SNF Expectations Document
Orthopaedic Surgeon Expectations (Steps 1–13 only):
Joint Replacement Patients Discharged to SNF
1. Patients receive therapy on day zero after admission to SNF.
2. Patients receive therapy two times per day, seven days
3. A discharge plan is created by day two, detailing expectations for recovery and estimation of discharge date.
4. Pain will be controlled and pain medications available
5. Patients will use an incentive spirometer to prevent
6. Patients will wear their TED compression stockings on
both legs for at least two weeks after surgery to prevent
7. Patients are expected to do their ankle pump exercises
10 times per hour when they are awake for a minimum
of one month after surgery to prevent blood clots.
8. Patients’ INR will be monitored since they will be taking
Coumadin for one month after surgery.
9. Patients are expected to elevate their leg (and use ice)
to decrease swelling.
10. Patients will not shower or use tub until approved by
physician to prevent infection.
11. Estimate for length of stay (LOS) for knee is five to 14 days
and LOS for hip is five to 14 days, as clinically indicated.
12. Patients will follow total hip precautions:
a. No bending hip past 90 degrees.
b. No crossing legs (OK to cross feet at ankles, or ankle
over thigh, but do not cross legs thigh over thigh).
c. No passive ROM unless prescribed by surgeon.
d. Do use a chair with armrests and a cushion to raise
your seat height.
e. Do place operated leg forward when getting out of a
chair and use an assistive device for six to eight weeks.
f. Do navigate stairs “up with the good” and “down with
13. For hip replacement patients, the most important rehab
is gait training.
of patients requiring a Foley catheter, which is associated with
increased hospital LOS.
This program was successful in reducing discharges to SNFs
and LOS for patients both in the hospital and at the SNF. The
percent of patients discharged to a SNF after a joint replacement surgery decreased from 30% to 13% between 2013 and
2016 (see Figure 2). The average hospital LOS following a total
OC TOBER 2018
Collaborative Clinical Pathway
for Patient Discharged from
1. Manage all Basic Activities of Daily Living (toileting, bathing,
dressing, eating, grooming) safely with the help of adaptive
equipment and/or caregiver support 100% of the time.
2. Manage indoor mobility safely with/without mobility
device and/or caregiver support 100% of the time.
3. Use any assistive device safely 100% of the time,
as verified by routine return demonstration.
4. Manage bed mobility/transfers 100% of the time with/
without the use of specialized bed/adaptive equipment.
5. Demonstrate energy conservation techniques and use
them routinely with Activities of Daily Living.
1. Show a thorough understanding of the various care continuity options available following discharge from SNF.
2. Demonstrate and verbalize the safety precautions associated with their condition.
Care Transition Goals
1. Participate in home evaluation to assess the suitability
of recommendations made by the therapists.
2. Demonstrate a thorough understanding of the equipment needed upon discharge by having a meeting of
the patient, their physical therapist, social worker, and
patient’s family (if applicable) with equipment to be used.
joint replacement decreased from 3.5 to 1.5 days (see Fig-
ure 3). The 30-day readmission rate also decreased from
~7.5% in August 2015 to 0% in March 2016. Also, 94% of
patients from September 2014 to July 2017 reported that
they would have the surgery again at the health system.
Through this initiative, the physician group and health system
learned the value of patient input and going to the gemba. It is
essential to involve the staff who will be delivering care when
designing an intervention; the initial roll-out of the inpatient
care pathway was unsuccessful because nursing input was
not initially obtained. Last, Michigan Medicine learned that
interventions do not need to be complex in order to be powerful and have an impact on patient care.
Adapted from Michigan Medicine’s Acclaim Award application, submitted by Chief Quality Officer Steven J. Bernstein, M.D., M.P.H.