Since joint replacement procedures debuted in the mid-20th century, people with limited mobility have gained a new lease on life. The general population no longer views arthroplasty as futuristic “bionics,” but accepts and endorses it as a viable option for staying active, productive, and independent. But replacement surgery alone does not catapult the patient onto the golf course or the dance floor. It takes time, focused rehabilitation, and a committed partnership with care providers to get the patient back on his or her feet.

Skilled nursing facilities (SNFs) increasingly offer rehab opportunities to patients with total knee or hip joint replacements. “Today, younger people are opting for new knees and hips,” says Glenda Mack, PT, director of clinical rehab for Peoplefirst Rehabilitation, “and joint replacement is no longer just an option for the elderly. Long-term care facilities are beginning to experience an influx of younger patients in their 40s and 50s because managed care organizations and/or Medicaid are more willing to cover care in a SNF rather than in an in-patient rehab setting.” She adds that younger patients usually experience shorter SNF stays unless they have medical comorbidities. “By and large,” says Mack, “younger people generally fare well in the SNF environment and, barring any medical issues, can complete their program in three to four days.” Rehab companies and SNFs are recognizing this market shift to provide care that focuses on the needs and expectations of a younger clientele.

Meeting Equipment Needs

Smaller facilities may not have the equipment needed to manage this type of patient. “If we are considering a patient for admission into a smaller facility,” Mack says, “it is important to have an up-front conversation between nursing, rehab, and administration to verify that we can provide an appropriate rehab program. The SNF might have to acquire a temporary rental or lease specific equipment, such as a continuous passive motion machine that is integral to total knee rehab.” She notes that if a facility accepts many of these cases, the appropriate therapy equipment generally is available on-site.

Rehab: A Team Approach

Patient evaluations are done with nursing staff participation to ensure that all parties are aware of the patient’s plan of care. “We want to make sure that the patient is not only mobile during therapy sessions, but that nursing helps to encourage continued mobility outside scheduled therapy hours,” states Mack. She notes that often family members are very proactive and involved with their loved one’s recovery and want to learn how they can help in the recovery process.

Mack believes that one of the keys to successful patient outcomes is communication between rehab and the nursing team. For example, caregivers must be informed about each patient’s precautions—especially with those patients who have undergone total hip replacement. “It is imperative that staff are aware of any joint limitations or weight-bearing restrictions imposed by the patient’s physician,” advises Mack. “This information is crucial to reduce the risk of harm to the patient when providing care and assistance during activities such as transferring, walking, and dressing.” Along with educating the nursing team on matters related to functional mobility, therapists provide training on and support with pain management. “And the best pain management happens when rehab and nursing effectively communicate,” says Mack.

The Importance of a Stable Staff

The ultimate goal of rehab is to get the patient mobile as quickly as possible. Of late, there has been a move to reestablish distinct units for managing both rehab needs and medical complexity in nursing centers. “Organizations recognize that although relatively stable, patients may have some medical issues,” notes Mack. “Distinct units are usually staffed with caregivers familiar with the rehab process and who become aggressively involved with the patients.” Consistent staffing is also beneficial because patients know their caregivers and are more receptive to working with people they know and trust. While distinct units have become more common, it is important to recognize that many nursing centers without distinct units provide excellent intensive rehab as well as skilled nursing services for medical complexities, she adds.

Outside therapy sessions, staff—CNAs, nurses, dietitians, etc.—keep the rehabilitation process going. Mack acknowledges that therapists are not the 24/7 caregivers. “Because of their constant interactions with residents, it is absolutely critical that nurses understand a patient’s physical limitations, as well as his or her physical abilities,” she says. “With rehab patients, we stress that the nursing team allows them to be as independent as possible. They are there to increase their mobility, so we have to encourage the patient to make the most effective use of their current mobility.” She adds that staff must switch their mentality from that of being a 100% caregiver—and that means letting the patient do for him- or herself, and only step in when assistance is necessary.

Challenging Residents

Occasionally, according to Mack, therapists may encounter patients who have challenges actively participating in the rehab process. They may have difficulty getting past their pain or might be suffering from depression or other psychosocial issues that need to be addressed before rehab can be effectively managed.

Pain. Pain management, too, requires a team approach. Uncontrolled pain makes it difficult to motivate a patient to face the hard work that is part of rehab. Therapists rely on nursing staff to communicate any problems the patient might manifest throughout the day. Is there an increase in pain? Did staff notice a change in the way the patient walks? The distance traveled? “Therapists need to know this sort of information,” says Mack. It’s critical that the therapist be made aware of any acute change the nursing team notices. “For example, a patient may have been dressing him- or herself and only required assistance with the right leg (the injured leg). But now staff notice that the patient is having trouble with pain and movement in the left leg, as well. This decrease in mobility and independence needs immediate attention and physician notification,” advises Mack. Providing and updating information such as this enables the interdisciplinary team to meet, review, and revise the care plan, as needed.

Weight management. Often, weight management plays a key role in successful rehabilitation following a joint replacement. Many joint replacements are a direct result of degenerative joint disease with obesity as an underlying factor. “It is important as a team of healthcare providers to determine patients’ willingness to participate in an active fitness and weight management program,” Mack says. “If they are ready, we can send them home more mobile and with a clear plan to support a healthier lifestyle, possibly mitigating future health risks.”

Depression and behavioral issues. Because successful therapy relies on attitude and teamwork, rehab must be aware of any issues with behavioral changes. “To create an effective care plan, it is important that the therapist is aware if a patient has cognitive and/or behavioral issues,” advises Mack. “A patient might do well in the morning, but it might take two CNAs to handle him or her later in the day. This could be caused by fatigue, pain, or dementia-related behaviors such as sundowning. All of these possibilities must be considered.”

Cognition and Joint Rehabilitation

The exercises for joint replacement therapy are relatively standard. However, cognition affects how instruction is given. A patient with good cognition might be shown the exercises and then would perform them independently while using the time with the therapist to focus on higher level mobility. “However, someone with cognitive issues is trained differently,” says Mack. “We do more repetition and provide more hands-on attention during the session, which enables the patient to learn the activity and gain strength at the same time.” Someone with cognitive issues may take longer to rehab than someone cognitively intact or may require alternative compensatory training techniques, she adds.

Anesthesia reactions after surgery can be an issue, especially in the geriatric population. The first few postoperative days in the hospital may leave the patient disoriented, confused, and possibly delirious. “In these situations, it is difficult to get the patient to cooperate and follow instructions,” reflects Mack. The patient also becomes a falls risk challenge because of post-anesthesia confusion. When the patient is discharged to the SNF setting for rehab, he or she endures another change of environment that may precipitate even more confusion. “At this point, however, the acute delirium triggered by the anesthesia begins to wear off and cognition improves throughout the SNF/long-term care stay,” Mack says. “We see significant turnaround within 48 to 72 hours as the patient accommodates to his or her environment.”

Conclusion

The time spent in rehabilitation for joint replacement is shifting downward because of multiple advances in medical procedures and pain management. Acute in-patient care lasts two or three days, down from the historical five to seven days and, unless the patient has other comorbidities, SNF stays may decrease, as well. In other cases, some joint replacement recipients are discharged immediately to home and receive their therapy as an outpatient or through home health providers.

But for it all to work smoothly, communication is the key. “There needs to be an open door between rehab and nursing—this partnership is the main ingredient for successful rehab under any circumstances,” says Mack. She acknowledges that rehab facilities that have the best outcomes and best patient satisfaction are those with effective communication and ongoing patient support from the entire interdisciplinary team.