Comprehensive Joint Replacement Therapeutic Approaches: Leading the Way as Clinicians, Care Managers, and Colleagues

Transcription

1 Comprehensive Joint Replacement Therapeutic Approaches: Leading the Way as Clinicians, Care Managers, and Colleagues Greg Young, PT, OCS Senior Director of Rehab Infinity Rehab

2 My Background Joint replacement rehab experience in the acute care, SNF, outpatient, and home health settings CJR videos, protocol collaboration and contribution to CEU 360 course Infinity Leadership Academy Class of 2016 Home Health Partnerships both sides of that coin

3 What does recent literature say about post joint replacement therapeutic settings, approaches, and outcomes?

4 Recent Evidence for TKR Predicting Poor Physical Performance after Total Knee Arthroplasty. Bade et al. J Orthopaedic Research, Nov 2012 Restoration of Physical Function in Patients Following Total Knee Arthroplasty: An Update on Rehabilitation Practices. Bade & Stevens-Lapsley. Colorado Rheumatology, March 2012

5 Recent Evidence for TKR Predicting Functional Performance and Range of Motion Outcomes After Total Knee Arthroplasty Bade, et al. Am J Phys Med Rehabil, May 2015 Weight-Bearing Asymmetry During Sit-Stand Transitions Related to Impairment and Functional Mobility After Total Knee Arthroplasty Christiansen, et al. Arch Phys Med Rehabil, Aug 2015

6 Bade, et al. Individuals with times of 10.1 s or longer on the TUG and aged 72 years or older before surgery had the poorest performance on the TUG 6 months after surgery. Individuals walking <314 meters on the 6MW test before surgery had the poorest performance on the 6MW test 6 months after surgery. Individuals taking 17 s to complete the stair climbing test and scoring <40 on the SF-36 mental component score before surgery had the poorest performance on the SCT 6 months after surgery.

7 Bade & Lapsley NMES applied to the surgical limb s quadriceps muscle for the first 6 weeks following surgery, has been shown to improve the speed of recovery from TKA and leads to long-term increases in strength and functional performance. Rehabilitation programs that incorporate higher intensity, progressive resistive exercises that target all major muscle groups of the lower extremity have demonstrated superior long-term strength and functional gains compared with lower intensity programs. There is emerging evidence that strength and functional gains can be made after the acute postoperative recovery period with programs focusing on the use of progressive aquatic exercise or eccentric exercise.

8 Bade, et al. For discharge planning in the acute setting, preoperative ROM and functional performance should ideally be used to identify patients who may require close monitoring or intensive rehabilitation. If preoperative measures are not available, acute postoperative performance on the TUG test can be useful for establishing a prognosis. Acute postoperative ROM measurements have very limited prognostic utility.

9 Christiansen, et al. Patients showed WB asymmetry during sit-stand transitions at 1 and 3 months after TKA, which improved by 6 months after surgery. Greater amounts of WB asymmetry correlated with poorer functional performance up to 6 months after TKA. WB asymmetry also was associated with quadriceps strength asymmetry through 6 months after surgery. As a whole, these findings suggest that WB asymmetry during tasks such as sit-stand transitions is an important impairment to consider when attempting to optimize rehabilitation and improve functional performance for people after TKA.

10 Clinical Practice Considerations Form What is/are your target muscle(s)? Hip flexion example Seated hip abduction versus exercise example Posture and Center of Mass Quadriceps, Gluteals, Hamstrings

11 Considerations Recovery time: between sets/activities and session to session (considering BID and 7 day/week schedules) Mixing up content i.e. muscle confusion, super setting

12 Considerations (cont d) Intensity Borg Scale (RPE), Vitals 1 Rep Max Alternative measures Joint Protection

13 Considerations (cont d) Potential Complications: IT Band Friction Syndrome Greater Trochanter Avulsion Hamstring Tendonitis

14 Infinity Rehab CJR Protocol Review of Phase 1 Protocol Exercises and Considerations

15 Infinity Rehab CJR Protocol Review of Phase 2 Protocol Exercises and Considerations

16 CJR Video Clips Here, we will view and discuss several video clips of protocol exercises and activities. Opportunity to work in pairs to reinforce keen observational and instructional habits for clinicians.

