When Katherine*, a 70-year-old semi-retired lawyer, was recently discharged from the hospital following hip replacement surgery, the hardest part of her recovery was learning to overcome her fear of doing certain activities that, as a New York City resident, had been part of her daily life before her operation. Climbing the stairs of a subway station suddenly seemed impossibly difficult, as did stepping onto a New York City bus.
Fortunately, Katherine was participating in a new rehabilitation program in which she received intensive physical therapy at home, rather than spending weeks in an inpatient rehabilitation facility or going back and forth to outpatient rehab. As a result, her physical therapist, Rosalea Manaog, was able to add highly personalized touches to Katherine's rehab protocol, including taking her on forays out into her own neighborhood, where Rosalea gently encouraged her to perform -- and master -- the very tasks she was afraid of. "Whatever I was most afraid to do," Katherine says, "Rosalea would say, 'Let's go do it!'" Within a couple of weeks, Katherine had made significant strides in terms of regaining both her physical function and psychological equilibrium.
While this type of intensive home rehabilitation for joint replacement patients is still relatively new, it is destined to become the standard of care in the very near future. One reason has to do with finances: Studies show that an effective home rehabilitation program can be implemented for about 25 percent less cost than the equivalent stay at a rehab facility. With joint replacement surgeries expected to increase dramatically in coming years -- a study in the Journal of Bone and Joint Surgery estimated that U.S. doctors will be performing 3.5 million first-time knee replacements per year in 2030, six times more than in 2005 -- this translates to billions of dollars in savings.
Just as important, these same studies are finding that when care is appropriately "front-loaded" -- meaning that the majority of the therapy is concentrated in the first two weeks or so following discharge -- a home rehabilitation program is every bit as effective as an inpatient rehab stay in terms of functional recovery and complication rates. "At the same time, the satisfaction rates from our surveys indicate that our patients are happier, because they're able to recover in the comfort and familiarity of their own homes," notes Dr. Charles Cornell, Clinical Director of Orthopedic Surgery at the Hospital for Special Surgery (HSS) in New York City, where Katherine's surgery was performed, and a professor of orthopedic surgery at Weill Cornell Medical College.
In 2014, nearly 800 HSS joint-replacement patients have gone through intensive home rehabilitation, working with physical and occupational therapists from the Visiting Nurse Service of New York (VNSNY) in a unique health care partnership designed specifically for today's changing medical landscape. This collaborative program utilizes careful pre-surgical screening to identify appropriate candidates for the home protocol, than implements a patient-centered plan of care focused on helping each client achieve his or her functional goals. The front-loaded regimen includes daily or near-daily physical therapy at home as needed, as well as frequent occupational therapy sessions during the first two weeks after surgery, supplemented by nursing, home health aide and social work services when ordered by the physician. From January through December 2014, the program demonstrated a low 30-day re-hospitalization rate of 2.8 percent.
As Katherine's case illustrates, this home-based approach can also provide benefits that don't necessarily show up in a cost-benefit analysis. By working on their recovery at home, patients immediately begin focusing on the functions and tasks needed to carry out their actual daily routines, while their therapists can quickly identify any specific home activities or environmental issues that require special attention.
The home setting also promotes a close bond between the therapists and their clients, as Donna, a 56-year-old New Yorker, discovered. Donna has always had a competitive streak: Though she lacked cartilage in one knee since her high school days, she became a dedicated road runner and cyclist as an adult. When it finally came time for knee replacement surgery, she was determined to bounce back quickly. "Immediately following the surgery, I had one of the fastest recuperations of anyone in the hospital," she recalled. "People were amazed how quickly I was up and walking at close to my usual clip."
In spite of her can-do attitude, however, she soon realized her recovery would be more involved than she'd anticipated. With her new prosthetic knee joint, she needed to retrain herself to do the simplest tasks, such as bending at the joint, walking and climbing stairs. For two weeks following her discharge home, Liz Opoka, a wonderfully motivating physical therapist, visited Donna five days a week. Carefully adapting her regimen to Donna's daily progress, Liz helped her improve her balance and flexibility and strengthen the muscles supporting her knee, and also gave feedback on how to avoid favoring one side so Donna wouldn't develop problematic long-term habits.
Throughout the program, Donna's surgical team was kept updated on her status. "Effective therapy is about setting achievable goals and managing expectations," says Liz. The close connection between therapist and client helped Donna stick closely to her treatment plan, ensuring a smooth recovery. A month after her operation, she was back in the bike saddle at her gym.
If family caregivers are involved, the home sessions also provide a chance for them to learn how to assist with exercises, as well as what precautions might need to be followed. As Dr. Cornell points out, however, the program has also proved highly effective for individuals who live on their own. "About one-third of our patients who have gone through this protocol live alone, and they've done just as well as those living with family members," he says. "It's really a spectacular program, with very innovative delivery of care. In fact, I'd like to see this model used across the country."
There is much to find fault with in today's complex healthcare landscape, but when dedicated professionals create patient-centered partnerships that promote thorough healing for their patients and demonstrate improved models of efficiency and affordable care, it reminds us that change often introduces new and better solutions that improve our lives in meaningful and valuable ways.
*Name changed to protect privacy