Coordinating Care from Amputation through Rehabilitation

By Laura Fonda Hochnadel

They say no man is an island, and that is likely true with regard to healthcare professionals providing the most effective O&P care. According to the experts The O&P EDGE spoke to, the more members of a patient's healthcare team coordinate with each other, the better the patient's outcome.

The O&P EDGE asked professionals from several different healthcare settings how they go about coordinating care from amputation through rehabilitation and how this improves their ability to care for their patients.

What Is "Coordinated Care?"

Due to a lack of a consensus definition of "coordinated care," the authors of the Agency for Healthcare Research and Quality's (AHRQ's) Care Coordination Measures Atlas (2011) defined the term using common data from 40 definitions they extracted after completing a targeted literature review. From that work, they developed a purposely broad definition of coordinated care.

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Coordinating care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.

The authors also identified five key elements comprising coordinated care:

  1. Numerous participants are typically involved.
  2. Coordination is necessary since participants depend on each other to carry out disparate activities in a patient's care.
  3. To carry out these activities in a coordinated way, each participant needs adequate knowledge about his or her own and others' roles and available resources.
  4. To manage all required patient care activities, participants rely on exchange of information.
  5. Integration of care activities has the goal of facilitating appropriate delivery of healthcare services.

Source: AHRQ's Care Coordination Measures Atlas
(www.oandp.com/link/254)

Communication and Information Exchange Are Key

team

Inherent in the term "coordinated care" is the involvement of multiple participants from a variety of medical backgrounds. For the care of individuals with amputations, it can be as inclusive as involving the surgeon, a case worker or case manager, a physician, a physiatrist, a physical therapist, an occupational therapist, nurses, a prosthetist, a social worker, and a mental healthcare professional. It can be as simple as involving the physician, physical therapist, and prosthetist. Or it can fall somewhere in the middle of these two ranges. Regardless of the size of the coordinated care team, our experts agree that communication and the exchange of information are critical to making the model work and providing the best possible outcomes for their patients.

Chris Wallace

Wallace

Jeff Erenstone

Erenstone

"Communication is so essential," says Chris Wallace, CPO, FAAOP, the director of orthotics and prosthetics at Methodist Orthotics and Prosthetics, a division of Methodist Rehabilitation Center, Flowood, Mississippi. "To have an understanding from all the stakeholders about [our outcome goals] is vital. When the care is coordinated between all the various members of the team we can all have that common goal in sight and all work together." Sometimes achieving that common goal involves stepping outside of defined positions or care models as well as some clever thinking.

Jeff Erenstone, CPO, president and head clinician of Mountain Orthotic & Prosthetic Services, Lake Placid, New York, owns and operates an eight-person O&P patient care facility in a rural area where there is a lack of physiatrists-the medical professionals who he believes are best suited to be the coordinated care leaders. To compensate, he has assumed some of those duties into his role.

"I'll work with the discharge planners from the hospitals to help make sure [the new amputee patient] goes someplace where they can get the continued care they need from a prosthetics standpoint," he says. He also works with the nursing staffs and hospitals, especially if a patient has been fit with an immediate post-operative prosthesis (IPOP). He has gone so far as to write IPOP-related protocols, which he has gotten sanctioned by the physicians and the hospitals with whom he works. "They now have this education on a device that they couldn't learn how to don otherwise," he says.

Erenstone says he made a concerted effort to get to this level of involvement. He opened his practice about six years ago and says he immediately starting introducing himself to local healthcare professionals. Whenever he received a prescription that he had a question about, he called the physician to ask about the patient and then followed up with some information about him and his practice methods. "It took work. It took a lot of steps," he says. But now he has formed relationships and gained the trust of local surgeons and physicians, and the lines of communication are open.

Patrick Logan

Logan

Both Wallace and Patrick Logan, CPO, work at rehabilitation facilities with no acute hospital affiliation-Logan is vice president of operations and development at Mary Free Bed Rehabilitation Hospital Orthotics & Prosthetics, a sister corporation of Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan. The O&P staff at Mary Free Bed O&P and Methodist Rehab have also formed relationships and opened avenues of communication with local surgeons who will call, fax, or send an e-mail when their services are needed. Logan and his staff make themselves available for pre-amputation consults with patients. Wallace says that reaching out in this way is beneficial to the patient and prosthetic care outcome.

"The patients are much more involved in their care at that point," Wallace says. "Rather than being reactionary to what is happening, they are beginning to investigate products and approaches so they become more involved in the process.... They ask more important questions. They are looking at more long-term solutions."