17 CEU 360 Course Title: Comprehensive Care for Joint Replacement Model You get 1.0 credits Take back to your team members

18 Leading the Way: Innovation not Emulation (sound familiar?)

19 The Five Practices of Exemplary Leadership Model the Way Inspire a Shared Vision Challenge the Process Enable Others to Act Encourage the Heart

20 In to the Community Hospital Partnerships Upstream downstream, aligning with Home Health Ortho navigators, tracking forms Evaluation at Hospital? Credentialing challenges

21 Downstream Home Health Partnerships Optimal HH at St Paul Very low NTUC rate Grand Rounds Pulse Reports Centura Health at Home New Colorado Partnership Future - In to the Community

22 Home Health Where the Action is? Study: Effect of Inpatient Rehabilitation vs a Monitored Home- Based Program on Mobility in Patients With Total Knee Arthroplasty; The HIHO Randomized Clinical Trial Buhagiar, et al. JAMA, March 2017

23 Buhagiar, et al. Main outcome measure of mobility at 26weeks after surgery was measured with the 6-minute walk test. Secondary outcomes included: Oxford Knee Score, which ranges from 0 (worst) to 48 (best) and has a minimal clinically important difference of 5 points. EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) visual analog scale, which ranges from 0 (worst) to 100 (best), and has a minimal clinically important difference of 23 points.

24 Buhagiar, et al. Among the 165 randomized participants, 68%were women, and the mean age was 66.9 years (SD, 8.4 years). There was no significant difference in the 6-minute walk test between the inpatient rehabilitation and either of the 2 home program groups, nor in patient-reported pain and function (Oxford knee score), or quality of life (EQ-5D visual analog scale). The number of post-discharge complications for the inpatient group was 12 vs 9 among the home group, and there were no adverse events reported that were a result of trial participation.

25 Buhagiar, et al. They Conclude: Among adults undergoing uncomplicated total knee arthroplasty, the use of inpatient rehabilitation compared with a monitored home-based program did not improve mobility at 26 weeks after surgery. These findings do not support inpatient rehabilitation for this group of patients.

26 The Even Bigger Picture: Savings, Costs, Demographics and Access to Care

27 CMS Savings in the First Year of CJR - Orthopedics Cost of a Home Health Episode Cost of SNF stay Cost of Outpatient-only Rehab

28 Hospital Participation in Bundled Payment Program Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payment and Quality Outcomes for Lower Extremity Joint Replacement Episodes Dummit, et al. JAMA, Feb 2017 Findings: In the first 21 months of the BPCI initiative, Medicare payments declined more for lower extremity joint replacement episodes provided in BPCI-participating hospitals than for those provided in comparison hospitals, without a significant change in quality outcomes.

29 Dummit, et al. For hospitals participating in the BPCI initiative, mean Medicare payments for the hospitalization and 90-day post discharge period were $30,551 during the baseline period and decreased to $27,265 during the intervention. In the comparison hospitals, mean episode payments were $ at baseline and decreased to $ during the intervention period. Payments declined $1166 more in the BPCI hospitals than in the comparison group. Almost all of the reduction in spending was from reduced use of institutional post-acute care.

30 Demographic Considerations The CMS Comprehensive Care Model and Racial Disparity in Joint Replacement Ibrahim, et al. Viewpoint article, JAMA, Feb 2017

31 New Developments in ACOs Provides an Accountable Care Organization opportunity for small practices: The new Medicare ACO Track 1+ Model will have more limited downside risk than Tracks 2 or 3 of the Medicare Shared Savings Program in order to encourage more practices, especially small practices, to advance to performancebased risk.

32 Up next: Cardiac & Hip Fracture Bundles New for 2017: Improve cardiac care: Three new payment models will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery. Improve orthopedic care: One new payment model will support clinicians in providing care to patients who receive surgery after a hip fracture, other than hip replacement. In addition, CMS is finalizing updates to the Comprehensive Care for Joint Replacement Model, which began in April 2016.

33 Thank you! Questions? Ready to go out and lead? Thoughts on future any crystal ball predictions?