Implementing Best Practice Rehabilitative Care for Patients with Hip Fracture & Total Joint Replacement
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1 Implementing Best Practice Rehabilitative Care for Patients with Hip Fracture & Total Joint Replacement A Toolkit for Implementing the RCA s TJR and Hip Fracture Best Practice Frameworks January 2018
2 Purpose & Intent of the Best Practice Frameworks 2
3 QBP Clinical Handbooks Clinical handbooks were developed by the MOHLTC and HQO to guide care for hip fracture and primary hip and knee replacement. These handbooks include only high-level recommendations for rehabilitative care. 3
4 HQO Quality Standards HQO also developed a Hip Fracture Quality Standard, published in October The Quality Standard focuses on care delivered from the point of presentation to emergency department until three months following surgery. 4
5 RCA Frameworks The RCA developed detailed Rehabilitative Care Best Practices Frameworks for Patients with Hip Fracture and Total Joint Replacement (TJR) in The Frameworks support implementation of QBPs by establishing guidelines for rehabilitative care, where not already defined in the QBP Clinical Handbooks. The Hip Fracture Framework complements the Hip Fracture Quality Standard by providing a more detailed set of best practices, specific to the rehabilitative phase of care. 5
6 About the Frameworks 6
7 How Frameworks Were Developed The Frameworks were developed by the Hip Fracture and Total Joint Replacement QBP Task and Advisory Groups of the RCA. These groups included representatives from surgical and acute care services, bedded and community rehabilitative care, the Ontario Physiotherapy Association, and regional and provincial home and community care services, including Health Shared Services Ontario (formerly OACCAC) 7
8 Supporting Best Practice Rehabilitative Care The Frameworks detail clinical best practices across bedded and community-based level of rehabilitative care, optimizing both safety and independence/function. They describe the processes and structures required to support delivery of best practice care and to enable optimal patient outcomes and flow by identifying: standardized best practices for hip fracture and primary total joint replacement, in rehabilitative care standardized rehabilitative models of care across bedded & community-based rehab for hip fracture & TJR populations indicators to support performance monitoring of QBP-related outcomes and system performance 8
9 Why Implement the Best Practice Frameworks? 9
10 Improves Outcomes and Patient Experience Why Implement? Quality rehabilitative care is critical to improving outcomes for patients with hip fracture and total joint replacement. Following hip fracture or total joint replacement, high quality multidisciplinary rehabilitation improves functional recovery and quality of life and increases the chances of continued community independence. Best practices continue to evolve. The Frameworks reflect the latest research and are designed to optimize health & functional outcomes and improve patient experience. 10
11 Supports System and Organizational Priorities Why Implement? Supports community care organizations in ensuring they meet evidence-based quality standards for rehabilitation services, as recommended in the MOHLTC s Levels of Care Framework Report Supports implementation of QBPs and bundled care by ensuring rehabilitative care is both effective and efficient Supports continuous quality improvement by identifying practice changes that can improve care and optimize outcomes 11
12 Why Implement? By improving patient outcomes and optimizing patient engagement and education, implementing the Frameworks will support efforts to improve performance on priority Quality Improvement Plan (QIP) indicators, including: i. Doyle, Cathal, Laura Lennox, and Derek Bell. "A systematic review of evidence on the links between patient experience and clinical safety and effectiveness." BMJ open 3.1 (2013): e
13 Tools and Resources for Implementing the Best Practice Frameworks 13
14 Quick Reference Guides 14
15 Quick Reference Guides The Frameworks are large, comprehensive documents which describe detailed clinical best practices for different levels of rehabilitative care, including TJR preoperative care and hip fracture rehab in Long Term Care. The following Quick Reference Guides provide a concise overview of the types of recommendations included in the frameworks, for each level of care. Red notations indicated where detailed information on a particular recommendation or topic can be located in the comprehensive framework. 15
16 Hip Fracture Framework Quick Reference Guides 16
17 Summary of Rehabilitative Care Best Practices Rehabilitative Care Best Practice Framework for Patients with Hip Fracture Quick Reference Bedded Rehabilitative Care Bedded Rehabilitative Care for Patients with Hip Fracture Initiation Duration Frequency Upon admission initiate range of motion, strengthening, mobility and balance activities Target length of stay is days; average length of stay is dependent on patient need Patients should receive daily PT and/or OT, seven days a week Use structured assessments to identify and differentiate between delirium /dementia /depression (3 Ds). Symptoms of the 3 Ds can be superficially similar *8-11 All individuals with a fragility fracture of the hip should be considered at high risk for osteoporotic fractures. Provide exercises, as per BONEFIT principles. *15 Assess transfers and mobility; provide education on the safe use of gait-aids; provide gait and stair training; progress safe mobility & independence with ADLs to improve function and reduce risk for falls; work towards safe, independent discharge. *17-18 Engage patient/family in ongoing communication to review treatment program and discharge plan. Provide patient and family with education on falls risk *19 Evaluate risk of readmission and revise care and discharge plans as required. *19-21 When planning for discharge, educate patient and family that changes in cognition, changes in medication, and reduced physical function can increase the risk of motor vehicle accidents and injury, among older adult drivers. Provide written individualized care and discharge plans to patients primary care provider and other community providers within 24 hours of discharge * Refer to page #(s) indicated, in the RCA Hip Fracture Framework, for more information 17 17
