Patient Perspectives on Transitions from Acute to Community-Based Physiotherapy Care Following Total Knee Replacement Surgery Within the Context of a Bundled Care Model

Abstract

Purpose:

Research on fiscal implications of the bundled care (BC) model exist; however, patient-perceived experiences are less well known. As BC expands in Ontario, this study aims to examine these experiences with physiotherapy care within the total knee replacement (TKR) BC programme.

Methods:

Qualitative cross-sectional study design. Semi-structured one-on-one telephone interviews were conducted with eight patients four to six weeks post-TKR. Thematic analysis was used.

Results:

This exploratory study identified three themes across the care journey that patients perceived as influencing their physiotherapy experiences: timely access to physiotherapy care, quality of physiotherapy care, and patient outcomes. Communication, clinical support, and social support were sub-themes.

Conclusions:

Patients’ overall experiences with BC physiotherapy were positive. Areas for improvement included coordination of postoperative physiotherapy and return-to-work support. Patients valued group settings and were interested in meeting previous TKR patients. Health system planners are advised to consider incorporating patient experiences when evaluating and developing BC programmes to achieve patient-centred outcomes.

Moving between health care settings and providers is known as transitions of care.¹ If poorly executed, patients experience fragmented transitions which can slow their recovery and affect quality of care and patient satisfaction,² and are associated with negative health outcomes and increases in health care costs.³ Understanding barriers to transitions, and incentivizing hospitals to work with community providers to shift care into the community, are important to sustain the health care system in Ontario.⁴

Bundled care (BC) is a service delivery and funding model developed to promote integration in health care delivery, drive high-quality, efficient care, and improve patient outcomes and experiences.⁵ The bundle holder (i.e., hospital) receives a single payment from the government to cover an individual’s care for a specific health issue from acute to post-acute services across a continuum of care.⁵ The bundle holder partners with community providers and develops agreements on fees, data reporting, and incentives to ensure each patient receives the care they need in their individual health care journey.⁶ The landscape of BC implementation continues to change as hospitals optimize their execution of BC.

The increasing volumes and associated costs of TKR significantly impact Ontario’s health care system.⁷ In 2018, 33 Ontario hospitals piloted the BC model with primary unilateral TKR.⁸ The Ministry of Health (MOH)^8,9 determined that TKR was suitable for BC because best practice guidelines, which facilitate optimal recovery based on evidence and clinical consensus, were available. These guidelines also helped inform TKR service delivery models in Ontario. In the fiscal year 2019–2020, full-scale implementation was adopted in all hospitals that perform TKR surgeries.⁵

Evidence shows BC leads to cost containment and system improvement¹⁰;however, knowledge about patient experiences with this BC model is limited. Several studies identified issues of communication and clinical support for patients transitioning from acute care to community-based physiotherapy,^11,12 but they do not discuss nor compare different funding and delivery models’ impact on patient experiences.

This study explored patient experiences with BC following unilateral TKR as patients transitioned from acute care to community-based physiotherapy postoperatively. Community-based postoperative physiotherapy includes settings such as hospital outpatient clinics, community-based clinics, and home care. Transitions to acute care in-patient physiotherapy and to rehabilitation hospital in-patient physiotherapy were not the focus in this study.

Methods

Study design

This cross-sectional study used a qualitative descriptive methodology to explore patient experiences in transitioning from acute care to community-based physiotherapy following a primary, unilateral TKR under the BC programme at St. Michael’s Hospital (SMH), a large urban tertiary care centre. SMH is a university affiliated teaching hospital in Ontario that sees large volumes of joint replacement surgeries. We obtained ethics approval from the Research Ethics Board (REB) of the hospital and the University of Toronto.

Inclusion criteria and patient recruitment

The target population was adults aged 18 and older who had undergone a primary, unilateral TKR performed by the same surgeon. Restricting recruitment to one surgeon ensured patients received similar care and instructions. We used a purposive sampling technique to recruit potential patients at the preadmission appointment. Primary means the first knee replacement performed on that knee. Participants also had to 1) have transitioned from acute care to community-based physiotherapy after discharge from the hospital, 2) be included in the BC programme at the time of their preoperative assessment, and 3) speak, read, and understand English.

The research team aimed to obtain a mixed representation of age, sex, geographical location, access to extended health benefits, employment status, and type of community-based physiotherapy. However, due to a limited patient pool, time constraints of the research team, and suspension of further research by the hospital’s REB due to the COVID-19 pandemic, achieving diversity was difficult. The recruitment process is detailed in online Appendix 1. In-patient physiotherapists approached eligible participants at their preoperative visit to inform them of the research opportunity. At the postoperative visit, the advanced practice physiotherapist (APP) determined participants’ continued interest, allowing researchers to then contact participants to answer questions, obtain verbal informed consent, and schedule a date/time for the interview. Verbal informed consent was confirmed again at time of interview.

