Since Hallmark Health began its program more than a year ago, the local healthcare system has driven orthopedic volumes and revenue, increased clinical quality, shortened length of stay, conducted research and, perhaps most importantly, developed a relationship with the community, said program and joint care coordinator Deborah L. Cronin-Waelde, RN.

Hallmark Health includes Lawrence Memorial Hospital in Medford, Melrose-Wakefield Hospital in Melrose, Hallmark Health Cancer Center in Stoneham, Hallmark Health VNA and Hospice in Malden and Hallmark Health Medical Center in Reading, MA.

"Our program is a nurse-led program, which is modeled on the best bone and joint programs in the country and is equal to - if not better than - some of the programs found in the most prestigious teaching hospitals," Cronin-Walde said. "We customize our care around the individual needs and values of each patient. Unlike other hospitals, our patients and their families have access to me 24 hours a day, 7 days a week."

Even though Hallmark Health hospitals are in a very competitive market, with the academic medical centers in Boston a short distance away, there is plenty of work for everyone when it comes to hip and knee replacement surgeries, which have skyrocketed in the past 10 years, she said.

In 2005, 285,000 total hip replacements and 523,000 total knee replacements were performed in the U.S., according to a study Richard Iorio, MD, senior attending orthopedic surgeon at the Lahey Clinic, Burlington, MA, presented at the annual meeting of the American Academy of Orthopaedic Surgeons in March.

By 2030, these two procedures are expected to jump to 572,000 and 3.4 million, respectively.
"The graying of America combined with the technological and product developments in orthopedics will continue to drive the need and it'll drive the demand for quality orthopedic care," Cronin-Waelde said.

Hallmark Health set out 2 years ago to look at service lines and, with a group of orthopedic surgeons and executive leadership, decided to target the total-joint program.

A task force with representatives from orthopedics, nursing, case management, physical therapy, home care, VNA and quality control developed the job description for the bone and joint coordinator, ultimately deciding the coordinator should be a nurse from the surgical services area.
Hallmark Health's nursing department embraces a professional model of practice called the synergy model, whereby the needs of patients are matched to the competency of the nurse.

Having a nurse run the bone and joint program would help incorporate the principles of that synergy model, matching competencies of teams to the needs of the total joint replacement patients and their families.

A PACU and surgical day care nurse, Cronin-Waelde was named to the coordinator role and charged with coordinating all of patients' preoperative needs, hospitalization, rehabilitation and discharge planning.

About 60 nurses and nurses' aides on two campuses underwent nursing-competency teaching and treatments were standardized while leaving room for individualized care.

"They understand what the physician's requirements are, what the patient's needs are. It makes a big difference in outcomes," Cronin-Waelde said. "So we develop clinical pathways and if patients fall out of a pathway, the nurse can assess why."

The task force quickly realized building community resources and educating potential patients about what Hallmark Health could do for joint pain would help them stand out among the competition.

"We do lots of lectures, monthly, to every community group out there, whether it be rotary or chamber of commerce or the AARP; there are a variety of different groups in all our surrounding communities," Cronin-Waelde said. "We just educate people about joint pain treatments and options. Hallmark Health backed up this new program with an extensive and integrated marketing and advertising campaign that included a TV ad, direct mail, newspaper ads and even ValPak marketing coupons announcing bone and joint community forums."

Once patients were drawn to the hospital and an orthopedist determined they needed total joint replacement, the focus shifted to preoperative education in the program's "joint camp," the focus of which "is to get a better preoperative education to get better surgical outcomes postop," Cronin-Waelde said.

With representatives from physical therapy, occupational therapy, home care, VNA, case management and surgery, joint camp meets once a month and reviews with patients the whole joint-replacement process.

"You want them to be better informed from the beginning to the end and they need to be active participants in their own care," Cronin-Waelde said. "A lot of issues surrounding surgery concern the fear of the unknown. If we can get the patient educated better preoperatively then they get a much better surgical outcome."

Patients can choose a family member or friend to become their "joint coach" and participate in their care and recovery process. Patients are given a personalized journal as a comprehensive guide to follow throughout the replacement experience, a preoperative assessment, a home environment assessment and a tour of the surgery unit.

"They get the opportunity to network with other joint camp participants, a checklist to complete prior to surgery and we do a complete discussion of their pre-operative exercise," Cronin-Waelde said.

Many patients have told Cronin-Waelde they were drawn to Hallmark Health for the informational session, but hadn't made up their minds about where to have the surgery, she said. Once they met the therapists, nurses and the rest of the staff, however, they felt comfortable and decided to undergo treatment at the hospital.

"They feel someone's really looking out for them," she said. "It's a great advocacy role."

Undergoing surgery in their community hospital also allows patients to be followed by their primary care physician while they're in the hospital, which can be particularly important for those with co-morbidities, such as diabetes and heart disease.

The most positive feedback Cronin-Waelde receives is when patients return to the hospital for their second joint replacement.

"The greatest reward is when I get the slip that says Mrs. Smith is coming in for her left knee because she had such a great experience with her right knee," she said. "Our volumes are definitely increasing. The message we try to get out is we can provide the same surgical quality with more personalized care in community hospitals."

About 250 joint replacements are performed at Hallmark Health each year and the local healthcare system has seen its general orthopedic volume grow by virtue of the community education, Cronin-Waelde said. "We have an amazing group of orthopedic surgeons, who are extremely skilled and focused on patient quality."

Cronin-Waelde is pleased with the program's success, but there is still more to achieve, she said.
"The ultimate goal is to become a center of excellence and get that distinction from the Joint Commission," she said. "We definitely have lots of strategies ongoing."

Some of those strategies include adding a self-contained orthopedic unit and pursuing nurse certification through the National Association of Orthopedic Nurses. And, of course, continuing to attract patients to the community hospital through education and high quality patient care, a goal Hallmark Health has already proved is possible to achieve.

"I really feel like I'm making a difference, and otherwise I don't think I could do the role," Cronin-Waelde said. "You see these patients preoperatively and they're immobile, uncomfortable and frightened because they've heard horror stories about people who have joint replacement."
After attending joint camp, they show up to the hospital feeling less anxious and well informed and, as a result, experience a more positive surgical outcome.

"When you ask the patients to be active participants in their care, the outcomes are so much better," Cronin-Waelde said. "I always do follow-up calls, days, weeks and months out. When I talk to them they say 'I'm traveling Europe; I'm back playing golf; I'm skiing; I'm doing all these things.' It makes it all worthwhile."


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