Yet he understands why surgeons don't always reach out to subsequent members of the amputee care team. "Their job is to resolve whatever it is that needs to be resolved through surgery and then get the patient to another physician who will manage the care," he explains.

Danielle Melton

Melton

Conversely, the amputee clinic at The Institute for Rehabilitation and Research (TIRR) Memorial Hermann, Houston, Texas, is affiliated with an acute care hospital, and the surgeons who perform amputations readily reach out to the clinic. A simple phone call is all it takes for a physical medicine and rehabilitation (PM&R) consult with a patient either preamputation or shortly thereafter. "In that case I use a lot of educational tools, which we have through the Amputee Coalition...[and] I give them two websites-one is the Amputee Coalition website...and the second is oandp.com...," says Danielle Melton, MD, director of the TIRR Memorial Herman Amputee Program and clinical assistant professor in the PM&R Department, University of Texas at Houston Health Science Center. She says this helps the patients "feel like they are gaining more control over their situation then they would have normally."

A Means to an End

All of our experts agree that the common goal with their patients who have undergone an amputation is restoring patient mobility and achieving the best possible prosthetic outcomes.

"We are here to rehabilitate people," Wallace emphasizes. "And part of that rehabilitation is to return them or restore them to their former capability as much as possible."

So how do our experts, within their various care models, go about restoring mobility to their patients with amputations?

For patients who undergo amputation surgery at TIRR Memorial Hermann, the typical protocol is that he or she is discharged home for recovery and then the patient follows up with the surgeon who transitions him or her to Melton and the amputee clinic for pre-prosthetic care. At the amputee clinic, the patient is seen by a multidisciplinary team comprising Melton, the prosthetist, the physical therapist, a member of the nursing department, and Melton's clinic coordinator. Melton says that though they are not a part of the patient assessment, the amputee clinic also has access to an onsite social worker and an onsite psychologist.

"I'll do the physical exam, and then we'll...go down the list of prosthetic needs. At the end, we'll say, 'Okay, you need to follow up,' or we recap on the things we are going to do as far as the [prosthetic] plan goes...," Melton explains.

Aside from direct interaction, the coordinated care team relies heavily on electronic medical records (EMRs) as a means to exchange information, coordinate care with the in-system staff, and receive patient updates. Another advantage of the insystem staff, Melton says, is they are just a phone call away. "[I] could pick up the phone and call the surgeon and say, 'Hey, at what point can we take out the sutures?' or 'Do you want me to take out the sutures?'" E-mail and text messages are also often used communication options for in-system staff and outside referrals, Melton says, emphasizing that her clinical coordinator plays a large role in facilitating this communication for her and ensuring patient care follow-up.

patient and clinician

The care coordination and information exchange is augmented by use of a template that the amputee clinic follows. Melton says the template is based on work the Amputee Coalition's Scientific & Medical Advisory Committee (SciMAC), of which she is chair, is doing with the Centers for Medicare & Medicaid Services (CMS) to establish what documentation is in the O&P patient's medical record, as well as a continually modified and refined version of the U.S. Department of Veterans Affairs (VA) amputee care template. "We are always trying to update it to make sure we have all the relevant information, especially from a documentation standpoint," she says. The template helps the amputee clinic assess issues from activities of daily living, to pain levels, to medical complications, to pre- and post-amputation functional status, to prosthetic fit, to past and current medical history, to exercise and therapy programs. In essence, the clinic notes Melton and her colleagues collect by using this template become the care plan, she says. This template, too, is the basis for the physical therapy and prosthetic prescriptions.

Mary Free Bed's amputee program provides an integrated approach to care, referred to as the Amputee Continuum. "We treat one aspect of the patient [in the O&P clinic], but it covers a broad continuum of what the patient needs," Logan says. That broad spectrum includes diabetes management, traumatic brain injury rehabilitation, post-stroke comorbidities, chronic pain, custom seating, orthoses, and assistive technology-provided through Mary Free Bed Rehabilitation Hospital. He says that many of the individuals with amputations that they see also require an orthotic device.

For the initial visit to the amputee clinic, the patient's needs are assessed under the guidance of the Amputee Program Director Benjamin Bruinsma, MD, with a prosthetist and physical therapist in attendance. Logan says that these needs can extend beyond prosthetic care and physical therapy to include medical, financial, or psychological assistance. A feature of the Mary Free Bed Amputee Program is that Bruinsma can make arrangements with the proper healthcare team member to provide the patient with the assistance he or she needs, Logan explains. "And they will assess training needs, any physical therapy needs...prosthetic needs, and...if they have some other needs beyond that." Mary Free Bed also offers its patients what Logan says is one of nine accredited motion analysis labs in the country. This allows them, he says, to "not only provide the prescribed devices but provide objective data to prove how they improve a patient's function. We can essentially quantify our outcomes."

