Patient-Centered Redesign of Total Joint Replacement Care: Achieving the Quadruple Aim


Kate Koplan MD, MPH, FACP, CPPS; Violeta Rabrenovich, MHA, CHIE

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Colorado, Georgia, Hawaii, Mid-Atlantic States, Northern California, Northwest, Southern California, and Washington

Background: The National Total Joint Replacement Initiative (NTJRI) Home Recovery Program was implemented across Kaiser Permanente—in the inpatient and ambulatory setting with a purpose of improving patient and physician experience, quality, and affordability of orthopedic care. The NTJRI team provides consultative support and facilitates spread throughout the program. Locally, each Region built on ongoing efforts within orthopedic services by carefully engaging orthopedic patients and clinical teams in proactive patient care and discharge planning, streamlining perioperative services, and designating a Total Joint Replacement Initiative (TJRI) case manager to ensure coordination of services throughout the whole episode of care.
Methods: The population includes patients who are clinically eligible based on evidence-based clinical recommendations and who agree to pursue a same-day elective unilateral hip or knee replacement. A method to spread and to implement the NTJRI program is an NTJRI playbook that includes preoperative evaluation, shared decision-making tools, home safety evaluation where available, patient education, pain control protocols, and instructions for follow-up care with physicians and physical therapy. A key intervention is having a TJRI case manager or an equivalent resource in care coordination and/or follow-up. Key inpatient components include appropriate anesthetic technique, and trained postsurgical physical therapy and ambulation. NTJRI metrics include an average length of stay (LOS) and the percentage of 0-day, 1-day, and 2-day stay procedures. In addition, we carefully monitor hospital readmissions, returns to Emergency Department or Urgent Care services, and surgical complications. The NTJRI dashboard incorporates all NTJRI safety measures and regional LOS targets. We also developed methodologies to assess physician and patient satisfaction with the NTJRI Home Recovery Program.
Results: As of third quarter (Q) 2018, programwide results were: 1) average LOS declined to 0.74, compared with 1.37 in Q4 2016; 2) 44.1% 0-day LOS surgeries, an increase of 34.7% from Q4 2016; 3) 44.0% 1-day LOS surgeries, a decrease of 15.3% from Q4 2016; 4) 30-day readmissions rate (2.4%) has decreased 0.2% since Q4 2016, whereas return-to-care rate (6.3%) has decreased 0.5% since Q4 2016; 5) For 0-day LOS, return to care was < 8% in 5 of 7 Regions and readmissions were < 3% in all participating Regions. The 2018 NTJRI Physician Satisfaction Survey results demonstrated improved physician experience compared with 2017 results: 93% vs 80% in 2017 of respondents agreed that they are welcomed to contribute to improvement efforts; 80% vs 76% in 2017 of respondents reported that the overall changes in the last 6 months has made the total joint replacement service better; and 83% vs 76% in 2017 of respondents reported that they are satisfied with their own practice. The results also improved physicians’ perception about NTJRI Home Recovery Program LOS (ie, 62% of respondents reported they are comfortable with a planned 0-day LOS). According to the 2018 NTJRI Patient Satisfaction Survey results, overall experience for total joint replacement was highly rated by most patients (93% report excellent/very good; approximately 80% reported extremely satisfied); shorter LOS (or same-day discharge) is associated with better care experience and patient reporting feeling ready to leave the facility; patient satisfaction with surgeons and other medical staff was 99% and 97%.
Discussion: As an integrated care delivery system, Kaiser Permanente is well positioned to codesign and integrate input received from patients and clinicians in an evidence-based care delivery program. The NTJRI Program provides a model that can be replicated in other programwide improvement efforts. Both patient and clinician engagement strategies and monitoring of their experience with the program are important outcome and balancing indicators of successful spread and implementation.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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