18 Summary of Rehabilitative Care Best Practices Initiation Duration Frequency Rehabilitative Care Best Practice Framework for Patients with Hip Fracture Quick Reference Ambulatory Rehabilitative Care Ambulatory Rehabilitative Care for Patients with Hip Fracture Rehab should commence no later than one week following discharge from the acute-care Duration of care is from 6 weeks to 3 months, averaging 8 weeks, and is dependent on the client s clinical needs Strong evidence supports intensive physiotherapy post discharge, though the optimal frequency of rehabilitative care in the community remains unclear. Use structured assessments to identify and differentiate between delirium /dementia /depression (3 Ds). Symptoms of the 3 Ds can be superficially similar. *22-25 Delirium may still be present at discharge. Caregivers require education on strategies to maintain the person s safety in the home. *22-25 Educate patient /family that changes in cognition, changes in medication, and reduced physical function can increase the risk of motor vehicle accidents and injury, among older adult drivers. Provide exercises, as per BONEFIT principles. Key components of rehab: education on safety/falls prevention; training to improve independence in self-care, transfers, ambulation and ADLs; balance and gait training; provision of a progressive strengthening exercise program, and environmental modifications. *28-30 Clients are discharged from outpatient rehab based on the achievement of goals and evidence from standardized outcome measures. *31 Incorporate principles of healthy lifestyles into the rehabilitation program by providing resources and/or referrals to external programs. Communicate hip fracture precautions, fall risk, and ongoing care plan and client goals with all care providers across the continuum of care. * Refer to page #(s) indicated, in the RCA Hip Fracture Framework, for more information 18 18
19 Summary of Rehabilitative Care Best Practices Rehabilitative Care Best Practice Framework for Patients with Hip Fracture Quick Reference In-Home Rehabilitative Care In-Home Rehabilitative Care for Patients with Hip Fracture Initiation Duration Frequency The first in-home rehabilitative care visit could be as early as 48 hours and should be no later than 5 days. 6 weeks to 3 months, depending on client s clinical needs. Gains are often made over longer periods of time, and clients should be reassessed and rehab extended when appropriate. Average 2-3 times per week, depending on the client s tolerance level and the number of health professionals involved Use structured assessments to identify and differentiate between delirium /dementia /depression (3 Ds). Symptoms of the 3 Ds can be superficially similar. *32-35 Delirium may still be present at discharge. Caregivers require education on strategies to maintain the person s safety in the home. *32-35 Provide exercises, as per BONEFIT principles. Key components of rehab: education on safety /falls prevention; training to improve independence in self-care, transfers, ambulation and ADLs; balance and gait training; provision of a progressive strengthening exercise program, and environmental modifications. *38-40 Incorporate principles of healthy lifestyles into the rehabilitation program by providing resources and/or referrals to external programs. *41 Educate patient /family that changes in cognition, changes in medication, or reduced physical function can increase risk of motor vehicle accidents among older adult drivers Monitor progress and transfer to ambulatory rehab once patient s ability to access services outside the home is no longer limited by their condition. * Refer to page #(s) indicated, in the RCA Hip Fracture Framework, for more information 19 19
20 Summary of Rehabilitative Care Best Practices Rehabilitative Care Best Practice Framework for Patients with Hip Fracture Quick Reference Rehabilitative Care in Long Term Care (LTC) Rehabilitative Care in Long Term Care for Patients with Hip Fracture Initiation The first rehabilitative care visit could be as early as 48 hours and should be no later than 5 days. Duration 6 weeks to 3 months, depending on resident s clinical needs. Moderate evidence supports 6-12 sessions of a 1:1 or individualized group-based functional strengthening program. Frequency Average 2-3 times/week depending on resident s tolerance level. Use structured assessments to identify and differentiate between delirium /dementia /depression (3 Ds). Symptoms of the 3 Ds can be superficially similar. *42-45 Delirium may be identified in the hospital setting, and will often still be present upon discharge to LTC. Educate resident/staff/family regarding identification and prevention of delirium. Contact Physician regarding any acute changes in condition. *42-45 Assess and progress functional abilities, to promote maximum level of function in the long term care setting. Review skills taught in the inpatient setting, to promote safe mobilization in the facility. Assess mobility aids and use within the long term care home environment. Key components of rehab should include: activities to improve independence in self-care, transfers, and ambulation, as per pre-injury level of functioning; balance and gait training; provision of a progressive strengthening exercise program; environmental modification. Consideration should be given to having residents attend ongoing exercise programs to optimize their conditioning for a minimum of 3-6 months post-hip fracture. *50 * Refer to page #(s) indicated, in the RCA Hip Fracture Framework, for more information 20 20
