Table 1 Overview of perioperative and post-discharge protocol for all patients in the study
Perioperative management (All patients) | Post-discharge management (All patients) | Medical home management (Patient-Centered Medical Home patients only) |
|---|---|---|
1. Perioperative risk assessment and management | 1. Follow-up with High-Risk Osteoporosis Clinic (if needed) | 1. Nurse Case Manager (CM) makes initial call to patient within 24–48 hours of hospital discharge. |
2. Timing of surgical intervention | 2. Continuation of aggressive physical therapy | |
3. Prophylactic antibiotics | ||
4. Thromboembolic prophylaxis | 3. Deep venous thrombosis (DVT) Prophylaxis | 2. CM reviews medication list with patient. |
5. Prevention and management of delirium | ||
4. Wound check, functional evaluation, and radiographic examination at 6 weeks | 3. CM ensures that follow-up visit is scheduled with primary care provider within 7 days. | |
6. Prevention of decubitus ulcers | ||
7. Prevention of Constipation | ||
8. Physical therapy intervention | 5. Periodic assessment (no less than every 3 months) until a baseline functional state or death occurs | 4. CM ensures that a patient-specific action plan is in case if patients have any trouble. |
9. Assessment for underlying osteoporosis | ||
10. Appropriate discharge placement | 5. Patients receive weekly calls (2–3 minutes) for 4 weeks, to ask about complications or areas that need follow-up from CM. |