Diehl CP, Brickley CT, Titus-DeSouza, MH; Musculoskeletal Program Spaulding Rehabilitation Hospital Boston MA USA; cdiehl@partners.org/

PURPOSE: To describe a clinical system developed to improve the continuity of care for orthopedic surgery patients within a healthcare network. The system produced education, enhanced communication, and clinical opportunities that improved patient outcomes. DESCRIPTION: This system was created in response to identified gaps in continuity of care between the acute care facility and the rehabilitation hospital. Miscommunication around patient care, current pathways, and changes in surgical procedures were identified and resolved in this system. A positive by-product was increasing cost efficiency. The system is two-fold. Firstly, it involves a reciprocal rounding scheme, whereby a group of Physical and Occupational Therapists round with the Partners orthopedic trauma service. Conversely, the orthopedic trauma surgeons round at Spaulding Rehabilitation Hospital (SRH) on their patients later in the week. Secondly, technology has facilitated intranetwork patient management. Within the Partners firewall, x-rays and pictures of wounds can be digitally imaged and sent to orthopedic surgeons. OBSERVATIONS: Patient admissions can be predicted and appropriate resources allocated in utilizing this system. Patients have been able to progress more aggressively. Orders and weight-bearing status are clarified expediently. Patients have not lost a day of therapy being transported to a clinical appointment in an acute care setting. CONCLUSIONS: This system has established a professional relationship between all clinicians caring for patients within the system. This relationship, augmented by technology, has improved continuity of care, communication, and expedited resolution of patient issues. Physical therapy at Spaulding Rehabilitation Hospital has gained increased recognition and responsibility among the orthopedic sub-specialties in the Partners network due to this clinical service line. FUNDING SOURCE: none.

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