21 Primary Hip & Knee Replacement Quick Reference Guides 21
22 Summary of Best Practice Care Rehabilitative Care Best Practice Framework for Patients with Primary Hip and Knee Replacement Quick Reference Pre-Operative Care Pre-Operative Care for Patients with Primary Hip & Knee Replacement Initiation Assessmet Screen pre-operatively to predict patients post-operative and discharge needs, inform proactive discharge planning, identify potential post-op and/or discharge issues, and to determine whether the patient would benefit from a preoperative in-home provider visit to assess the home environment. A variety of factors including coping skills, self-efficacy, and social support are associated with perceived well-being and satisfaction after TJR surgery and should be identified and addressed pre-operatively. Assess functional ability and cognition; confirm discharge location and identify post-operative equipment needs. Consider referral to a pre-operative strengthening/rom exercise program appropriate for joint replacement*9-10 Patients & families benefit from education on how to participate in a successful recovery. Provide a patient information package with standardized, consolidated information*10-11 Review pain management techniques and the importance of joint protection*11 Identify post-operative rehabilitation needs and initiate referral *11 Range of motion, strength, and gait speed should be measured, along with at least one patient reported and performance outcome measure in order to establish a benchmark for post surgery progress *11 Refer to page #(s) indicated, in the RCA TJR Framework, for more information 22
23 Summary of Rehabilitative Care Best Practices Rehabilitative Care Best Practice Framework for Patients with Primary Hip and Knee Replacement Quick Reference Bedded Rehab Bedded Rehabilitative Care for Patients with Primary Hip & Knee Replacement Initiation Duration Frequency Inpatient rehabilitation should not be the first choice for the typical patient following total hip or knee replacement. The Orthopaedic Quality Scorecard indicates that no more than 10% of hip/knee replacement patients should require inpatient rehabilitation. The timing, frequency and intensity of rehabilitative care services provided in a bedded level of care should be defined in consideration of functional tolerance and goals of the patient. *12 Therapeutic interventions should include exercise for ROM and strength, functional training (gait, stairs, transfers), and ADL/IADL assessment and training. Rehab should be provided by a dedicated interprofessional MSK/orthopedic team, knowledgeable in TJR rehab *12 Interventions to reduce knee swelling may help improve quadriceps strength and gait speed. Include principles of healthy lifestyles and active living in the rehabilitation program Patients/families require accessible, actionable health information in order to manage their health and make fully informed decisions about their treatment and care*12-13 Assess pain using a standardized pain assessment instrument and use multimodal pain management to maximize effect and outcomes. *13 Criteria for discharge: ambulate & transfers safely with mobility aid; stairs, as necessary able to perform safe/supported ADLs; home exercise program provided; ongoing rehab plan in place. *13-14 Range of motion, strength, and gait speed should be assessed, to measure progress, along with at least one patient reported, and performance-based, outcome measure.*14 * Refer to page #(s) indicated, in the RCA TJR Framework, for more information 23
24 Summary of Rehabilitative Care Best Practices Rehabilitative Care Best Practice Framework for Patients with Primary Hip and Knee Replacement Quick Reference Ambulatory Rehab Ambulatory Rehab Care for Patients with Primary Hip & Knee Replacement Initiation Duration Frequency TKA: Rehab should begin within 7 days of discharge from acute care THA: The rehab session should occur approximately 2-6 weeks post discharge TKA: Rehab should include intensive exercise to achieve range of motion and function throughout the first 12 weeks post-surgery. THA: 1-2 sessions will be suitable for 75-80% of THA patients, 20-25% of patients may require up to 8 individual sessions. TKA: Treatments should be offered 2-3 times per week. THA: Frequency depends on achievement of goals, typically no more than once per week. The majority of the patient s recovery will take place in the community, therefore, the patient & family require instruction and ongoing education regarding exercise and functional activities to be completed at home.*17-18 In regards to function, ROM and health -related Quality of Life, individualized group-based physiotherapy provides similar outcomes as 1:1 Rehab should include exercises for ROM and strength, including home exercises; functional training and progressive resistance training. *18-19 Include principles of healthy lifestyles and active living in the rehabilitation program Interventions to reduce knee swelling may help improve quadriceps strength and gait speed. Range of motion, strength, and gait speed should be assessed, to measure progress, along with at least one patient reported, and performance-based, outcome measure.*19 * Refer to page #(s) indicated, in the RCA TJR Framework, for more information 24
