Registered nurse (RN)-led, team-based principal care management (PCM) significantly improves pre- and postoperative outcomes for patients undergoing ambulatory orthopaedic joint surgeries, while generating sustainable reimbursement to fund nurse roles.

A new study published in Orthopaedic Nursing by Brenda Luther and colleagues including Faith Jones, a consultant with CrossTx introduces a transformative model of care for joint replacement patients treated in ambulatory surgery centers (ASCs). The model centers on RNs embedded in orthopaedic offices delivering structured, protocol-driven care management through Medicare-reimbursable PCM services.

By combining medical optimization, psychosocial support, patient education, and chronic disease coordination, this RN-led model improves surgical readiness, enhances recovery, and addresses health disparities—particularly for high-risk patients like those with obesity, diabetes, and socioeconomic barriers.

The authors illustrate the model using a compelling case study of a 67-year-old woman with severe knee osteoarthritis, hypertension, and depression. Over seven months of RN-coordinated PCM—including goal-setting, referrals, education, and emotional support—the patient achieved critical surgical benchmarks, underwent successful knee replacement, and continued receiving post-op monitoring under the same nurse-led framework. The program generated over $1,500 in Medicare reimbursement for the practice, demonstrating how team-based nursing can be both clinically impactful and economically viable.

This study highlights that team-based care coordination—anchored by RNs practicing at the top of their license—is not just supportive but essential to managing rising surgical volumes, comorbidities, and bundled payment pressures in orthopaedics. The authors urge broader adoption of PCM and call for policy reform to eliminate out-of-pocket costs that deter Medicare patients most in need of these services.

The CrossTx platform offers a compelling, annually updated care management, principal care management and behavioral health integration-based compliance system for rural health clinics, federally qualified health centers and physician-owned clinics across a spectrum of specialization.  Ms. Faith Jones along with founder Chad Nybo developed one of the first Centers for Medicare and Medicaid Services-compliant chronic care management applications.

Source: Luther, B., Sedlak, C. A., & Jones, F. M. (2025). Patient Optimization for Ambulatory Orthopaedic Total Joint Surgery Utilizing RN-Led Team-Based Care. Orthopaedic Nursing, 44(2), 71–83. DOI: 10.1097/NOR.0000000000001101