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Poster Abstracts

Bringing Integrated Care Home: Piloting a Patient Care Navigation Role for Total Joint Replacement Patients


Sandralee Rose ,

University Health Network - Toronto Western Hospital, CA
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Silvi Groe,

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Christian Veillette,

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Michael Zywiel,

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Rajiv Gandhi,

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Samra Mian-Valiante

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Over 137,000 patients in Canada receive life-changing hip and knee replacement surgeries at an annual cost of $1.4B . Due to the significant personal and system impact, ensuring patients achieve the best outcomes and experience from their surgery is critical. Patients have expressed they want connected care, delivered at the right time and place. Early assessments by University Health Network’s Schroeder Arthritis Institute identified that key care and communication gaps in transitions across the total joint replacement (TJR) journey lend themselves to implementing a patient care navigator (PCN) role to meet patient expectations..

Aims Objectives Theory or Methods

The aim was to improve the quality and value of perioperative care for TJR patients within a high volume orthopaedic program, through the introduction of a PCN role. This quality improvement initiative used an iterative plan-study-do-act approach. The PCN supported patients who underwent joint replacement surgery by one of two orthopedic surgeons starting in July 2020. This involved a PCN call to patients 48 hours pre- and post-surgery to review surgery/recovery planning, provide education, and address patient questions. Data were collected between July 2020-January 2021, including qualitative interviews, retrospective chart reviews, and patient satisfaction surveys. REB exemption was obtained.

Highlights or Results or Key Findings

Of the 249 patients recruited, 162 patients completed both pre-op/post-op PCN calls. Patients reported high satisfaction (99.5% (n= 162)). Qualitative interview evaluations revealed that patients felt the PCN helped to reduce their anxiety, reassured them, and better connected them to their care team. Patients also reported that the education/information across their patient journey was overwhelming. About 88 patients were found to have risks to their recovery: educational material misplaced/not provided (58%), misunderstood surgery instructions (32%), no co-pilot arranged (6%), lack of equipment (6%), communication barriers (5%) and other (4%). The PCN worked with patient to address these issues prior to surgery. During post-operative calls, patients concerns were: pain (20%), gastrointestinal symptoms (17%), swelling/numbness (13%), medication (7%), fever (4.2%), surgical site (6%) and other (3%). These were largely managed by the PCN (64%), with some requiring an interdisciplinary approach for resolution [surgeon (17%), physiotherapist (12%), family physician (4%) and other (3%)].


The findings highlight the benefits of a PCN in improving care quality of patients undergoing TJR and enabling their recovery at home. This is especially important as hospital stays for TJR becoming exceedingly shorter. PCN roles are an ideal opportunity to integrating hospital care with a patient’s recovery at home.

Implications for applicability/transferability sustainability and limitations

The patient value for a PCN in our TJR program suggests an important role in enabling integrated care models. Sustainable system level PCN care models that support patients with transitions to the home and community are needed. Further work will be explored to understand the equity aspects of the model.

How to Cite: Rose S, Groe S, Veillette C, Zywiel M, Gandhi R, Mian-Valiante S. Bringing Integrated Care Home: Piloting a Patient Care Navigation Role for Total Joint Replacement Patients. International Journal of Integrated Care. 2022;22(S2):81. DOI:
Published on 16 May 2022.


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