The Group Experience: Remodelling Outpatient Rehabilitation after Joint Replacement Surgery

The Holland Centre has created an innovative, evidence-based, patient-centred model of care that is class-based and time-limited. Nationally, rehabilitation practices vary widely, and in Ontario, limited availability to community funded outpatient services as well as a reduction in hospital-based outpatient physiotherapy has significantly impacted patients’ access to care. By increasing the number of patients (from 3-4 to 10-14 per class) treated in a given time period, the group model improves access to outpatient physiotherapy while reducing reliance on inpatient rehabilitation. After Total Knee Replacement (TKR), an immediate period of intensive exercise and active rehabilitation is needed. Patients now attend a 90 minute goal-based post-operative class consisting of group and individualized treatment twice a week for 4-6 weeks. Patients undergoing Total Hip Replacement (THR) often have movement restrictions; therefore treatment later in the continuum of care can be of greater benefit. In the revised model, at the first follow-up appointment (6 week point), patients receive a 90 minute group session (up to 6 participants) which covers progression of functional activities, along with individualized gait, stair and exercise progression. Creative elements of the program include: • the development of a standardized care pathway that accompanies the Postoperative TKR Class which includes validated outcome measures; initial and discharge assessment components; a section for charting attendance and a treatment key to facilitate abbreviated documentation. • From a human resources perspective, there has been a shift from using physiotherapists only to a team which includes a physiotherapist, physiotherapy assistant and a volunteer who is often a past patient from the classes. Better educational materials have been added to support the classes. • One of our Advanced Practice Physiotherapists worked with the Canadian Orthopaedic Association in developing “Get Moving: Maximizing Your Activity after a Hip or Knee Replacement” which patients find a wonderful resource. • To improve the transition to active living upon discharge from the classes, we have also partnered with the YMCA for patients to continue to exercise with instructors that have been trained by our team and physiotherapists from the Arthritis Society. Patients are achieving positive outcomes, exemplified by the following: • average reduction in pain score of 8.3 • average improvement in range of motion [knee flexion] of 33.4 • improvement in function [average reduction in stair time of 33.2 seconds], and • improvement in strength [average increase in Quads 1 repetition 50.8 lbs.] • Patients also scored very high [8.3 out of 10] on meeting their treatment goals. • overall satisfaction measures were high. The redesign of the model represented a bold move when many organizations were still offering a more traditional approach of individualized therapy. Based on our tracking and research, the model has increased patient access and improved outcomes without compromising patient satisfaction.