25 Summary of Rehabilitative Care Best Practices Rehabilitative Care Best Practice Framework for Patients with Primary Hip and Knee Replacement Quick Reference In-Home Rehab In-Home Rehabilitative Care for Patients with Primary Hip & Knee Replacement Initiation Duration Frequency Rehab should begin within 7 days of discharge; earlier if patient is high risk. TKA: Rehab should include intensive exercise to achieve range of motion and function throughout the first 12 weeks post-surgery. THA: The duration of rehab is dependent on patient needs. The typical maximum duration of in-home rehab is 12 weeks, if patient is unable to access outpatient rehab TKA: Frequency is more intense in the first few weeks (2-3 times per week) due to risk of contracture or loss of range of motion. THA: The typical number of visits is once per week, for the first few weeks, and then based on the progress of the patient thereafter Treatment is focused on safety at home, as well as optimizing the physical and functional abilities necessary for daily activities.*20 Include principles of healthy lifestyles and active living in the rehabilitation program Interventions to reduce knee swelling may help improve quadriceps strength and gait speed Patient education should reinforce the benefits of ongoing participation in exercise. A selfmanagement component should be incorporated in the rehab program, to empower patients to continue with exercise, post-discharge*21-22 Discharge criteria: patient has achieved their discharge goals, or they have reached a plateau *22 Monitor progress and transfer to outpatient rehab once patient s ability to access services outside the home is no longer limited by their condition. Range of motion, strength, and gait speed should be assessed, to measure progress, along with at least one patient reported, and performance-based, outcome measure*23 * Refer to page #(s) indicated, in the RCA TJR Framework, for more information 25
26 Referral Decision Trees 26
27 Optimal Location of Rehabilitative Care Referral Decision Trees To support alignment with provincial directions for rehabilitative care, the TJR and Hip Fracture QBP Task Groups adapted the RCA s Referral Decision Tree to serve as a decision-making tool regarding the optimal location of rehabilitative care for patients following hip fracture and primary hip or knee replacement. 27
28 TJR Referral Decision Tree 28
29 Hip Fracture Referral Decision Tree 29
30 Self Assessment Tools 30
31 Using Self-Assessments to Inform Best Practice Implementation Click here to download the Self Assessment Tools Sector-specific self-assessment tools have been developed to support organizations and programs in identifying how well their current practices align with the best practices described in framework. The self-assessment tools allow organizations to identify practice areas where implementing a change in practice could improve care. The tools automatically generate a list of priority areas for quality improvement. 31
32 Completing the Self-Assessments Depending on the services provided by your organization/ program, you may want to complete a Hip Fracture selfassessment or a TJR self- assessment, or both. Identify the relevant self-assessment tool for your sector. Identify whether your current practice is aligned; partially aligned; or not aligned with each of the best practice statements Aligned: Most team members/staff would say we do this consistently Partially Aligned: Staff/team members do not agree on how consistently we do this, or it is still a work in progress with opportunities for improvement Not Aligned: Most staff/team members would say we do not do this practice to the extent described
33 Who Should Be Involved? Director, Manager or Coordinator of program being assessed Representative from each discipline of the interprofessional team Professional practice lead/representative where applicable Nursing profession (especially for bedded rehabilitative care) Where available, consider also involving: o Quality improvement specialist o Patient/caregiver representative 33
34 How Long Will it Take? The self assessment should take approximately minutes to complete. The tools include a space for comments next to each best practice, allowing programs/organizations to provide additional information regarding their level of alignment or ongoing/planned work related to the best practice. Depending on discussion generated and the amount of detail provided in the comments, the time it takes to complete the self-assessment process may vary. 34
35 Supports Best Practice Implementation Once completed, the self-assessment tool automatically generates a list of priority areas for quality improvement which can be used to plan & prioritize best practice implementation efforts in your program Example: Summary of Priority areas for Quality Improvement Assessment - Overall Alignment with Best Practice Well Aligned Delirium/Dementia/Depression - Overall Alignment with Best Practice Well Aligned Interprofessional Intervention - Overall Alignment with Best Practice Patient & Family Education - Overall Alignment with Best Practice Transition Planning - Overall Alignment with Best Practice Well Aligned Well Aligned Priority for Improvement 35
36 Online Resources The Best Practice Frameworks, and all of the associated tools and resources can be accessed on the RCA website: o Rehabilitative Care Best Practice Framework for Patients with Hip Fracture o Rehabilitative Care Best Practice Framework for Patients with Primary Hip and Knee Replacement Quick Reference Guides Self Assessment Tools Frequently Asked Questions 36
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