Home healthcare clinicians, including physical therapists (PTs) and occupational therapists (OTs), and nurses provide essential care for postoperative recovery and rehabilitation for patients undergoing total joint replacement (TJR), one of the most commonly performed operations in the United States. The Centers for Medicare and Medicaid Services aims to control rising costs related to these surgeries through the Bundled Payments for Care Improvement (BPCI) initiative in test regions across the country. The bundle allots a fixed payment for a 90-day episode of care beginning with hospitalization and including all postoperative recovery costs.

In preparation for the progression of the value-based healthcare movement, Henry Ford Home Health Care (HFHHC) instituted the Total Joint Replacement Center of Excellence. HFHHC is part of the Henry Ford Health System (HFHS), a multihospital healthcare system in southeast Michigan that receives more than 2,200 referrals for joint replacement annually. I was provided the exciting opportunity to transition from physical therapy field clinician to the coordinator of the TJR program. In addition to myself, the TJR Center of Excellence is led by an interdisciplinary team that includes HFHHC senior leadership, the manager of therapy services, nursing supervisors, a PT and an OT, and a leader in business development. This team meets on a regular basis to continuously evaluate the service provided to this unique patient population, and has implemented multiple strategies to elevate the level of patient-centered care. I also represent this team at interdisciplinary team meetings across the health system to address the change in TJR patient service.

The initial task was to develop a dedicated team of specialized clinicians. The desired characteristics of the specialized PTs and OTs include: 1) excellent case management skills; 2) commitment to consistent and effective communication with all team members; 3) flexibility with scheduling home visits to maintain continuity with physician-requested protocols; and 4) demonstration of thorough understanding of the policies and processes of the TJR program, the nursing and therapy protocols, and the established communication pathways. Additionally, specialized clinicians are required to complete an annual competency to demonstrate proficiency in clinical skills related to the care of this unique patient population. The ability of the PT and OT to effectively case manage is paramount as the number of nursing visits were reduced in response to BPCI economics. Therapists are now addressing medication and pain management, dressing removal and incision inspection, management of comorbidities, and identifying potential complications with increasing frequency.

As the TJR Center for Excellence has evolved, processes have been refined and opportunities for education and growth among clinicians identified. Team meetings, which I lead as a component of my TJR coordinator role, have been initiated at the regional branch office level and include an interdisciplinary team of therapists, nurses, and hospital liaisons. This forum for interdisciplinary teamwork has proven to be an exceptional way to promote cohesion among nurses and therapists.

An example of effective interdisciplinary teamwork occurred recently at a branch team meeting. A discussion between nurses and therapists revealed there is inconsistent education provided from both the hospital and home healthcare clinicians regarding the medication schedule for pain management. The result is that some patients adhere strictly to the ordered schedule of medication and are unwilling to reduce their medication over time, whereas others are wary of taking any medication at all, fearing addiction. We discussed the role of consistent education in addressing a realistic expectation for pain and edema due to the inflammatory process, and alternative strategies for pain control. It was also stressed that patients contact their home healthcare provider or surgeon, rather than going to the emergency room for care. This exchange added value to patient care, organizational outcomes, and staff satisfaction.

HFHHC has experienced tremendous success following the initiation of interdisciplinary team meetings. Patients receive consistent yet individualized care, with open communication between the therapist and surgeon to maximize patient progress and to efficiently identify and remedy potential complications. These improvements are reflected in each of the eight functional outcome scores as recorded by the Outcome and Assessment Information Set that HFHHC tracks for this specific population, including M1242 Frequency of Pain Interfering with patient's activity or movement, M1850 Transferring, and M1860 Ambulation. This has been accomplished while the census of TJR patients has consistently grown year to year. Therapists have voiced improved confidence, self-efficacy, and report feeling more respected by other healthcare professionals. This is supported by prior research that suggests that efficient, accurate, and timely communication is strongly linked to healthcare staff job satisfaction (Gausvik et al., 2015). Kristi Kornacki, HFHHC PT states,

Each member of the interdisciplinary team has their own skill set and goals for the patient based on their education and experience. When team members communicate and work together, it allows them to look at all aspects of the patient's life and determine which strategies will work best for the patient and family. The team approach improves patient compliance with the treatment plan and, in turn, leads to improved functional independence and quality of life. Seeing patients succeed as a result of our collaborative effort is very fulfilling and working with team members that value my opinions as a physical therapist increases my job satisfaction.

As the TJR joint coordinator, I also attend interdisciplinary team meetings with hospital-based orthopedic physician teams across the health system. During these meetings, data from the Michigan Arthroplasty Registry Collaborative Quality Initiative are presented and analyzed, and plans are developed to prevent complications that, ultimately, reduce hospital readmissions. Collaboration with this team provides the opportunity for HFHHC therapists to contribute to the patient-centered care solution. Therapists have the unique advantage of treating the patient within their own home and are able to identify challenges or barriers to care that were not anticipated in the hospital setting. This intimate relationship affords the PT and OT the ability to address functional limitations in each patient's specific environment. The established relationship with hospital providers has resulted in their increased awareness of the value of our roles, leading at times to collaboration for specialized services for complex cases prior to the transition home. An additional benefit of our partnership with the hospital team is educational opportunities for therapists, including lectures from and discussions with HFHS surgeons as well as the opportunity to observe joint replacement surgery.

The prevalence of TJR surgery is expected to steadily rise. The specialized and dedicated therapists at HFHHC embrace the opportunity and obligation to provide efficient and effective care as we continue to move toward value-based healthcare.

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