CASE MANAGEMENT |
the early 1980ís the hospital length of stay for a patient
undergoing a total hip or total knee surgery was fourteen
days. Length of stay for patients having revision surgery
was even longer. Insurance companies usually paid in full
for these hospitalizations, and as hospital costs continued
to mount, it became apparent that changes in hospital insurance
and patient care policies were necessary. With physical therapy,
occupational therapy, dressing changes, and other treatments
being available in either the patientís home or an outpatient
setting, the push to reduce hospital length of stay intensified.
response to this, the Division of Arthritis Surgery, under
the direction of David S. Hungerford, M.D., initiated in 1989
the position of orthopaedic nurse coordinator. Functioning
as a patient advocate and providing patient education were
the primary goals of the nurse coordinator. Established to
assist the patient, hospital, and physician, this position
became the model for the development of the case management
program, which was instituted hospital-wide several years
later. Within the first two years of beginning our program,
the length of stay for our total joint patients had been decreased
to 8 days hospital stay. More importantly, this decrease in
hospital stay was made while maintaining optimum patient care.
Today, the length of hospital stay for patients having joint
surgery is four days. Case management continues to play an
active role in assisting the patient, hospital and physician
to achieve the most efficient and beneficial care possible.
Currently, the case management department is hospital-wide
and is composed of thirty staff members including social workers,
R.N. case managers, and utilization review personnel.
goals of case management are to:
the highest level of patient care in the most cost-effective
coordination and efficiency of the patientís surgical
experience- pre-operatively, during hospitalization,
and after discharge.
the patient with the proper monitoring needed post-operatively
to assure optimum care in the hospital.
in establishing any services needed in transferring
the patient from an inpatient care status to an outpatient
(home) care status.
proper follow-up of the patient during the post-discharge
phase, detect any problems, and treat those problems
you have scheduled surgery with one of our physicians, you
will have a case manager who will follow your case pre-operatively,
during your hospitalization, and after you are discharged
PRE-OPERATIVE PHASE IS ONE IN WHICH THE EMPHASIS IS PLACED
ON PLANNING, EDUCATION, AND CAREFUL ESTABLISHMENT OF A CONTACT
PERSON TO ASSIST THE PATIENT IN ALL ASPECTS OF HIS/HER CARE.
contact with the case manager occurs at the time of scheduling
surgery or by telephone prior to admission. The purpose
of this contact is to assess the patientís functional status,
home environment, and available assistance. In addition,
a brief medical and surgical history, a listing of medications,
and demographic information is obtained. By conducting the
pre-operative interview, the patient is introduced to a
contact person for himself and family members. Any questions,
problems, or concerns can then be brought to the case managerís
attention throughout the pre-operative phase. If any need
for referrals to social services, a rehabilitation facility,
or home care are identified during this time, they can either
be initiated or noted for reference when the patient is
admitted to the hospital. In addition, the pre-operative
phase includes inviting and encouraging the patient and
family members to attend a pre-operative class concerning
total joint surgery. These classes are held weekly and alternate
between discussion of total hip and total
knee surgeries. Pre-op Class
HOSPITALIZATION PHASE EMPHASIS IS PLACE ON MAINTAINING AND
ADJUSTING THE PRE-OPERATIVE DISCHARGE PLANS AND PROVIDING
ACCESS TO HOME CARE NEEDS IN A SAFE AND TIMELY
this phase, the case manager follows the patient and reviews
the prior to discharge planning with the patient, physician,
and other hospital personnel. Any adjustments to the original
plan or referrals to other areas are then made. The case
manager will be overseeing the discharge plans and coordinating
any post discharge services required by physical therapy,
nursing, or other home care programs. It is also during
this phase of interaction that the patient is given instructions
regarding scheduling follow-up appointments and the reporting
of post-discharge problems directly to the case manager.
appointments and signs and sypmtoms to report post-op.
DURING THE POST DISCHARGE PHASE IS PLACED ON FOLLOW-UP CARE,
MAINTAINING CONTACT, AND EARLY INTERVESTION IN THE EVENT
OF ANY POST DISCHARGE PROBLEMS.
case manager contacts each of our patients within 48-72
hours after discharge. The patient is contacted for the
purpose of evaluating his/her status and adjustment to home.
Specific questions are asked to assess progress, assistance,
pain levels, wound status, and physical therapy instructions.
If any problems are identified, the case manager either
resolves them or refers them for physician instructions.
The case manager also reinforces with the patient previous
discharge instructions and the importance of reporting any
problems or questions regarding the post-discharge period.
It is during this time that the case manager also verifies
or assists the patient in making their first follow-up appointment
and maintains further patient care by doing so.
Division of Arthritis Surgery has been and will continue
to be committed to improving the efficiency and coordination
of the orthopaedic patientsí care from the outpatient setting
to the hospital and back to the home environment. It is
our belief that through the case manager/patient relationship
these goals can be achieved safely, effectively, and in
a timely manner.