Ok I’ll admit it. I’m more than ready to be fully recovered, that is, symptom- and pain-free, 100 percent mobile, back at work full time, and getting prepped for the spring golf season.
You see I’m one of those people who has always exceeded the benchmarks, especially the physical fitness ones. Remember the annual Presidential Physical Fitness Award from elementary and middle school? As I recall, we had to complete a whole bunch of pull-ups, sit-ups, v-sits and a mile run – all within a timed minute – and each year, the illusive number to earn the coveted patch increased. I was one of the few in my school to receive more than one patch.
Fast forward many years and today is day 22 of my recovery from total knee replacement surgery. By all accounts, my recovery is going well – and yet, I’m still eager to feel ‘good as new’ and frustrated it isn’t happening quicker.
Despite my impatience, I know I’m one of the lucky ones. I have full faith in my entire care team – my surgeon, physical therapist, primary care physician, and all of the nurses who tended to my needs during my three nights in the hospital. The confidence I feel in my care team isn’t a coincidence; it’s directly related to how coordinated my care is, how engaged I am in my care and recovery and, just as importantly, my health literacy.
I know my primary care physician, who practices in Harrisburg, PA, and my surgeon who treats patients at Wentworth Douglas Hospital in Dover, NH, talked before my surgery and shared important information about my history with each other, and they both have been in touch with me since I was discharged from the hospital. The physical therapist from Cornerstone Visiting Nurses Association in Rochester, NH who regularly visits me at my home in southern Maine, uploads her assessment and notes each night in order to communicate my progress to the surgeon’s office. She’s also in touch with the surgeon’s staff by phone. The regular communication among the members of my care team assures me my care is coordinated and personalized to my health situation, and I have felt supported throughout my recovery.
I wish every patient had this kind of experience.
Take Kristy Tupper, the director of Geneia’s project management office. When her mother’s health began to decline and she was much more frequently interacting with the healthcare system, she assumed her mother’s physicians and care team were talking to each other and coordinating her mother’s care.
In Kristy’s words, “I was flabbergasted to learn that when the dermatologist or nursing home physician adjusted her Coumadin, her primary care physician, cardiologist and other doctors were not notified. It seemed like she went from one doctor to the next with revised prescriptions every few days, and no one knew who changed what or why.”
Physicians and Care Teams Need a Seamless Way to Communicate and Collaborate
Like Kristy, I believe we need to make it much easier, even seamless, for providers, caregivers and patients to communicate and collaborate as a care team. Given the increasing administrative demands on physicians and providers, it’s increasingly unrealistic to think they’ll talk to each other by phone, as my care team has done.
That’s why a tool like Geneia’s Theon® platform is so helpful. In short, the Theon® platform integrates patient information from all kinds of sources – lab results, diagnoses, surgeries, prescriptions, PT notes, and more – to create a comprehensive, 360-degree view. This view is shared with all the members of the patient’s care team, and even more importantly, changes to the treatment plan and patient’s condition are quickly and easily communicated across the care continuum.
For knee replacement surgery, the bundled payments program is helping to improve care coordination and patient outcomes. The introduction of a single payment for an episode of care – in this case, the knee replacement surgery along with all of the pre- and post-surgical care – incents all of the hospitals, skilled nursing facilities, rehabilitation centers and home health agencies involved to work together from beginning to the end of care. For hospitals, that means being held accountable for the first time for the critical 90-days of care following the patient’s discharge. For knee replacement patients like me, the bundled payments program means “the peace of mind that comes from knowing they will receive high quality, coordinated care from the minute they are admitted to the hospital through their recovery” and confidence that all of the members of the care team are working together to improve recovery and avoid preventable complications and the associated costs.
By all accounts, knee replacement patients should be able to return to their daily activities within six weeks of the surgery. I am determined to beat the odds, and my care team has done everything possible to make that happen. The rest is up to me, and that means it’s now time to do one more set of my leg-strengthening exercises.