October 1999 Bulletin

Case management works well, too

Provides equivalent functional outcomes in a more informal setting

By Robert R. Karpman, MD

There is no doubt that the management of the senior adult must include a comprehensive multidisciplinary approach. Many studies in the geriatric literature have previously documented the improved functional outcomes in geriatric patients managed through this approach.

Several articles in the orthopaedic literature also have demonstrated improved outcomes in hip fracture patients including decreased length of stay and early return to premorbid function following a formal comprehensive geriatric orthopaedic inpatient program. These programs, however, are extremely time consuming and costly, particularly in regards to professional time and opportunity costs. The question that arises is this: Can a multidisciplinary approach to the geriatric orthopaedic patient be accomplished in a less formal and a more cost-effective fashion in a routine community hospital while maintaining equivalent functional outcomes? The answer is an unequivocal "yes."

My current practice is located in a high density retirement community where more than 90 percent of patients seen in both the outpatient and hospital setting are over 65 years of age. Currently, more than 540 hip fracture patients are seen in one of our hospitals on a yearly basis. In addition, many patients are enrolled in Medicare HMOs, necessitating rapid inpatient turnover and enhanced coordination of care to decrease inpatient costs.

Coordination of in-hospital and postsurgical care have been accomplished through a series of both formal and informal interdisciplinary programs.

Written clinical pathways designed by both orthopaedic, nursing, rehab and social service professionals. The pathways specifically describe what actions should be taken for each patient entering the hospital with a hip fracture on each day of his or her hospitalization. This includes not only medical treatment of the patient, but also physical therapy, discharge planning, psychosocial needs, nutrition, future placement home care needs and most importantly; patient education. All members of the hospital staff, including physicians, nurses, therapists, social workers have a clear understanding of who is responsible for which aspect of care and when and how the process should proceed.

These pathways have avoided significant duplication of services and misunderstanding between professionals regarding responsibility for care. Patients receive educational brochures, which are explained by the nursing staff upon admission. The educational information includes the type of fracture, and various aspects of treatment, including postoperative care, rehab and home care.

A strong case management system. A case manager, usually a registered nurse, is assigned to each patient immediately upon hospital admission. The case manager assigned is chosen upon his/her affiliation with a Medicare HMO or other insurance carrier. The case manager can not only facilitate the various aspects of care, but also is familiar with the insurer's contracted providers so patients are not assigned to home health care agencies that are not covered by their insurance, or durable medical equipment delivery is not delayed because of a lack of coverage. In essence, the case manager serves to coordinate the various professional disciplines and aspects of care during the patient's hospitalization. He or she informally discusses the patient with the orthopaedic surgeon, primary care physician, nurses and other health care professionals to assure a smooth and effortless transition from the acute to subacute or home care. The case management system has been extremely helpful to physicians, particularly with facilitation of community and outside services.

Step-down inpatient units. Several subacute hospital units have been established to allow for continued rehabilitation and ultimate coordination of home care following hip fracture. These units include an acute rehab center, skilled nursing facility and transitional unit. The type of unit to which the patient is assigned is dependent upon their medical and rehab needs, and their primary insurance coverage. All units, however, are capable of providing postoperative physical, occupational and recreational therapy and discharge planning. The geographic proximity of the step-down unit to the inpatient unit allows for continued follow-up by the orthopaedic surgeon and primary care physician with minimal additional time commitment, compared to making rounds at off-site facilities. Following discharge from the step-down units, patients are transitioned either to their previous home environment or long-term care facility, if needed.

The incorporation of these programs has significantly reduced our acute care length of stay to an average of 4.5 days. A single, formal weekly conference, therefore, would not be adequate since the majority of our hip fracture patients are already out of the acute care setting.

In addition, quality performance indicators such as readmission rates to the hospital mortality and morbidity have been consistent with national standards. Since a majority of the patients are community dwellers prior to the injury, most of them do return to their own home environment after discharge.

There are several reasons why our informal multidisciplinary program is successful in our community, and can provide equivalent outcomes compared to the formal program suggested by others.

For the most part, a patient who is admitted to the hospital with a hip fracture represents a small portion of the entire continuum of care that is provided to this patient in our community. Frequently, the primary care physician who is managing the patient during the acute hospitalization has seen the patient for many years on an outpatient setting and is quite familiar with the patient's medical comorbidities. In a large university or academic health center, an entirely new health care team may be managing the patient during the acute care phase with a prolonged learning curve regarding the patient's past medical history, as well as social setting. A formalized coordination of care would therefore be necessary, as all of the professionals are just getting to know the patient. In the community setting a significant majority of the health care professionals are already familiar with the patient and his/her medical problems. In addition, most of the primary care physicians are board-certified geriatricians and are already familiar with the concept of interdisciplinary care.

Written clinical pathways and coordination of care by a case manager serves as a sufficient substitute for formal multidiscipline meetings to discuss a geriatric patient's physical and psychosocial needs. Both the orthopaedic surgeon and primary care physician are more than happy to relinquish the coordination of care to the inpatient case manager since the case manager is much more familiar with community and outpatient services, and which of those services are covered by insurance.

The familiarity and experience of all of the hospital professional staff in managing geriatric patients significantly reduces the need to teach new house staff or nursing staff about the unique problems of the senior adult, such as incontinence, acute delirium, drug reactions, the need for early mobility, etc. Perioperative morbidity and mortality can therefore be significantly reduced.

In summary, whether the senior adult patient with musculoskeletal disease is in a large academic health center or in a community hospital there exists a definite need for interdisciplinary coordination of care, not only regarding the patient's medical status, but also psychosocial needs. Dependent upon the location and experience of the professional staff, this coordination can be provided in a formal comprehensive program or in a more informal setting as long as the patient's needs are met and functional outcomes remain equivalent. In a heavily penetrated managed care market there is no question that a case management system is much more cost effective than a formal geriatric orthopaedic multidisciplinary team.

Robert R. Karpman, MD, is in private practice in Sun Cities, Ariz.

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