RED FLAG #4: “I’m 87-Years-Old, Live Alone, & Have 3 Flights of Stairs – You Are Not Making Me Go Home, Sonny”
Adolph V. Lombardi, Jr., M.D., F.A.C.S.: I started practice in 1988. We were keeping patients in the hospital 10 to 14 days. We then started transferring patients to skilled facilities associated with the hospital, then transferring to outside facilities, then the whole rapid-recovery minimally invasive surgery craze, building my own hospital, and getting length of stay down to 2.5 days and now about 40% of my patients are done the same day.
In 2001, I published paper on simultaneous bilateral knees and in that group there were 897 unilateral knees. We then broke them down into age less than or greater than 80. Of course, there were more complications in our older age group even in the unilateral as more so than in the bilateral. Then we looked at discharge disposition: 57% of those patients greater than age of 80 were going to a skilled facility back in that day and only 21% for those less than 80.
From 2013 through 2018, I’m crazy enough to have done 27 patients that were 80 to 90 in an outpatient facility and 284 that were between the age of 70 and 80.
Looking at length of stay, 228 or 3.8% stayed overnight and you do see that for those 228 or greater than the age of 80 for 1.8%
In 2016-2018, discharge to skilled facilities goes down to 12.8% from that initial high number of almost 50%.
The average length of stay for our patients is 19 days. Cost per day is anywhere between $500 and $525. Average cost is about $9,500 per patient.
If you look at the discharge size for adults greater than age 65, in 2010, primary knee, 50% are going home, 8.7% were discharged transfer to skilled or short-term facility, and 29% to a long-term care facility.
It starts with the surgeon evaluating the patient, setting the stage, and understanding the home situation. To decide, “is the patient a candidate for the operation?” we need to know where is that patient going to be operated on, do they have adequate support at home, what’s their home environment? We want to minimize risk when optimizing patient’s medical condition and have the appropriate support systems available by patient’s preference.
A medical consultant evaluates every patient to correct the correctable and let us know what is uncorrectable. I’m not looking for “clearance,” I’m looking for them to optimize the patient so that the patient undergoes this operation with minimal risk. We have to start talking about the patient about discharge planning right from the get-go. When we see the patient, they are called by a pre-op nurse to make sure they have a plan for when they’re going home.
Skilled facility cost can be anywhere from $6,000 to $11,000, so you have to be able to partner with the skilled facility you’re sending the patient to if you’re in a bundle situation.
Can patients living alone safely be discharged to home? Yes, if the patient is medically optimized and has somebody that’s going to look after them on occasion. Even octogenarians can safely be discharged, but you need to make sure that they are pre-operatively optimized.
Please visit orthosummit.com for more information at this year’s upcoming event on December 11-14, 2019 at the Bellagio in Las Vegas, Nevada.
