Home care a big part of joint replacement surgery

Joint surgery patients of Cape Cod Healthcare get coordinated care that begins before their operation and continues afterward.

Physical Therapist Ann O’Neil, a specialist in orthopedic rehabilitation, runs the Visiting Nurse Association of Cape Cod’s (VNA) program, which prepares patients for surgery and provides post-operative supportive care. She works with surgeons to follow their recommendations for each patient.

“It all depends upon the surgeon’s protocol and what they want,” she said.

Before Surgery

All patients get a pre-operation phone call to go over safety issues and what to expect, O’Neil said. She also leads a class at Falmouth Hospital for patients in advance of joint surgery. Orthopedic surgeons encourage patients to have PT prior to surgery, or “pre-hab” at a Cape Cod Healthcare outpatient facility, to prepare them for surgery and teach them some exercises prior to surgery.

Patients also get education from the VNA by either attending a total joint replacement class or a pre-op call, said O’Neil. “This allows for questions to be answered prior to the VNA admission,” she said.

Patients also typically have an appointment with their surgeon for some tests and assessments prior to surgery. The orthopedic surgeons advise patients to stop smoking several days before their surgery date, and to eat a healthy diet and exercise regularly. They may be told to stop taking certain medications until after surgery.

After Surgery

VNA post-orthopedic-surgery home care focuses on getting patients able to safely walk, toilet and bathe themselves, and transfer to and from a wheelchair. It utilizes a variety of staff – nurses and both physical and occupational therapists.

“Nurses will work on pain management, constipation and nausea (from pain medications and anesthesia),” O’Neil said. “They teach family members, too.”

Occupational therapists instruct shoulder surgery patients how to get a shirt or sling on and off, and how to shower safely, she said. Physical therapists lead patients through exercises to regain flexibility, strength and range of motion.

“Your therapy is so important,” O’Neil said.

Patients are also shown how to get in and out of bed and on and off the toilet, and how to get safely to a car. “That doesn’t mean they can drive themselves,” O’Neil said.

A caregiver – whether it be a spouse, partner, relative or friend – is vitally important to help the patient during recovery, which is why the VNA program aims to educate both patients and their caregivers.

“Patients who take on these elective surgeries” need someone to help during the first few weeks after an operation, O’Neil said. “You can’t do this on your own.”

VNA home care usually lasts about two weeks after joint surgery. The focus of this care is patient/caregiver education and the patient achieving safe functional mobility in their home, including bathing, toileting, transferring and ambulating, according to O’Neil. At that point they are ready to progress to outpatient PT. In some rare cases, the VNA in-home care may be extended, she said.

While the program is aimed at elective joint replacements, the VNA also closely coordinates post-operative care with orthopedic surgeons for trauma patients and can provide home care for Cape residents who had orthopedic surgeries performed off-Cape.

“The VNA has been wonderful,” said orthopedic surgeon Paul Dimond, MD, of the Falmouth Orthopedic Center.

He said he used to think joint replacement patients should go to a rehabilitation facility, such as JML Care Center in Falmouth, for a few days following surgery.

“As it turns out, most patients do better at home,” he said.

The program’s team approach ties together nurses, therapists and surgeons and their staffs. “They have access to our protocols. They have access to all our surgeons,” he said, citing as an example that nurses can take a picture of a wound and send it to a surgeon via the EPIC online portal.

Meeting Growing Demand

Advances in pain management, prevention of deep vein thromboses (DVTs) and surgical procedures have greatly reduced the time joint replacement patients spend in the hospital or rehabilitation facility, Dr. Dimond said.

“Somebody falling and breaking their hip – they need to go to rehab,” he said. “Most knee and hip replacements are not going to rehab.”

Because knee and hip replacement procedures are often day surgeries, the VNA follow-up care is an integral and important part of the program, O’Neil said.

“You can’t have them waiting,” she said. “They have to have (home care) services within 24 hours.” Nowadays, more older people seek these surgeries to stay active, further driving the need for standardized and effective pre- and post-operative care, she added.

In light of this trend, the VNA plans to start educational presentations on the program at area senior centers within the next few months, said Meg Payne, VNA director of public health and provider relations, and O’Neil’s supervisor.

“We’re in the centers on a daily basis, doing screenings and talks,” she said, because the VNA serves as town nurse to 14 of the Barnstable County’s 15 towns.

The presentations could help ease anxiety for people considering joint surgery, but have been putting it off.

“They can meet some of the people who’ll be doing home visits,” Payne said.

While the pre-op class is now only held at Falmouth Hospital, the VNA may expand to offer it at locations in the Mid or Lower Cape in the future, she said.