Faster, Safer Recovery at Home After Joint Replacement: CJR Model Participant Stories

Providers participating in Comprehensive Care for Joint Replacement Model say shift to home recovery delivers major benefits for patients

Hip and knee replacement often results in long recoveries at a skilled nursing facility, where patients are bed-bound, face higher risk of infections, and potentially have worse outcomes.

But now, with better education and care coordination before surgery, many patients can safely recover at home, healing faster with fewer complications and with a greater sense of empowerment in their own recovery. That’s a key goal of the Comprehensive Care for Joint Replacement (CJR) Model, a Center for Medicare and Medicaid Innovation pilot program, which aims to reduce the length of time spent in the hospital or in a skilled nursing facility after surgery.

For American Fork Hospital, a CJR participant near Salt Lake City, Utah, one of the biggest challenges to reducing complications after hip and knee replacement surgeries was changing expectations – for patients and clinicians alike.

“That’s what we needed to change, was that culture, that it was safe for them to go home with their family members,” said Melanie Johnson, a clinical initiatives manager for Intermountain Health, the system that owns American Fork Hospital. Meanwhile, she said surgeons also needed some convincing.

“It was the surgeons that were more resistant than the patients,” she said. “But when they started looking at the data, they started changing their minds.”

American Fork has been a CJR participant since 2016, the first year of the model. Before the model, nearly half of the hospitals’ hip and knee patients would be discharged to a skilled nursing facility after surgery. Now, only around 10% of the hospital’s hip and knee replacement patients are discharged to a skilled nursing facility after surgery, while the rest recover at home. The hospital said it cut its post-surgical complication rate in half, to 1.2%, well below the national average. This approach also can lower costs.

“You have patients younger and younger who want to stay active, interact with their grandkids,” Lee said. “To be able to have them come back and say, ‘I can do the things I never thought I could do again’ and be pain free – it’s a huge reward.”

Evaluations of the CJR Model have found that measures of health care quality, such as hospital readmissions and the complication rate, improved or remained the same.

At PIH Health Whittier Hospital near Los Angeles, Calif., joint replacement nurse practitioner Aimee Lee had a similar experience in the early years of the model, starting in 2019.

“Initially, it was tough trying to explain to patients that as long as it’s safe, we’re going to expect them to go home,” Lee said.
But the COVID-19 pandemic brought a shift.

The pandemic “forced health care as a whole to think, do we need to keep patients in the hospital, or can they do things at home?” she said.

Now, Lee spends much of her time educating patients on what to expect after their surgery and how to have a successful recovery. The process includes a detailed booklet on how to prepare the home for recovery, a virtual class and answering questions.

To be sure, not every patient is a good candidate to go home right hip or knee replacement surgery, for instance if they have a lack of family support. But Lee said most patients can be safer going home rather than to a skilled nursing facility. The hospital checks up on the patients at home and can send home health nurses.

“When patients are in their home environment, they do a lot more things for themselves,” Lee said. “It pushes patients to be more independent quicker, but in a safe way.”

Lee said since the hospital has made these changes, their readmission rate has not increased, and patients are more satisfied and feel more invested in their recovery.

“You have patients younger and younger who want to stay active, interact with their grandkids,” Lee said. “To be able to have them come back and say, ‘I can do the things I never thought I could do again’ and be pain free – it’s a huge reward.”