MAKING FAST RECOVERY A GAME PATIENTS WANT TO WIN
Providers need to be confident that patients will follow their treatment plans. Once patients leave their practice site, providers have no automated way to monitor the patient’s levels of pain relative to exercises completed, complications, functional status and compliance to recommended exercises. If patients do not follow their treatment plans, providers may be challenged with unsatisfactory patient outcomes.
We interviewed several Physical Therapists (PT) and identified that the hardest part of physical therapy is often that patients simply do not understand the exercises or how to perform them in a nuanced way. Also, many factors are at play in patient adherence to exercise regimens:6
The exercise’s role in overall rehabilitation
The physiotherapist’s “verbal” and “visual” explanation
The quality of physiotherapist’s explanation and patient interaction
The physiotherapist’s reassessment of home exercises and patient satisfaction.
With the wearable device and app, not only were patients able to view their data, but patients received real-time visual coaching via an avatar or likeness of themselves.
Many interviewees spoke to the “Hawthorne Effect.” When we told the story of how the solution brings the know-how and the watchful eyes of the PT and doctor into the patient’s home, patients responded that they felt encouraged, supported and held accountable, particularly when pain levels (VAS) were high. Furthermore, PTs also commented that sensors could save data entry time by automating the capture of vital functional outcomes data used in Hoos, Koos, WOMAC surveys that were required for quality reporting purposes. Also, PTs felt that mobile communications, including telehealth chats could help patients stay motivated and compliant. PT’s felt this form of communication would be effective for patients requiring multiple visits when annual therapy caps were reached. Reactions to the “avatar” likeness of the patient on tablets and real-time visual coaching was favorable; viewed by patients as a way to guide them to correctly perform exercises in their homes without the need for special equipment or large TV screens. The transparency of the data and patient status dashboard meant that patient recoveries could be monitored by the entire health team, including updates to the Orthopedist before a post-operative visit. As star players with coaches watching over them at any moment, patients were held accountable. The gamified experience coupled with motivational check-ins and encouragement led patients and PT’s alike to respond with “who wouldn’t want to play to impress?”. The most significant motivation was for patients to see and experience tangible progress, reinforced by a wearable application, in getting their activities of daily living back in order.
PREPARING FOR SUCCESS: PRE-REHABILITATION AND PATIENT EDUCATION
Benjamin Franklin famously said, "by failing to prepare, you are preparing to fail.” Providers are finding this statement holds true for CJR episodes, particularly when pre-rehabilitation (“Prehab”), can be performed before surgery. Prehab involves patient education, pre-operative PT and home exercise services.
VenAdvisory spoke with organizations that used inter-disciplinary care teams and clinical pathways for TJR. Several organizations also require patient enrollment in education classes before surgery. The classes level set patient expectations effectively and lay out a plan of preparatory activities leading up to and following surgery. The classes also create opportunities to assess patient risk factors before surgery. Several of these organizations were using Prehab, some were not.
Published, peer-reviewed studies show varied results for Prehab.7,8,9 In these instances, it was helpful to review meta-analyses that consider account sample sizes, risk of bias and study quality to weigh the net result of an intervention. A meta-analysis of 21 studies published in Physiotherapy in 2014 concluded that Prehab not only reduced length of stay, pain, complications and improved function, but it reduced cost.8
Resulting post-acute care use
A 2014 study published in the Journal of Bone & Joint Surgery (JBJS)10 found that “the use of preoperative physical therapy was associated with a significant 29 percent reduction in post-acute care use,” including the use of skilled nursing facilities, home health agencies and inpatient rehabilitation. This shows that prehab can and should be a valuable part of a CJR services package. While prehab services can increase costs (they are outside the CJR index event period), they can generate a positive return by reducing post-acute services and create a foundation for successful patient recoveries.
“The ability to see patient functional status before surgery would be key. It would inform the risk assessment with greater confidence in functional status than the patient interview.”
—Orthopedic Service Line Manager, Health System
Keswani, A., et al. Discharge Destination After Total Joint Arthroplasty: An Analysis of Postdischarge Outcomes, Placement Risk Factors, and Recent Trends. Journal of Arthroplasty. June 2016. Volume 31, Issue 6, Pages 1155–1162.
Centers for Medicare & Medicaid Services. Comprehensive Care for Joint Replacement Model. Web. Accessed 1 February 2017.
Alliance for Home Health Quality Innovation, “Distribution of Post-Acute Care under CJR Mode of Lower Extremity Joint Replacements for MS-DRG 470”. 2011-2014 Standard Analytical Files (SAF) Limited Data Set (LDS); 5% and 100% sample of Medicare beneficiaries, All Part A and Part B Care Settings.
Harris Meyer, Replacing joints faster, cheaper and better? Modern Healthcare, June 4, 2016
Yao, Dong-han, et al. Home Discharge After Primary Elective Total Joint Arthroplasty: Post discharge Complication Timing and Risk Factor Analysis. Journal of Arthroplasty. February 2017 Volume 32, Issue 2, Pages 375–380.
Breg. Breg Flex: Mobile Patient Therapy Monitoring for Value Based Care. Results of observational studies of patients. Carlsbad: Breg, 2017. Print.
Wang, Li., et al. Does preoperative rehabilitation for patients planning to undergo joint replacement surgery improve outcomes? A systematic review and meta-analysis of randomized controlled trials. BMJ Open. 2016 Feb 2;6(2): e00985.
D. Santa Mina, et al. analysis. Physiotherapy 100 (2014) 196–207.
Brown K., et al. Prehabilitation and quality of life three months after total knee arthroplasty: a pilot study. Perceptual & Motor Skills. 2012;115(3):765-774.
Snow R., et al. Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement. The Journal of Bone and Joint Surgery. 2014 Oct 1;96(19): e165. Web. Accessed 12 Feb. 2017.
To be continued: This insight is Part 2 in a series of four parts.
A full download of the article will be available at the end of the series.