Same-Day Joint Replacements

 Bundles / Financing 
 Care Coordination 

Home Nursing Agency, Altoona, Pennsylvania.
Agency Description:
Since 1968, Home Nursing Agency has been the largest post-acute provider of services between Pittsburgh and Harrisburg, Pennsylvania, specializing in home health, hospice, behavioral health, private duty, pediatric care, and a host of additional community-based waiver services.
Population Impacted:
A target group of patients in west central Pennsylvania with low co-morbidities under the age of 65 requiring a hip or knee placement. 
Strategic Partners:
In this program, the strategic partner was University Orthopedics Group. This group provided all surgery services, including the surgeons, support staff, and anesthesiology. In addition, Highmark Blue Cross Blue Shield (BCBS) of western Pennsylvania was a funder in this project.
Project Description:
The avatar program is embedded on a tablet given to each patient enrolled in the study. The avatar provides the patient with an overview of what to expect before, during, and after the surgery. Most importantly, this program teaches the patient signs, symptoms, and self-care techniques to recover from surgery. The patient is provided with techniques to change dressings, handle pain management, and what to expect following physical therapy appointments. 
The program has had positive clinical and financial results. Clinically, patients had a quicker recovery time and quicker range of motion (ROM) response. This led to a savings of approximately half the costs (about $15,000 per patient served) as compared to an in-patient DRG payment. This is an estimate based on what the hospital would have received as a DRG payment as compared to what the orthopedics group and Home Nursing Agency received for these services. Highmark BCBS has set a date for bundled payment compensation, however, the savings sought by Home Nursing Agency are being realized outside the bundled payment model. It is expected that when Highmark BCBS begins paying under the bundled payment pilot, quality outcomes will be part of the incentive portion of the payment. 
Outcome Measures:
No patients were readmitted to the hospital for knee-related issues during this episodic coverage period. There were no emergency room visits nor were there any unscheduled visits with the orthopedic physician group. Furthermore, no patients in the program reported complications. 
Barriers to Implementation:
There were very few barriers to the success of this project, namely because this was an independent setting with University Orthopedics Group. Digital avatars were used to reinforce patient education both before the joint replacement and after surgery regarding recovery expectations. The avatars were supported by mobile tablets and used by patients throughout the duration of the care episode.