Total Joint Procedures to ASC Settings: Key Steps in Making the TransitionAt the 19th Annual Ambulatory Surgery Center Conference in Chicago on October 27, John R. Moore, IV, MD with Orthopedic and Joint Replacement Center in Pinehurst, N.C., and Tracey Harbour, BSN, RN, administrator with Surgery Center of Pinehurst, part of Overland Park, Kan.-based Nueterra Healthcare, shared best practices for ASCs to shift total joint surgery to an outpatient basis.
Surgery Center of Pinehurst began performing total joint replacements in May 2009. Ms. Harbour began the presentation by discussing steps taken when shifting total joints to an outpatient basis. Initially, the center evaluated their existing line of business. This includes investigating new procedures that could be performed in an ASC, evaluating the possibility of doing total joint replacements and the possibility for 23-hour stay to determine if joint replacements were possible in the ASC setting.
The next step was a financial evaluation, including reimbursement steps for joint procedures. In the Pinehurst area, payors reimbursed either on a percent of billed charges or a flat fee plus implants. Medicare, Medicaid and Tricare, however, do not reimburse for joint replacements in the ASC setting. Consequentially, those cases are not treated at the ASC. Overall, joint procedures were found to be profitable on an outpatient basis. The surgery center's program charges co-pays and co-insurance based on percent of billed charges.
Ms. Harbour and Dr. Moore discussed several benefits of joint replacements in the ASC setting, including lower costs to patients, a flat fee per procedure and implant, decreased infection rate, lower cost to payors, improved pain management and better recovery at home. "From the patient perspective, many patients say, 'I just don't want to be in the hospital. If I can do this, it is better if I just go home,'" said Dr. Moore. "If I were to have my own joint replacement done, I'd prefer to do it as outpatient and go home and sleep in my own bed."
Post-op, patients and home health agencies have direct access to physicians and physician assistants via telephone. The providers share their contact information so patients are able to call with any questions. "And we do call the patients every day," said Dr. Moore. "That's part of the concierge part of [the ASC]. It doesn't take much to call the patient and say, 'How was your night last night? Is there anything you need?'"
For outpatient joint procedures, patient selection is key. Factors that go into determining the best patient are age, medical history, size (a body mass index less than 40), family support, psychological functioning and insurance considerations. As for staffing, these procedures call for one nurse and one CNA for a 23-hour stay. The most experienced registered nurse is used for the 23-hour stay, preferably a nurse with PACU and ICU experience.
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