Faced with length of stay challenges and a multitude of PAC providers, Dr. John Wright and the BWH Care Coordination team initiated a program to improve the transition of care for single joint patients. In November 2007, a pilot was started to move the bulk of single-joint patients' care planning from post-operative to pre-operative. The pilot proved so successful, it has since officially earned "program" status, and is spearheaded by Wilma Frieson-Gaskin, RN, Care Coordinator for the Single Joint Program.

Since its inception, the program has managed the post-operative care needs of over 650 patients, and reduced the acute length of stay by a full day, or one-third the previous time patients remained hospitalized. Dr. Thomas Thornhill, Chairman of the Department of Orthopedic Surgery at BWH, has also joined Dr. Wright in managing his patients care under this model.

It's been a win-win situation. Lisa Wichmann, Program Manager for Care Coordination at BWH, explained that not only does the hospital benefit from a reduced length of stay, but the pre-planning and pre-admission processes help prepare patients and families to think about their needs following discharge. Wichmann noted that advance planning for the next level of care (inpatient rehab, skilled nursing, and homecare with services) helps put the patient's mind at ease. Care coordination and case management can become more challenging if such decisions need to be made following surgery when pain, mobility or other medical issues might come into play. When asked how she would portray the benefits of this successful program to other care coordinators and case managers, Wichmann said, "Devoting care coordination and case management resources in a pro-active manner, up front, has helped decrease work on the back end."

The post-acute providers of PCC offer specialized rehabilitation services using surgeon-directed orthopedic protocols. PCC's liaisons work closely with Brigham and Women's Care Coordinators to assure a seamless transition of care between the acute care hospital and one of our post-acute settings. Sheridan Bergdorf, a PCC liaison at BWH, commented that PCC's expertise in rehabilitation and full array of post-acute options combine perfectly with the Single Joint Program's proactive approach to care coordination, leading to timely patient discharge.

If you would like further information about the Single Joint Program at Brigham and Women's Hospital, please contact Lisa Wichmann at 617-732-5500 ext. 31934, lmwichmann@partners.org.