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These days, it's becoming increasingly common for orthopedic surgery patients to receive a call from their inpatient nurse after they go home. With shorter lengths of stay for joint replacements-patients are discharged within 48 hours after surgery-staff are striving to ensure that patients have all of the information they need to care for themselves at home.
"We ask patients if they had trouble getting pain medications, how their pain is, whether the visiting nurse and physical therapist came to the house and if they know when their follow-up appointments are," said Mary Anne Kenyon, MPH, MS, RN, ONC, nursing director of Orthopedics.
Through the calls, staff have learned important information about improvements they can make to ensure patients have a seamless transition home. That includes making sure prescriptions for pain medications are available and that patients understand how to take their medications appropriately through education while patients are still in the hospital.
This type of enhancement to care delivery and communication is being developed and tested throughout "Innovation Units" across the hospital. As part of the Partners HealthCare patient affordability strategy, seven units at BWH are seeking ways to make care safer and more effective and efficient.
Partners is striving to make health care more affordable by implementing system-wide cost savings of $300 million over three years (2012-14), reviewing best practices, eliminating duplication, using process improvement tools and streamlining patient care. The Innovation Units were formed to test new models of care delivery and communication, and quickly determine which changes work.
The goals are to:
.Assure that care remains patient- and family-centered
.Make care safer and more effective, timely and equitable
.Improve the quality of care
.Make care more cost-effective by decreasing the length of stay
While complete results are not yet available, some common themes have emerged across the Partners hospitals involved. This includes the notion of an attending nurse or care facilitator to serve as a consistent voice in communication between the patient and family and hospital team. This role would be an advocate who could envision the entire journey of a patient across the continuum of care, making the experience as smooth as possible.
A second theme is enhancing communication to improve care, such as BWH Orthopedics' effort is to call patients after discharge.
Some of these efforts are emerging as best practices and are being tested across several institutions, with early indicators of success. Communication has increased, length of stay is decreasing and patients are reporting improved pain management.