1. The Role of Home Health and Case Management in Discharge Planning for the Orthopedic and Spine Patient Michele Blanchard, MPT Samar Hireish BSN, ACM-RN

2. Proactively Managing Patient Risk
Ensuring patients are at their best health before surgery.
Engaging patients so they know what to expect before, during and after their hospital stay.
Adopting evidence-based guidelines around patient safety (e.g., infection prevention, rehab protocols)
Identify and intervene on high risk patients

3. Guided CarePaths for Elective Surgery
Total Hip Arthroplasty
Total Knee Arthroplasty
Lumbar Fusion
Cervical Fusion
Total Shoulder Arthroplasty *Coming Soon*
Features:
Patient Education and Engagement
Activate their online Care Pathway
Attend the Pre Op Total Joint Replacement/ Spine Class
Check-ins - pre and post-op
Patient Reported Outcomes

4. Navigating the Patient Journey

5. Navigating the Episode of Care Online Care Path

7. Help Us Plan for Your Discharge
The following questions will assist the discharge planning team to coordinate a safe and timely discharge plan after surgery. Your physician's goal is always to get you home as soon as possible to aid in your recovery. You will receive a call to briefly review this information by a physical therapist. Completing this form helps us plan for your discharge.
Background Information
What is the best time of day for you to be reached? *
What is the best phone number for you to be reached? *
What is your height? *
What is your weight? *
Have you attended the Total Joint Replacement/Spine Surgery Class?*
Do you currently take care of yourself independently? *
Have you had a joint replacement/spine surgery in the past? *
What is the address you will be going to when discharged from the hospital? *
Home Environment
Please provide information regarding your home environment
What type of home do you live in? *
If you live in a Residential Care Facility or Skilled Nursing Facility, please provide name:
Do you have someone that will be able to provide support for you after surgery? *
Functional Status
Are you currently using and/or do you have any of the following equipment at home. (Check all that apply.) *
Walker (2 wheels in the front)
Cane
Wheelchair
Crutches
Oxygen
Shower Chair
Raised Toilet Seat
I do not have or use any of the items above
lease give us some information about your current functional status.

8. Stairs???

9. Caregivers and Equipment

11. Pets???/ Clutter???

12. Prepare Your Home Put away throw rugs.
Move furniture so that you have enough space to move around easily with a walker, crutches or cane.
Put away or tape down electrical cords.
Set up pet care.
To avoid injury, infection and to promote the safety and wellbeing of your pet: Avoid having pets share the space where you are sleeping and resting until after your incision is completely healed.
Ensure adequate lighting to maximize safety.
Plan for a cordless phone or cell phone to be near you at all times.
Have option(s) for non-moving chairs (NO rocking, rolling or swivel chairs).
Use solid chairs with arm rests.
Ensure your toilet seat is secure.
Consider borrowing or purchasing a raised toilet seat if your toilet is low.
Identify narrowest hallways or areas to ensure walker will easily pass through.
Identify the number of stairs required to travel through to complete activities of daily living.
Use nonskid socks or foot wear that has a closed heel.
Consider shoes that fit snug without laces (tying your shoes will be difficult for a while after surgery).
Plan activities so you can take your time. DO NOT rush.
Anything else you feel is important to address for your own safety.
You will want to make arrangements for caregiver support at home. It may be several days to several weeks until you are independent with activities. You will need to have someone available to assist with:
Showering,
Dressing,
Meal preparation and
Driving to appointments

13. Remove loose rugs!!!

15. Transition Care

16. Proactively Managing Patient Risk
Ensuring patients are at their best health before surgery.
Engaging patients so they know what to expect before, during and after their hospital stay.
Adopting evidence-based guidelines around patient safety (e.g., infection prevention, rehab protocols)
Identify and intervene on high risk patients

17. The Benefits of Early Transition Care and Case Management
Alerts CM to any “Red Flags” such as transportation issues, patients without caregivers or patient anxieties regarding home challenges.
Verifies discharge demographics which help reduce any delay in receiving Home Care.
Allows patients to ask questions in regards to going home or living environment.
Assists CM in managing equipment needs such as walkers.

18. Case Management and Transition Care Team promote Center of Excellence Goals
A primary COE goal is “ZERO” avoidable readmissions. CM proactively manages patient risk to effectively reduce readmission rate:
In 2014, 21% of Total Joint Patients were discharged to SNF, Today 12%. The majority go home!
Total Joint Replacement Length of Stay is 1.5 days!

19. Transitions of Care
Patients are provided with a choice of post discharge providers for rehab services (Home Health, SNF, ARU) based on MD orders. However, they are educated about the benefits of staying within the Palomar Health System for continuity of care.
Educated on equipment options for home
Provided with community resources
Rides with Care
Disability Placard through DMV
Meals on Wheels
The key to success is the effective and continuous communication along the continuum of care and includes the patient, surgeon and interdisciplinary team!

20. Final Thoughts…