Data collection

Researchers conducted pilot interviews with physiotherapists to ensure the interview guide (online Appendix 2) was clear, captured research objectives, and was delivered consistently between interviewers. The guide included demographic data, and further sections were organized according to the recovery pathway: discharge from hospital, entry into physiotherapy, duration of physiotherapy care, completion of physiotherapy, and outcomes of physiotherapy treatment. There were also probing questions related to information/communication and patient outcomes, experiences, and needs. The interview guide aided discussion. A semi-structured interview style enabled deeper discussion to better capture patients’ experiences. We collected data via audio-recorded, semi-structured telephone interviews in a private room at the hospital by one interviewer and one note taker. Three members of the team took on different roles in a rotation. Interviews were 25–45 minutes long. After each interview, the interviewer and note taker reflected on participants’ responses and recorded their initial thoughts. The remaining researchers transcribed the audio files verbatim, de-identified participant names using numerical code, and removed other identifiers from the transcript such as demographic data and names. The responsible interviewer checked the transcripts for accuracy.

Data analysis

We used an inductive thematic analysis and semantic coding approach, guided by Braun and Clarke’s six steps on thematic analysis.¹³ A team member with extensive qualitative research experience led the team in coding the first interview and developing the preliminary codebook. Six researchers then independently coded two or three transcripts each. Those who coded the same transcripts met in pairs to resolve coding discrepancies and to reach a consensus. Four to six researchers coded each transcript several times.

The coded transcripts were uploaded to NVivo version 12 (QSR International, Doncaster, Australia). The researchers then met as a group, discussed all the interviews, and finalized the codebook. Individual codes, such as miscommunication or transportation, were analyzed for themes across the dataset using the study’s purpose statement and objectives as a guide. The themes were checked and revised to ensure the codes were clearly and accurately represented. A thematic map was developed to portray how they fit into larger themes across the dataset. We considered the analysis complete when themes were clearly supported by quotes. Theoretical saturation was reached for the major themes of this paper. Codes and themes were refined throughout the analysis process.

Results

Eight participants, three men and five women, were interviewed. Their age range was 48 to 88 years old (Table 1). Two participants (P2, P7) had multiple transitions between acute and community-based physiotherapy which the researchers had not accounted for. Although the interview guide did not explicitly ask about discharge to in-patient rehabilitation, the decision to discharge to this setting after participants were initially considered for community-based physiotherapy could not be controlled. To include these participants’ transition experience, their data were retained in the study. P8 opted for private physiotherapy services outside of the BC program so only their transition from hospital to home, and not the experience of community-based physiotherapy, was analyzed. The hospital’s standard TKR recovery pathway is provided in online Appendix 3. All participants were interviewed four to six weeks postoperation. The structure of physiotherapy sessions is included (online Appendix 4).

Table 1.

Participant Demographics

ID	Age, y	Sex	Employment status	Postoperative physiotherapy chosen by participants	Days to first community-based physiotherapy appointment
P1	65	M	Full-time	Hospital outpatient clinic	7
P2	88	M	Retired	In-patient physiotherapy → bundled care home care physiotherapy	2
P3	48	F	Unemployed	Hospital outpatient clinic	7
P4	76	F	Retired	Hospital outpatient clinic	6
P5	57	M	Full-time	Community-based clinic	5–7
P6	71	F	Retired	Community-based clinic	18
P7	74	F	Retired	In-patient physiotherapy	N/A
P8	72	F	Retired	Private home care	10

Through content analysis, four main themes were identified: timely access to physiotherapy care, patient outcomes, quality of physiotherapy care, and patient recommendations (Figure 1). Sub-themes were communication, clinical support, and social support. These sub-themes were found to influence both access to, and quality of, physiotherapy care, which affected patient outcomes and recommendations.

Figure 1.

Patient perceptions on primary unilateral total knee replacement under the bundled care programme.

Timely access to physiotherapy care

This was defined as the participant’s perceived ability to access physiotherapy to their satisfaction, from acute to community-based physiotherapy. Most accessed care within one week (online Appendix 5). In general, all participants felt they were able to access the right level of care and felt supported throughout their journey, apart from P7 who said they “fell through the cracks.” P7, after returning home from a week of in-patient rehabilitation post-operation, had been waiting for five weeks to hear back from their community-based physiotherapy referral. P6 waited 18 days before attending their first community-based appointment.

