The Evidence for Rethinking Post-Discharge Rehab Services
How much of the typical cost of care for your total joint arthroplasty patients goes toward costs incurred after patient discharge?
When the surgeons at The Rothman Institute in Philadelphia, Pennsylvania, asked themselves that question of their practice, they found that more than 50% of the cost of managing their total hip and total knee arthroplasty patients was spent on care after discharge, including:
- Long-term care facilities
- Skilled nursing facilities
- Inpatient rehabilitation
- Medicare Part B
- Durable medical equipment
What’s more, post-discharge costs were inconsistent across surgeons in the practice, ranging from a low of $500 to a high of $17,000.
Recognizing that they could decrease costs through standardization of post-discharge care, the surgeons adopted a practice-wide, demand matching program for rehabilitation of total hip and total knee patients. As the name suggests, this program matches the type of physical therapy to the patient’s health status.
For example, a healthy, active patient would be assigned to web-based physical therapy exercises done at home, while a patient who cannot safely be discharged home would go to a rehabilitation facility. As expected, the cost of a self-directed, home-based exercise program is much lower than the cost of inpatient rehabilitation.
At ICJR’s annual Winter Hip & Knee Course, Matthew S. Austin, MD, described the demand matching program used at The Rothman Institute, as well as the evidence behind it.
Dr. Austin said that in 2011, before adoption of the demand matching program, 33% of Rothman patients were discharged to a rehabilitation facility, 55% were discharged home with prescribed home health services, and only 28% were discharged home without additional home health services. In 2016, after adoption of the program, only 20% of patient were either discharged to a rehabilitation facility or to home with home health services; 80% went home without additional home health services.
Patients may still want to be discharged to a rehabilitation facility, Dr. Austin said, but he and his colleagues can point to research showing that rehabilitation facility admissions are associated with increased adverse events and readmission rates.  Those who want home health services, even if they are not indicated, can be assured that research shows no difference in complication rates, with favorable patient satisfaction, whether or not home health services are utilized.  The cost savings are significant: $1100 per total hip and $1600 per total knee. 
Even patients who live alone and are concerned about discharge to home can be accommodated, Dr. Austin said: A study showed no difference in unplanned 90-day clinical events when patients stayed in the hospital for a few extra days and were discharged with some home health services instead of going to a rehabilitation facility.  No differences in HOOS and KOOS scores were noted, with 84% of patients being satisfied with discharge home and 89% saying they would do this again.
Two randomized controlled studies from The Rothman Institute showed that formal physical therapy is not needed for recovery in most patients. [4,5] In the hip study, patients either had formal physical therapy or unsupervised physical therapy using a paper exercise manual. No differences were seen in Harris hip scores at 1 month and at 6 to 12 months after surgery. 
For the knee study, a third option was added: web-based physical therapy. No differences were seen in KOOS scores or return to activities of daily living (unassisted walking, driving, and returning to work) among the formal physical therapy, paper-based physical therapy, and web-based physical therapy groups. 
The Rothman surgeons then conducted a retrospective review of total hip and total knee patients who had not participated in the randomized controlled studies. [6,7] They found that two-third of these patients did not need formal physical therapy.
Click the image above to watch Dr. Austin’s presentation and learn more about post-discharge care of total joint arthroplasty patients.
Disclosures: Dr. Austin has disclosed that he has intellectual property/ownership in Force Therapeutics and Pulse.
- Keswani A, Tasi MC, Fields A, Lovy AJ, Moucha CS, Bozic KJ. Discharge destination after total joint arthroplasty: an analysis of postdischarge outcomes, placement risk factors, and recent trends. J Arthroplasty. 2016 Jun;31(6):1155-1162. doi: 10.1016/j.arth.2015.11.044. Epub 2016 Jan 20.
- Ponzio DY, Park AG, Bhat SB, Purtill JJ. Can we reduce the utilization of home-visiting nurse services after primary total joint arthroplasty? J Arthroplasty. 2016 Sep;31(9 Suppl):50-3. doi: 10.1016/j.arth.2016.02.078. Epub 2016 Mar 17.
- Fleischman AN, Austin MS, Purtill JJ, Parvizi J, Hozack WJ. Patients living alone can be safely discharged directly home after total joint arthroplasty: a prospective cohort study. J Bone Joint Surg Am. 2018 Jan 17;100(2):99-106. doi: 10.2106/JBJS.17.00067.
- Austin MS, Urbani BT, Fleischman AN, et al. Formal physical therapy after total hip arthroplasty is not required: a randomized controlled trial. J Bone Joint Surg Am. 2017 Apr 19;99(8):648-655. doi: 10.2106/JBJS.16.00674.
- Fleischman AN, Crizer MP, Tarabichi M, et al. 2018 John N. Insall Award: Recovery of knee flexion with unsupervised home exercise is not inferior to outpatient physical therapy after tka: a randomized trial. Clin Orthop Relat Res. 2019 Jan;477(1):60-69. doi: 10.1097/CORR.0000000000000561.
- Klement MR, Rondon AJ, McEntee RM, Kheir M, Austin MS. Web-based, self-directed physical therapy after total hip arthroplasty is safe and effective for most, but not all, patients. J Arthroplasty. 2019 Mar;34(3):513-516. doi: 10.1016/j.arth.2018.10.032. Epub 2018 Nov 3.
- Klement MR, Rondon AJ, McEntee RM, Greenky MR, Austin MS. Web-based, self-directed physical therapy after total knee arthroplasty is safe and effective for most, but not all, patients. J Arthroplasty. 2019 Jul;34(7S):S178-S182. doi: 10.1016/j.arth.2018.11.040. Epub 2018 Dec 3.