Table 9.
Period 4: postdischarge rehabilitation and followup care (20 suggestions)
| Processes for providing safe, effective, efficient, and patient- and family-centered care |
| System-level suggestions |
| Postdischarge care providers should follow a standardized pathway for care and rehabilitation, including therapy, wound monitoring, venous thromboembolism prophylaxis, and surgical and medical followup |
| Identify at-risk patients who may need more thorough postdischarge followup to prevent readmission (continued from Period 3b). |
| Develop and follow an anticoagulation protocol, including a dedicated postoperative management team |
| Patient-level suggestions |
| For patients discharged to home health services, arrange home health visit to occur within 24 hours |
| Continue postdischarge communication with patients and family/caregiver, including issues around health and recovery and what went well or could have been improved with the care experience |
| Tips for reducing waste |
| System-level suggestions |
| Consider the value and cost-benefit tradeoffs of different technology and equipment |
| Identify the proper interval for patient followup; use patient-reported outcome measures and assessments from other providers to help determine the frequency of followups |
| Track outcomes and implant life in a joint registry. |
| Patient-level suggestions |
| Use an algorithm with specific criteria to determine discharge readiness for patients admitted to acute rehabilitation, a skilled nursing facility, or home health services |
| Provide continuity of physical therapy between inpatient and outpatient settings |
| Provide patients with transportation options to facilitate access to outpatient care, and reduce the need for skilled nursing or home health services |
| Tips for avoiding communication pitfalls |
| System-level suggestions |
| Develop a contractual arrangement with acute care, skilled nursing facility, home health, and outpatient therapy providers to ensure that standard care and communication protocols are followed |
| Define customer service level and clarify whom the patient or family/caregiver should contact with questions (eg, some settings offer 24/7 telephone access to a surgical care team member) |
| Identify an individual who is responsible for coordinating care among providers (eg, joint program coordinator) |
| Standardize care transition and handoff communication among the hospital staff, surgical care team, and postdischarge care providers; and between the surgical care team and primary care physician for up to 1 year postsurgery (eg, communication checklist and templates, transfer of rehabilitation and medical notes, notice of discharge); include standardized electronic communication between sites, if possible |
| Patient-level suggestions |
| Followup with patient within 24 to 48 hours after hospital discharge, using a communication checklist |
| Consider connecting new patients to experienced patients through written and verbal communication (eg, a “joint buddy”) |
| Document patient and provider goals for physical therapy (eg, range of motion, gait, and desired activities); educate patient and family/caregiver in the process and specific milestones for achieving personal goals; assess delays in reaching goals |
| Ask patients to complete a “journal” that documents progress toward recovery and helps to engage and hold the patient accountable for their recovery |
| Provide patients with a list of frequently asked questions and a guideline of other specific questions that may be appropriate for asking the medical (hospital/primary care physician) or surgical care team |
Note In this Care Pathway, the postdischarge rehabilitation and followup care period lasts for 12 months after the patient is discharged from the hospital following the initial surgery; however, ongoing monitoring typically continues throughout the patient’s life to assess for deterioration of the implant