Communication

Almost all participants played an active role in deciding where they would receive their postoperative physiotherapy. P4 requested a community-based physiotherapy provider that was not on the bundle holder’s list. P4 had attended that location for rehabilitation for a prior surgery, and it was close to home: “the [surgical] hospital was familiar with that [clinic] … they [surgical hospital] set it all up for me and [hospital outpatient physiotherapy clinic] were very welcoming.”

Arranging community-based physiotherapy during the preoperative visit or prior to surgery appears to have facilitated access to care for several participants. P1, who accessed a hospital outpatient clinic one-week post-operation, remembered that the outpatient clinic called as soon as the surgery date was confirmed.

On the other hand, lack of communication and coordination hindered access to care. P6 experienced a delay due to incorrect paperwork: “I had a form that the doctor gave me before surgery but [community-based physiotherapy clinic] wanted something that said bundled care on it so it took about a week or so for me to get it set up.” P6 later recalled their delay was 18 days, not a week, before their first community appointment.

P3 recounted how they were told the hospital would arrange the referral on their behalf, and to wait for the hospital outpatient clinic to contact them. P3 received no response so they called the clinic and learned that their contact information had not been attached to the referral. Afterwards, P3 was able to book and attend their first community appointment seven days postoperation.

P7 described another case of miscommunication between the in-patient and outpatient providers: “The physiotherapist at [in-patient hospital] was supposed to have put in an application for me to go for the follow-up physiotherapy at [hospital outpatient physiotherapy clinic] but I haven’t heard anything.”

Clinical support

Hospital physiotherapists provided information about accessing postoperative physiotherapy to patients during preoperative meetings. Multiple participants reported receiving and discussing with the hospital physiotherapists the lists of clinics within the BC programme, as well as receiving education about their care pathway. Five participants reported their rehabilitation plan was set during this meeting. The location of postoperative physiotherapy that patients chose determined how the community-based postoperative physiotherapy was booked (Table 1). The hospital utilized an internal referral system to book participants attending hospital in-patient and hospital outpatient physiotherapy. Community-based clinics required participants to book directly with the clinic, and to bring a hospital-provided BC referral form so the clinic could bill the physiotherapy sessions appropriately.

Social support

Many participants relied extensively on caregiver support to access care. P3 spoke of how the presence of family influenced their readiness for discharge: “I probably would have been hesitant if I was alone but I had support [partner] with me.” P7 described their family as a facilitator in getting them access to the right level of care (in-patient rehabilitation) despite the hospital team’s encouragement to be discharged home to receive outpatient physiotherapy:

I had no clue that I was going to be able to go to [in-patient hospital] or not until I was at the hospital because there was no firm confirmation until my daughter stepped up to the plate and said our mother needs to go to [in-patient hospital] because she lives alone …. So it was because my daughter pushed for it that I was accepted into the programme. It was very frustrating.

Most participants who attended community-based physiotherapy relied on family for transportation. Alternative plans included public or private transportation (e.g., Uber, taxi). P1 described being approved for a municipal programme that provides accessible transit for persons with physical disabilities. Conversely, P6 described having difficulty accessing this same programme due to living outside the catchment area and having to rely on private transportation.

Quality of physiotherapy care

This was defined as participants’ perceptions of their experience with physiotherapy in both the acute and community settings. Most patients had an overall positive impression of their physiotherapy care and acknowledged its critical role in recovery. P7 explained: “you realize how vital [physiotherapy] is to the whole process of improving your mobility and you have to be really determined to be able to do it.” Common factors that impacted their perceived quality of care were grouped into sub-themes of communication, clinical support, and social support.

Communication

Three participants indicated that different providers gave an appropriate level of communication and transfer of participant information between each other. P2 expressed a positive impression: “They certainly seemed to be [prepared]. I felt they knew me. I wasn’t an unknown factor for them.” Four participants were not certain whether there was appropriate communication, saying most information about them and their surgery had been provided by themselves through questionnaires and their initial assessments. P3 did not believe the hospital providers communicated well with the community providers regarding hardware limitations. At their four-week postoperative follow-up with the hospital, they learned they might have been “maximizing the mechanical limitation of [the] hardware in [their] leg” during rehabilitation. P3 reported this limitation was not communicated to the community outpatient clinic and wished they “were better informed about the procedures done to [their] leg.”

