Ortho Clinical Pathways for Patients Discharged to Home/ALF's?


Good Evening:

We are in the planning stages of implementing a Orthopaedic Respite Care program at the suggestion of several prominent Orthopaedist in our area.

We are an Assisted Living Community who has a fully operable Outpatient Therapy program within our community and a partnership with a Home Health Company to handle our skilled Nursing needs.

The short of the long is we provided Respite care for 21 days for a Total Hip Replacement patient who was being discharged back to her personal home with Outpatient PT/OT. The patient is 82 years old, fairly independent and lives along and her family decided they didn't want her to recover at home alone. Her surgeon ordered for her therapist to work with her in our community 72 hours post op and we provided room, board, meals, socialization and oversight. The patient was able to do her own Lovenox injections, so the surgeon did not order Home Health (ALFs in Georgia cannot administer any injections, except Epinephrine and Insulin). The patient recovered so well under our care and partnership of those involved, that the surgeon referred her to us for her second replacement in August. Now, we are having surgeons inquiring if we will be willing to respite their residents.

It took us a lot of time to coordinate her care, as this was new to us. We are seeing three times more patients have Ortho surgery and coming home.

Our facilities have both LPN/RN's on staff and on call 24 hours a day and can meet the needs of any resident that doesn't require 24 hour skilled nursing care. We meet the State's regulation by partnering with Home Health providers and Hospice to meet the temporary skilled needs of our residents.

So, now I've been charged with quickly creating a program that will ensure we are providing high quality care and services to patients who are receiving after care in our facility. I wanted to know if there is a Clinical Pathway or process which we should be following for an Ortho patient who is discharged home? We will be involved in the perioperative process as well, as it is important for us to establish the resident's baseline, assess post operatively to ensure their needs can be met in our facility.

Any help would be appreciated. Forms, websites, suggestions, etc.

Thanks so much.