Home Health Does Not Outperform Self-care For Many Knee Patients 

In-home care has long been considered a key component in ensuring optimal recovery from knee replacements, but self-care appears to be as effective for many patients.

Patients who receive home-based care following a total knee arthroplasty do not uniformly report better outcomes than those who recover via self-care at home, according to a study from the Cleveland Clinic. 

“Overall, patients who had home health services achieved similar improvement at one year as those who had only self-care,” Dr. Nicolas Piuzzi, enterprise vice chair of research for orthopaedics and rehabilitation at Cleveland Clinic, said in a statement. “For us, this is reassurance that in correctly selected patients, we might achieve the same levels of satisfaction and improvement regardless of the care path.”

Researchers analyzed data from over 10,000 patients, of which about 7,000 were discharged to home health services and about 3,000 were discharged home with self-care. One year after surgery, the two groups showed similar improvements across multiple patient-reported outcome measures.

The similarities in outcomes between home care and self-care patients may be due to trends in patient demographics.

“With changes in outpatient surgery and other advances, we’re starting to see more patients who are younger and healthier, who may do well with self-care, outpatient physical therapy or other modes of recovery,” Piuzzi said.

Additional research is needed to pinpoint the specific patient populations who require home health services, researchers said. Data from wearable sensors could be one way to detect patients’ activity levels before surgery and therefore predict who is likely to be able to recover through self-care.

The Cleveland Clinic study is the latest update to continually evolving approaches for knee replacement recovery. A decade ago, 30% to 40% of patients were discharged to inpatient rehabilitation centers, and now 90% are discharged to their homes, according to Piuzzi.

Changing regulations have also shaped approaches to knee replacement recovery. In 2016, the Centers for Medicare and Medicaid Services (CMS) created the Comprehensive Care for Joint Replacement (CJR) Model, which became mandatory in 2021. CJR was a bundled payment model meant to incentivize greater care coordination among hospitals and post-acute providers, including home health agencies, for a 90-day period of care after lower extremity joint replacement patients were discharged from the hospital. CJR was originally set to expire at the end of 2020, but was later extended, before expiring at the end of 2024.

CJR was a “win” for home health care providers, Brian Fuller, managing director of ATI Advisory’s value-based care design and delivery practice, told Home Health Care News. The model increased home health care utilization for certain hip- and knee-replacement patients and, while not a panacea, modestly increased the number of joint replacement patients receiving home health care. 

Home health providers who participated in CJR will still reap long-term benefits, according to Fuller.

“They’ve got tons of learning because they’ve been in a mandatory bundle payment model,” Fuller said.

Agencies will be able to apply those lessons to other bundled payment models, he emphasized, noting the forthcoming Transforming Episode Accountability Model (TEAM) in particular. TEAM will be mandatory across many areas of the country and aims to drive care coordination through a 30-day post-discharge period after LEJR procedures, along with four other types of surgery.

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