Patient- and family-centered care leads to better outcomes

Being able to view care through the eyes of patients and their families is critical to delivering the ideal care experience, believes Anthony M. DiGioia, MD. That belief led him to develop a patient- and family-centered care (PFCC) model, which he piloted at the total joint replacement program at the University of Pittsburgh Medical Center (UPMC).

“Patients and their families can serve as additional resources in helping clinical providers deliver care and, in doing so, they become active partners in the care process,” explained Dr. DiGioia.

“Artificial silos exist in the current healthcare delivery system that prevent us from delivering exceptional care experiences to everyone, all the time. This methodology cuts across departmental silos by changing how care is viewed and delivered. It’s a transformational approach,” he said. “The key to making it work is requiring caregivers to view all care experiences through the eyes of the patients and families.”

According to the AAOS, patient-centered care is “the provision of safe, effective, and timely medical care achieved through cooperation among the physician, an informed and respected patient (and family), and a coordinated healthcare team.”

PFCC’s meaning of caregiver goes well beyond the typical definition of doctors, nurses, and therapists. PFCC caregivers also include parking attendants, housekeepers, dietitians, administrative staff, and more.

“It’s a broad, but very necessary, definition.” said Dr. DiGioia. “Because all these people directly touch a patient’s care experience, they must be included in the process.”

PFCC yields big dividends
The PFCC process at The Orthopaedic Program at Magee-Womens Hospital of UPMC has become the Hip and Knee Arthritis Care “Home” for patients and families because it covers the full cycle of patient care, beginning with the in-office visit. That visit sets the stage for the remainder of the patient and family care experience. Two to three weeks before their surgery, patients come to the hospital for preoperative testing and a required 2-hour educational session. Each patient brings a “coach,” a family member or close friend who goes through the entire care experience with the patient.

The nurses who perform the preoperative testing and education, are also the day-of-surgery nurses. This helps reduce patient anxiety.

“Setting the stage for the patient preoperatively also improves efficiencies for the surgeon and operating room,” said Dr. DiGioia. “We rarely have a cancellation on the day of surgery, and we rarely have delays in surgery. The efficiencies achieved also carry over into the operating room by having focused teams that significantly improve performance there, too.”

To gauge their performance, The Orthopaedic Program, based on the PFCC Methodology and Practice, which currently includes four total joint surgeons and two spine surgeons, conducts a patient survey at 1-month postoperatively. When asked if they would refer a family member or friend to the program for treatment, 99.5 percent of the patients respond yes, according to Dr. DiGioia. That response, he says, generates word of mouth in the community that is unparalleled.

The program also has an impact on clinical results, as the following statistics from the program’s 2009 Outcomes Report indicate:

• Average length of stay (ALOS) for 560 total knee arthroplasty (TKA) patients was 2.9 days, compared to the national ALOS of 3.8 days. ALOS for 275 total hip arthroplasty (THA) patients was 2.5 days, compared to the national ALOS of 4.9 days.
• Infection rates were 0 percent for the TKA patients and 0.3 percent for the THA patients.
• 92 percent of the TKA patients and 94 percent of the THA patients were discharged directly home.
• The mortality rate was 0 percent for both the TKA and the THA patients.

Getting started
The PFCC model can be applied to any healthcare experience, usually within a matter of months. Following Dr. DiGioia’s six steps to transforming care is a good place to start (Table 1).

PFCC has been implemented in dozens of clinical and nonclinical care areas throughout the UPMC system, thanks to an active exporting process and, more recently, to the PFCC “buzz.”

“In recent years, there’s been a lot of interest, discussion, and excitement about PFCC. Providers are recognizing that this is a methodology that can not only improve patient care and outcomes, but also improve the delivery of care and increase safety, efficiencies, and cost-effectiveness. They want to learn about applying it in their own care areas,” Dr. DiGioia said.

In the next 2 years, patient care experiences will be tied to Medicare reimbursement, says Dr. DiGioia.

“The uncertainty surrounding healthcare reform is an opportunity for us to get back to basics. That means focusing on the care experiences of patients and their families, which will also position us to compete in the future,” he said.

The PFCC model is a step toward delivering the ideal care experience, says Dr. DiGioia. It is also a grassroots effort that, once in place, takes on a life of its own, quickly yielding benefits to patients, families, and providers.

“The bottom line is that no matter how far you take this methodology, no matter how far you go in the journey toward delivering patient- and family-centered care—if you improve the care experience for one patient and for one family, you’ve succeeded.”

Maureen Leahy is assistant managing editor for AAOS Now. She can be reached at leahy@aaos.org

Sharing care
Thanks to the extraordinary efforts of Lawrence D. Dorr, MD, founder of the not-for-profit volunteer organization, Operation Walk, Dr. DiGioia says he’s been able to bring the PFCC approach of delivering care to patients in developing countries. Dr. DiGioia is founder of the Pittsburgh branch of Operation Walk, one of 10 Operation Walk chapters in North America.

Operation Walk provides free joint replacement surgery for impoverished patients in developing countries. Each medical mission comprises a team of dedicated professionals, including orthopaedic surgeons, anesthesiologists, internists, physical therapists, nurses, surgical technicians, and nursing support staff—all of whom donate their time.

“Operation Walk really brings the whole team together and is a tremendous experience for both caregivers and patients. It’s incredible what we accomplish in 7 days,” said Dr. DiGioia. “One strength of our group is that have learned to be a special focused care team by using the PFCC methodology back home.”

For more information on Operation Walk, visit www.operationwalk.org

AAOS definition of patient centered care:
The provision of safe, effective, and timely medical care achieved through cooperation among the physician, an informed and respected patient (and family), and a coordinated healthcare team.