Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 4. Replacement


At Keystone East, once an enrollee has been identified as requiring joint replacement, a nurse care manager who specializes in orthopedics telephones the patient prior to surgery, and assesses his or her condition, asks about the layout of the house, and gauges the pain and discomfort level. This is followed by two separate home visits. The first is by a nurse who reviews the patient’s physical and social needs, evaluates the safety of the home, and provides education about the surgery, such as instruction on postsurgery breathing techniques. The second is by a physical therapist who evaluates gait and postsurgery needs for durable medical equipment. The physical therapist may also provide instruction on presurgical strengthening exercises and on how to use the equipment. Once the patient is discharged from the hospital, a care manager and physical therapist follow the patient as needed.

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