Palomar Health

Brian Cohen

Starting on March 11, 2020, Palomar Health canceled all in-person community classes, including pre-operative education classes intended to prepare patients for surgery, due to the pandemic. Although these classes had shown significant benefits to patients, Palomar felt confident that it could rely on its Online CarePath to prepare patients and their caregivers for surgery. The Online CarePath played a critical role in keeping patients informed and engaged during the shutdown, as well as ensuring patients were ready for surgery as soon as their surgeon felt it was safe.

Palomar Health is a California Healthcare District that operates two acute care hospitals in San Diego County, California. As a participant in several risk-bearing arrangements that aim to increase quality and decrease the cost of care, Palomar offered free weekly two-hour in-person education classes to patients and their caregivers once they were scheduled for Total Joint or Spinal Fusion surgery. Pre-operative patient education is demonstrated to improve patient’s post-operative pain and anxiety as well as reduce the length of stay for patients entering a surgical episode. However, it can be difficult for some patients to attend the in-person class, particularly for patients coming from out of the areaand for patients who have difficulty ambulating outside the home. Patients who did attend the Total Joint or Spine Fusion class were provided a large amount of information in a two-hour period, testing the limits of their learning retention. In response to these barriers, Palomar initiated an online education tool, referred to as Online CarePath, in September 2018. Originally conceived of as a complement to in-person education, the Online CarePath has proven to be invaluable since the coronavirus pandemic forced Palomar to cancel in-person pre-surgery classes.

Navigating the Patient Journey

Developed using Wellbe Inc.’s online technology, the Online CarePath features content from the in-person pre-operative class that navigates the patient from pre-admission through post-operative surveillance at home. In contrast to the in-person class that feeds patients’ information all at one time, the Online CarePath pushes the education content out in small doses, individually called CareCards, which are spaced out over an extended timeline. Patients receive their first CareCards four weeks prior to their surgery date, and their final CareCards one year after their surgery date. The patient is also able to communicate vital information back to their care team through interactive forms and surveys.

Maximizing Patient Compliance

Patients are enrolled in the Online CarePath at the same time they are scheduled for their surgery. Palomar understands that patients are more likely to be compliant when their surgeon directly instructs them to do something. Therefore, all CareCards are signed by their surgeon and include the surgeon’s photo. Patients are also encouraged to add additional caregiver’s contact information so that their care circle can receive the same content.

"Originally conceived of as a complement to in-person education, the Online CarePath has proven to be invaluable since the coronavirus pandemic forced Palomar to cancel in-person pre-surgery classes"

Once activated, the patient will continue to receive CareCards specific to their needs, based on the predetermined timeline. Each CarePath can include CareCards that are specific to a patient’s condition, like diabetes. Two surveys are administered before surgery, a Discharge Assessment Form that is designed to remove barriers to a timely return to home (e.g., Durable Medical Equipment, transportation), and a baseline Patient Reported Outcome Measures (PROM). After surgery, the patient completes a survey measuring their perception of preparedness. They continue to complete their PROMs at 90-days and one-year post-operatively. If any responses areflagged as concerning, the care team is alerted, and a call can be made to the patient or their designated caregiver.

Measuring CarePath’s Effectiveness

A concern in implementing an Online CarePath is whether patient participation rates would be high enough to justify the added resources needed to support the platform, especially given the older ages of total joint replacement patients. Of the 455 patients that were enrolled over an eight-month period, 375 activated their accounts (82.4 percent). Activation rates by patient gender and age were evaluated. Men had a higher probability of activating their CarePath than women. Patients ranged in age from 28 to 89, with the average age of a joint replacement patient as 68.7 and the average age of a spine fusion patient being 63.3. The 80+ age cohort expectedly had the lowest activation rate, but at 76 percent, this cohort remained engaged at a rate higher than was expected.

To evaluate the effectiveness of the Online CarePath, patients were sorted into comparison groups (including patients who didn’t utilize the tool). Total Joint Replacement patients who activated the tool experienced 15 percent lower lengths of stay over the patients who were enrolled but did not activate their accounts. Spine Fusion patients who activated the tool experienced 30 percent lower lengths of stay; 98 percent of those that activated felt prepared for their surgery. Since the pandemic began, Palomar has enrolled in 195 new patients in the Online CarePath. The overall activation rate has increased to 85 percent, and the rate of patients stating they felt prepared for their surgery improved to 99 percent. With a small investment in time and resources, the Online CarePath met its goal of preparing patients for a quick and safe return home after total joint replacement or spine fusion.