In-N-Out Joint Replacement

While not exactly drive through, with Kaiser Permanente’s innovative home recovery program, you can pick up a new hip or knee and be home the same day.

Sander Rogoff was in pain. The 76-year-old retired police officer had severe arthritis in his right knee. He’d been an avid athlete since childhood, but the pain in his knee had gotten so bad that, when he got on base, the team would often tap a faster pinch runner to round the bases for him. “When you start running, you feel the creak in your knee,” Rogoff remembers. “It was constant pain. After a game I’d be sore all day. I couldn’t even lay in bed at night, it hurt so much.”


Rogoff’s condition was hardly atypical. He was suffering from osteoarthritis, a condition that affects 30 million American adults, according to the Centers for Disease Control (CDC). In Rogoff’s case, the cartilage that provides cushioning between the bones in his leg and knee had worn away. Like the more than five million Americans who underwent knee surgery between 2000 and 2010, he’d need a new knee made of metal alloys and cutting-edge plastics.


But there was one very profound way in which Rogoff’s treatment was different from that of those other patients: nationally, people receiving hip and knee replacements can spend up to three nights in the hospital following surgery. Sander Rogoff went home the same day.

Sander Rogoff was one of the first participants in a groundbreaking program developed at the Kaiser Permanente Downey Medical Center, whereby patients receiving elective hip and knee replacements are able to recover at home—on the same day as their surgeries.

Dr. Abe Lin, a total joint specialist at the Kaiser Permanente Downey Medical Center, initially conceived the program after his first child was born with jaundice, a common condition caused by high levels of bilirubin in the blood. To treat the condition and break down the bilirubins, children are placed under bright lights in a warm, enclosed bed. In the case of Dr. Lin’s son, rather than put him in a “Bili Bed” in the Neonatal Intensive Care Unit (NICU), a portable Bilirubin Blanket and nursing care were delivered to Dr. Lin’s house so that the newborn could recover at home instead of in the hospital.


Dr. Lin says seeing the amazing care his newborn received at home sparked an idea. “The homecare experience with our newborn inspired me to think about how we could deliver the hospital and healthcare team to our total joint patients’ homes,” says Dr. Lin.

Working with Glenn Shulman, another orthopedic specialist at Kaiser Permanente Downey Medical Center, Dr. Lin set up a multi-disciplinary group to study his idea and design a patient-centric way to execute it.

“We knew we had to devise a wide-ranging program around safe practices, and Kaiser Permanente’s model allowed us to do that,” says Dr. Shulman. Unlike many other care provider situations, where the hospitals, doctors and insurers are separate, unrelated entities, Kaiser Permanente operates under an integrated structure in which the health plan, the hospital, and the physicians and medical group work together in a coordinated fashion for the benefit of the patient.

“We worked with nurses, health plan administrators, device experts and others involved in patient care to make sure the program was completely safe and that our patients would be the central focus, whether they were in the hospital or recovering at home,” says Dr. Shulman.

After several months of development, the Kaiser Permanente team was ready to roll out its new program. Sander Rogoff, whose family agreed to help him with recovery at home, was instantly sold on the idea. “He [Dr. Lin] asked, ‘Would you like to try going home the same day?’ Between my daughter, son and my wife, I had three really great caregivers right here in my house.”

Rogoff’s home recovery plan began a few days before his surgery, when a Kaiser Permanente physical therapist and care coordinator visited him at home to explain what his treatment and recovery would entail. They also made sure that Rogoff’s home would be a safe one in which to recover. They rolled up rugs and moved furniture so Rogoff would be able to safely navigate the home with a walker. The team helped Rogoff determine that the large sofa on the first floor of his house would be the most comfortable place to recover, and explained that he’d need some simple 9-inch risers to elevate the sofa, which would make it easier for Rogoff to get up and down. The physical therapist taught Rogoff “prehab” exercises, which he could begin right away, and which would allow him to recover more quickly after the operation.

Likewise, the team also went over what recovery would entail with members of Rogoff’s family. Not only did these actions set expectations for a home recovery, they gave Rogoff and his family the chance to become acquainted with—and to develop trust in—his care team.

On the morning of the surgery, Rogoff drove to the Kaiser Permanente Downey Medical Center. Drs. Lin and Shulman’s working group included anesthesiologists who helped to develop shorter acting spinals and improved regional blocks that would allow Mr. Rogoff to walk a few hundred feet and up and down stairs within a few hours of the operation.


“By 10:30,” explains Rogoff, “I was still under strong anesthesia and the nurse walked me down the hall. By four o’clock I did some more walking, climbed some steps and got the a-ok to go home.”

The next day, a registered nurse visited Rogoff at home to change his dressing. A physical therapist came twice that day, and an RN case manager called to check in and answer his questions. “Our goal was to deliver the same quality care that patients receive in our hospital to Mr. Rogoff’s house,” says Dr. Lin. “My vision is that someday our patients don’t see joint replacements as such huge and invasive operations anymore.”

Over the next week, the physical therapist made repeated visits to Rogoff’s home. “They made me feel confident knowing they were there to check my chart and keep track of things,” he says. And yet, even with that expert care in his house, it was his surroundings that he says meant the most to him during the recovery period. “It motivated me to get better quicker,” he says. “The atmosphere of being home with your family…it was a benefit for me.”

Indeed, many of the patients who have participated in the home recovery program say they prefer to be surrounded and cared for by their loved ones. After all, at home there are no visiting hours. Patients get to sleep in the comfort of their own beds, watch their own TVs and eat their own, home cooked food.

But those aren’t the only benefits of same-day discharge. According to the CDC, every day about one in 25 hospital patients has a hospital-acquired infection. But when patients like Rogoff spend just a few hours in the hospital, their chances of acquiring infections is greatly reduced.

Likewise, Kaiser Permanente’s data show that the readmission rate for patients who go home immediately after surgery is about 2 percent–exactly what it is for patients who recover in the hospital.

Encouraged by the results of patients like Rogoff, Kaiser Permanente is expanding the same day recovery program across Southern California, where physicians perform about 3,400 elective hip surgeries and 7,800 elective knee surgeries each year. Last year, 11 percent of hip and knee patients—about 2,300 people—recovered at home after their surgeries with no overnight hospital stay. By the end of this year, Kaiser Permanente anticipates that 25 percent of hip and knee replacement surgery patients in Southern California will recover at home. And by the end of 2018, it could be as high as 50 percent.

Five months after his knee surgery, Sander Rogoff returned to the softball field he loves so much. This time, something was different. “The pain was gone,” he says. “It was a new lease on life. When I escaped the pain, I felt relieved, grateful, thankful.”

Rogoff also didn’t feel alone. “In my age group, half the guys have had knee surgeries,” he says. Then again, Rogoff had something none of those other guys had. He got to go home the same day as his surgery.

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