Like the amputee clinic at TIRR Memorial Hermann, Mary Free Bed O&P relies heavily on communicating and exchanging information via EMRs; the facility is in the process of updating its EMR system to one that is better suited to meet its needs, Logan says. Communication is also made possible via pagers, e-mail, and phones. "They can call us, and we can pretty much be reached anytime, anywhere with cell phones," Logan says. "We are accessible. If something is needed inpatient- or outpatientwise, we are a phone call or e-mail away. Sometimes they just come and get us."

The convenience of being just a walk away is something that Wallace and the O&P department at Methodist Rehab have in common with Mary Free Bed O&P. "Because the main outpatient O&P patient care facility is physically connected to the outpatient neurophysical therapy department, there can be a lot of walking back and forth between the two departments to collaborate on patient care," Wallace says. If the patient is in the O&P facility "and having some issues that either aren't being addressed with therapy, or need more extensive therapy, we have that availability to talk to the therapist, converse with the physician, and get those things worked out," he says. But it is not this easy, he acquiesces, for patients who have not gone through Methodist Rehab's inpatient amputee rehabilitation or who are not seeing physical therapists at its Flowood facility.

"For many, it is still a matter of getting on the phone and talking to [the physical therapist]," Wallace says. "[W]e'll actually make a trip to the patient's physical therapist's office on one of their first visits. That way we can describe the componentry the patient is using. If the therapist is not really familiar with some of it, we can give them some education at the same time so that they are training the patient correctly. We will provide that interaction early on as much as we can to make sure that we are getting the best outcome from these therapy services as well."

Erenstone likewise avails himself to accompany patients to physical therapy appointments so he can be at hand to make adjustments to the patient's prosthesis or share his knowledge and resources with the physical therapist. "I have amputee gait education videos that I loan out to therapists in case they don't feel comfortable or are unfamiliar with amputees," he explains. He says that physical therapists are easier to contact, which he does via e-mail or phone, and he finds that the best way to contact physicians is to forward his suggestion or request through their nursing staff. "A lot of times I'll contact the nursing staff and they'll run it by the doctor when the doctor has a free moment, and then the doctor will go forward with it." When necessary, however, he has contacted physicians via e-mail, phone, and pager. "Very seldom do I get face-to-face meetings. When I do it takes many scheduling attempts," he says, adding that physicians are generally so pressed for time that it is not worth pursuing.

Benefits

The benefits to the patient are what make this extra work worthwhile, our experts agree. While it takes more work on the front end, it reduces the back-end work and increases patient satisfaction and outcomes.

"If I manage their care a little bit more, they're probably going to be a higher functioning amputee who is going to need additional prostheses in the future," Erenstone says. "It makes the patients happy, it makes the doctor happy, and it makes the patient outcome better. I am always looking for win-win situations." Further keeping patients in mind, he has compiled a list of resources including home health agencies, independent living centers, and places to go for assistive devices such as hand controls for a car.

Melton says coordinated care is all about accessibility. "[W]hatever it is they need from a medical necessity standpoint, it is really important that we coordinate what is going on....You can't get things done unless you include everyone who is responsible for their pieces. [I]t's driven from one central process that knows what issues the patient is going to face...."

Coordinated care models instill confidence in the patients, Wallace says. "I certainly believe that when the patient sees that collaboration take place they have greater confidence in...both the system that is the delivery model and also in the prosthetic system, what components they are going to receive."

Indeed, the benefits of coordinated care also extend to the healthcare team as well. They are better informed about the patient's needs, comorbidities, and ancillary care. "We definitely have the advantage to have more than one practitioner in the room if we need it," Wallace says. "So if we get a complex case, and this happens very routinely here, we may bring two or three or four of us in the room to discuss what is going on. I think it is a great experience for the patient. And it really is good for us because we are cross-pollinating our education with each other."

"[I]f there are other needs of that patient, you are not just focused on your little silo, where I am just looking at putting this prosthesis on this person and getting them out the door and sending them to the next medical practitioner," Logan adds. "I think it makes us better clinicians, too, because we constantly have to work with our coworkers from other fields, from other areas of expertise, and we have to be familiar with their areas and they need to be familiar with ours, so we have to communicate.... [I]t takes away the tunnel vision."

Laura Fonda Hochnadel can be reached at