/1471-2474-6-3

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Appendix B: Champlain LHIN Orthopedic Physiotherapy Discharge

Communication Report

(Insert Hospital or

CCAC logo)

ORTHOPEDIC PHYSIOTHERAPY

DISCHARGE COMMUNICATION

REPORT

Client name:

Address:

Date of birth:

Health Card #:

Instructions for use: For use when a patient is discharged from one physiotherapy provider to another

physiotherapy provider (e.g. hospital to CCAC, CCAC to outpatient clinic).

Surgical Procedure:

______________________

Date of Procedure: ___________________ Surgeon Name: ______________________________

Orthopedic Clinic Follow-Up Date: ________________________________

CURRENT STATUS

Weight Bearing Status:

Contra-Indications:

° (___ wks)

st gravity (___ wks)

Transfers and Mobility:

Transfer status (with or without aids):

Ambulation Aids:

Distance: _____________ meters

Comments / Other Functional Information:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

______________________________

Outpatient physiotherapy referral completed: NO YES Location: ________________________________

Signature: __________________________________________ Date: _______________________________

Name (print): _______________________________________ Phone #: _____________________________

Discipline: PT OT RN MD SW Pager # ______________________________

Origin of Report: Champlain Orthopedic Rehabilitation Working Group (May 26, 2014)

Hip and Knee Replacements - GTA Rehab Network · Guiding Principles ... Hospital or Private/Public...

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