Clinical support

In the acute setting, five participants said they received adequate care from the hospital physiotherapists, who provided them with exercises, education on pain management, and assessed their readiness for discharge. P5 reported appreciation for their hospital physiotherapist for facilitating access to more appropriate pain medication postoperatively. Some patients reported more equivocal experiences about the quality of service they received while in acute care. When asked if they were satisfied with the level of support provided by the hospital physiotherapist, P3 responded:

I guess so. They have a lot of clients that they have to take care of so I know they just want to check off their list … they’re rushed, they have a lot of people to tend to … If you seem like you’re okay, you’re going to be out the door as soon as they can get you out the door. I get that. That’s fine.

In the community-based setting, where one-to-one or group physiotherapy was provided depending on patient needs, participants reported their physiotherapist was supportive, encouraging, and helped build their confidence, allowing them to have positive recovery outcomes. P1 appreciated how the exercise setting allowed immediate correction of mistakes, further range-of-motion gains, and access to exercise equipment.

Social support

Family and/or friend support was integral to all participants as they relied on them to assist and prepare them for the surgical process, improve their readiness for discharge, and enable a positive transition experience. Participants also expressed that others in their group-based community physiotherapy sessions were sources of information about pain control, physical function, and encouragement. P3 said: “it’s a nice way to get [out] of your [residence], and have an outing, … have some resources of talking to people who are in the same boat as you are.” P2, who received home-based physiotherapy, received support from a friend who kept them motivated to do their exercises.

Patient outcomes

This was defined as how participants perceived their progress throughout their care journey and their current functional status at the time of the interview. The majority of participants felt positive about their progress, and reported moving around easily, improving well, or feeling they would reach their functional goals by the end of their physiotherapy care. However, some sought supplemental therapy.

Three participants planned to return to work, two of which sought supplemental therapy. P1 reported making plans post-physiotherapy to help them return to their fast-paced workplace:

I go to the YMCA right now. Two or three times a week … And then when my physiotherapy is over, I will be having a personal trainer … To basically allow me to strengthen my knee … which I believe is necessary for me.

P3 sought additional non-bundle-funded supplemental therapy from different health care providers to support their recovery. They did not state it was to support their return to work. They explained that these health care providers were familiar with their body and could compare how it had responded to the TKR, and provided additional exercises:

For example, when you take a step up, use your core. You don’t get that in group [physiotherapy]. They just make sure you’re executing your exercises as per the paperwork … how you’re executing that is not necessarily that important for them as long as it’s being executed.

P5 reported interest in supplemental therapy but did not make any appointments. P5 did not express concern about their recovery process and returning to work. They did comment on how their employer was supportive in helping them return to work.

Patient recommendations

Many participants provided recommendations to improve the transitional experience, such as providing stairs training before returning home even if there are no stairs at home. Another was to provide the appropriate referral forms at discharge to ensure outpatient appointments could be scheduled right away. Participants also expressed the need for more information on the availability of community-based physiotherapy and the status of their applications following discharge from in-patient care. Improving the sharing of key clinical information about patients between hospital and community-based physiotherapy providers (e.g., hardware range-of-motion limitations) was also important. Participants also suggested more frequent community-based physiotherapy appointments would benefit their recovery, explaining that a greater total number of sessions would provide extra encouragement, confirmation of correct exercise form, and improved access to equipment. Finally, patients would also have liked opportunities to connect with past TKR patients to gain insight into the recovery process and relate through shared experiences.

Discussion

Participants’ overall experiences transitioning from acute care to community-based physiotherapy post-TKR in the BC programme were positive. Some findings were similar to previous research, such as the desire to communicate with past TKR patients to gain insight into the recovery process, and valuing group-based community physiotherapy for its social support.¹⁴

This highlights the importance of providing TKA patients opportunities to engage with previous and current TKA patients.

Participants identified challenges along their journey. One participant did not follow the hospital’s typical discharge, and was having a problematic experience undergoing multiple transitions. At time of interview, they were waiting for their outpatient physiotherapy referral after a prolonged in-patient stay. Little research is available about the experiences of patients undergoing multiple transitions post-TKR. Qualitative research on patient experiences transitioning from hospital to outpatient physiotherapy clinics post-TKR typically examines time to access therapy, impact of physiotherapy, unmet expectations postoperatively and informal support.^14,16 Patients transitioning from in-patient to home care in Corrigan’s thesis found 77.8% of them especially needed family/ friend support.¹⁵ However, it was not noted whether these patients went on to participate in outpatient physiotherapy clinics after home care. Best practice guidelines for TKR encourage practitioners to monitor patients who were discharged to home care to have adequate follow up in case a referral to community physiotherapy is needed to meet functional goals.⁹ Further research into which populations likely require multiple transitions and their subsequent experiences may guide programme design and influence funding.

