Casing the Joint: How Minn. Community Paramedics Help Orthopedic Patients

To prevent readmissions and ER visits following joint replacement surgery for patients living in rural areas of north-central Minnesota, Cuyuna Regional Medical Center (CRMC) has found great success with its novel flagship community paramedic initiative, Rapid Recovery Protocol, which debuted in April 2013.

Initially considered for sepsis control, the program’s partnership between the hospital and the Minnesota Center for Orthopaedics (MCO) represents one of the nation’s first community paramedic programs that involves home visits with patients before and after joint replacement surgery.

“We want to be more proactive, instead of reactive,” says CRMC’s Jana Keefe, RRT/CP, whose community paramedic classroom project to identify gaps in coverage for patients turned into a viable program and potential model for other communities across the United States. “Two of three joint replacement patients now spend only a night in the hospital, and ours average a 40-mile commute home to north-central Minnesota. Because patients are bombarded with so much information upon hospital discharge, even with clearly written discharge instruction papers reviewed by staff with the patient, a majority have ‘discharge amnesia’ when they walk through their front door.”

One Number, One Call

Here’s how it works: When Adam English, CNP, total joint coordinator for MCO, is notified about a rural patient’s upcoming orthopedic joint replacement surgery, he contacts Keefe, who reaches out to the patient and conducts a pre-op home visit. There she follows a checklist that includes a safety survey inside and outside the home, vitals check and inspection of needed supplies. When the patient is in the hospital, she visits briefly, then sees the patient again in their home the day after discharge.

English works closely with Erik Severson, MD, a fellowship-trained orthopedic surgeon, and MCO medical director Mark Gujer, MD, to coordinate the practice’s joint replacement surgeries (an average of 300–350 annually). The practice has reduced the average length of hospital stay for those patients from 3.5 to 1.7 days. In 2014, the last year for which records are available, there were more than 275 total patient referrals to the program.

“Jana and I are in constant contact,” says English. “Every joint replacement patient is given a card with a number to my patient cell phone. We want patients to call one number, rather than calling A, getting transferred to B, C and D, with different answers along the way. One number, one call, one person within the practice—that’s my role. Jana’s role is integral to our success. She’s my eyes on the ground.”

Each patient receives another “touch” by phone from Keefe, ensuring their pain level is well-controlled and the wound is clean and dry, before she makes the post-op visit. There she follows her medical assessment guidelines, also with the pre-op inspection on hand.

“Let’s say in the pre-op visit, I recommended either using double-sided tape on throw rugs or removing them temporarily,” says Keefe. “If the patient ends up coming back to the hospital days later because they slipped on their throw rug, it’s documented that this safety step was recommended and the patient chose not to follow the recommendation.”

The program isn’t limited to the few days pre-op and immediately post-op. If a patient, for example, is two weeks past knee replacement surgery and needs a dressing change on his knee, Keefe becomes another extension of English on the road.

“If Jana’s at the patient’s home and calls me to say the patient looks a little bit pale and suggests checking their hemoglobin, she can draw blood, bring it to our lab, and we check it,” English says.

Who pays for this program? Not the patient. “We use the cost avoidance model,” says Keefe. “We bill for certain things, but if the insurance company won’t reimburse us, the patient never sees a bill. The hospital eats the cost of it. Minnesota’s state insurance reimburses us, but only a few patients are on it. Medicaid reimburses $60 a visit. We want the patients to get well and not worry about the cost of our part of post-op care.”

If a post-op patient sidesteps the communication instructions to contact English first and uses the ER as a crutch, the ER calls English first anyway.

“That rarely happens,” he says. “It all goes back to the prevention of readmissions and ER visits.”