Jack and Jill: The Whole Story

Jack and Jill went up the hill and got totally new hips. The following two cases (identifying information changed) occurred over the past 12 months and demonstrate the importance of communicating functional limitations to incorporate the whole patient rather than their current diagnosis and resultant presentation. By proper documentation and coding, we can show the value of therapy services to the populations we serve.

Jack is a 76-year-old male with a long medical history. His first hip replacement was in 1991 after falling from a ladder from about eight feet. Twenty-five years later, he needed a new prosthesis. Jack’s medical history includes heart disease, hypertension, diabetes and hypercholesteremia. He had a heart attack and has had several stents placed via catheter. Jack is retired but enjoys restoring old vehicles. He does the majority of the work, which requires him to lift, kneel, crawl, scoot and climb. He lives with his wife in a single-story home that is handicap accessible. Prior to surgery, Jack was able to work in the shop, perform all yard work, and take care of any household responsibilities.

Jill is a 74-year-old female with a medical history including Stage I breast cancer in 2012, TIA in 2005 and contralateral THA in 2013. She is retired and lives with her dog and cat in a split-level home. Prior to surgery, she vacuumed daily and enjoyed walking her dog and antique shopping. She would exercise frequently prior to the hip becoming painful.

Both patients are limited by standard total hip precautions and score a 13/80 on the Lower Extremity Functional Scale (LEFS).

Jack spent five post-surgical nights in the hospital, one week in a rehab hospital and was discharged home for three weeks of home-health services. He then participated in four weeks of outpatient therapy. Four months after surgery, Jack dislocated his hip and returned to the hospital for relocation under anesthesia.

Jill spent one post-surgical night in the hospital and was discharged home for home-health services, which lasted one week.

As we move forward in the Comprehensive Care for Joint Replacement Model (CJR), we must consider the total picture of each patient that comes in the door. In this example, Jack not only presents with a medical history that restricts his recovery, but a prior level of function that is grossly more strenuous than Jill’s. Both patients need therapy services and both have great potential for recovery. Our plans of care and subsequent coding need to incorporate more than just an objective measure score. Jill represents the model patient, a fit patient with a clean THA that really doesn’t require much aftercare. However, we can’t cherry-pick our patients from the Jill’s of the world. In order for Jack, and other medically complex patients, to receive the care he needs, we must be able to advocate for him by documenting and communicating not just his deficits but all contributing factors of care.

As clinicians we must paint the portrait of who our patients really are.

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