Communication in scheduling postoperative physiotherapy was challenging for this current study’s participants. Other studies also reported challenges securing postoperative physiotherapy, such as needing to advocate for themselves¹⁴ or “chase” their referral.¹⁶ Finnish health care practitioners in fast-track TKR reported that real-time referral status technology would benefit practitioners and patients.¹⁷ Electronic communication methods should also be integrated between health care settings¹⁷ as it could support the sharing of pertinent clinical patient information across the health care system that is so encouraged in the BC policies.⁶ Our data concur and highlight opportunities for better integrated transfer of information through electronic communication between care settings and to patients and caregivers, as well as communication processes for community-based physiotherapy clinics that are not formally part of the BC models.

Some participants in this study were returning to work and sought private, supplemental therapy. The majority of TKR patients in Ontario are retired. Only 35.7% of TKR patients in 2018–2019 were younger than retirement age.¹⁸ Returning to work is a highly individualized process. Two systematic reviews found that successful and fast return to work (RTW) depended on sex, being self-employed, positive motivation, working in an accessible workplace, high urgency to return, high job qualifications, limited sick leave, and compensation.^19,20 Facilitators included necessity, rehabilitation, and job flexibility.²¹ TKR best practice guidelines include patient and family member education around “return to work/sport”⁹ without much detail, inviting variability depending on the health care professionals’ experience and knowledge. In the UK, patients reported receiving little information and advice on RTW.²¹ The current study’s findings suggest the BC model is not as inclusive of the variety of rehabilitation needed by patients to achieve outcomes meaningful to them. Options for RTW programming can include asking relevant questions at the preoperative assessment and planning process. Patients with high work demands and limited access to work adjustments and tools should be referred for work rehabilitation assistance.²² Having employers support RTW by changing the work environment and/or roles, revising duties and hours, and having colleague support can be significant.^21,23

Study importance and contribution

This study provides insight into patient experiences transitioning from hospital to community-based physiotherapy clinics post-TKR within a BC programme in Ontario. Participants reported gaps in care that are not captured by current metrics collected by BC and the Canadian Institute for Health Information (CIHI) and should be discussed by health system planners and hospital programme administrators to better reflect patient-centred care.

Future research directions

Further investigations in BC can examine patient experiences in non-urban settings, transitions through multiple care settings, returning to work, and provider experiences. The type of agreement between bundle holders and community-based physiotherapy providers (e.g., ad hoc arrangements, standing/formal agreements) and how that affects communication processes could also be researched. A comprehensive sex-based analysis could also be investigated.

Our study has several limitations. Patients had difficulty differentiating between physiotherapists and physiotherapist assistants, potentially impacting their perception of the experience. During recruitment, patients’ decisions to participate in the study may have been influenced by the potential that the in-patient physiotherapists, who informed patients of the study, could be involved in their care. Only English speakers were included in an urban hospital that serves a very multicultural population, many of whom do not speak English proficiently. This study was limited to a tertiary care centre that performs large volumes of TKR, meaning the staff are well experienced in treating TKRs. This hospital’s policies and procedures may not reflect those of other hospitals within the same city or in rural areas and so this study’s findings would not be generalizable. Return to work (RTW) was an incidental finding and the interview guide unfortunately was not equipped to further explore this topic. Only three participants’ data could be used to exame RTW, and data saturation was not reached.

Conclusion

Our research contributes to understanding patient experiences within the TKR BC programme provided by an urban Ontario hospital. Through qualitative methodology, this study revealed aspects of the TKR recovery journey that were important to participants. Familiar findings were the benefit of peer support and the opportunity to optimize electronic communication. Other findings include challenges surrounding multiple transitions post-TKR and returning to work. The BC programme collects quantitative data to improve system factors and programme efficiencies, but future metrics need to include consistent collection of data about the patient experience. Opportunities exist for health system planners and hospital programme administrators to engage in discussions that incorporate patient experiences into the evaluation and development of the BC model to optimize efficiency and achieve outcomes that centre around patients and what is meaningful to them.

Transparency declaration

The lead author affirms that this manuscript is an honest, accurate, and transparent account of the study being reported. No important aspects of the study have been omitted and discrepancies from the study as planned have been explained.

Key Messages

What is already known

Input from participants undergoing TKR report support and communication were key to determining their experiences of transitional care.

What this study adds

Coordinating postoperative physiotherapy, including multiple transitions, communicating between providers, and return to work were areas of concern. These concerns are not well captured by current metrics collected by BC and should be considered by health system planners to better reflect patient-centred care.