Lessons from ANESTHESIOLOGY® 2016 on the Perioperative Surgical Home
SUMMARY The perioperative surgical home (PSH) offers anesthesia providers an excellent opportunity to add value to their institutions and practices as healthcare moves from a volume-based to a value-based model, according to presenters at ANESTHESIOLOGY® 2016. Hallmarks of an effective implementation include strong multidisciplinary collaboration, solid relationships with surgeons and an information technology system that is hardwired from the start with the necessary data.
As healthcare transitions from a volume-based to a value-based reimbursement paradigm with the implementation of the Quality Payment Program, bundled payments and other alternative models, how will anesthesiologists, certified registered nurse anesthetists, surgeons and other members of the care team find their place in the new world order? The American Society of Anesthesiologists (ASA) and other medical organizations point increasingly to the model already familiar to many of you, the perioperative surgical home (PSH).
The ASA defines the PSH as "a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated care that helps meet the demands of a rapidly approaching health care paradigm that will emphasize value, patient satisfaction and reduced costs." In a session at ANESTHESIOLOGY® 2016, Zeev N. Kain, MD, MBA, of the University of California Irvine and president of the American College of Perioperative Medicine, defined the PSH as "a multidepartmental initiative aimed to transform surgical care by improving quality, lowering costs, and increasing patient and provider satisfaction."
Session co-presenter Lee Fleisher, MD, of the University of Pennsylvania, presented his institution's PSH vision statement: "This new patient-centered model is designed to achieve the triple aim of improving health, improving the delivery of healthcare and reducing the cost of care. These goals will be met through shared decision-making and seamless continuity of care for the surgical patient, from the decision for surgery through recovery, discharge and rehabilitation. Each patient will receive the right care, at the right place, and the right time."
The wording of the definitions varies, but all three underscore the value of multidisciplinary cooperation, with anesthesia providers as key players and collaborators with an expanded, value-added role through the entire perioperative episode. As Dr. Kain writes in Anesthesia & Analgesia:
Conceptually, the PSH model aims to reduce variability in perioperative care given that variability increases the likelihood for errors and complications. One way in which this variability can be reduced is through assuring continuity of care and treating the entire perioperative episode of care as one continuum rather than discrete preoperative, intraoperative, postoperative, and post-discharge episodes. This can be achieved by having one team headed by anesthesiologists, to manage all aspects of this continuum from the time that the patient and the surgeon make the decision for surgery until 30 days after discharge. During this perioperative episode, the goal of the PSH is to ensure that best evidence/best practices are applied in a consistent and standardized way to every patient undergoing surgery.
Bundled Payments
Anesthesia providers need to find their niche in a value-driven environment because the quality-over-quantity exemplar is here to stay, says Dr. Kain, noting that anesthesia providers are trained to provide the tenets of the PSH. The Centers for Medicare and Medicaid Services (CMS) remains committed to having 50 percent of all Medicare fee-for-service payments made through a value-based model by 2018. CMS launched the mandatory Comprehensive Care for Joint Replacement (CJR) bundled payment program in early 2016, which holds approximately 800 hospitals in 67 metropolitan statistical areas (MSAs) accountable for the quality of care for Medicare beneficiaries undergoing hip and knee replacements and/or other major leg procedures. The agency plans to expand this first bundled payment model to cover hip and femur fractures as well. This past July, CMS also proposed a new mandatory bundled payment program for heart attacks and bypass surgery that would be implemented in 98 randomly-selected MSAs. (While bundled payments by third party payers probably will be more common initially, they aren't the only payment system to allow anesthesia providers to share in the costs and the gains of a PSH with the hospital. For more information, please see "The Perioperative Surgical Home: Of Economics and Value," by Rick Bushnell, MD, MBA, in the spring 2016 issue of our quarterly newsletter, The Communique.)
Building Trust
Dr. Fleisher stresses the importance of anesthesia's relationships with the surgeons in gaining acceptance for the PSH. "We are perioperative physicians, we need a field of perioperative medicine and it must be multidisciplinary. But the patient comes to the surgeon," he says. This teamwork and cooperation are reflected in a joint statement on physician-led team-based surgical care issued in August by the American College of Surgeons and the ASA.
"We need to figure out where our niche is in this paradigm, and I think it changes depending on who the patients, surgeons and hospitals are," he says. (Cardiovascular critical care and postoperative care at his institution is anesthesiologist-led as a result of successful relationship-building between surgery and anesthesiology.)
A Team Sport
Dr. Kain, who has implemented PSHs in seven locations, including a university setting, describes the PSH as very much a "team sport" consisting of groups of professionals dedicated to the service's clinical, operations, information technology/finance, patient experience and change management aspects. The model, as realized in the institutions at which Dr. Kain has implemented it, brings together professionals from a multitude of disciplines in addition to anesthesia, including surgery, perioperative nursing, quality, critical care, case management, decision support/finance, information technology/informatics, pharmacy, hospital leadership and administration, physical therapy, nutrition, the blood bank and the emergency department. "If you think anesthesia can do it by itself, think again," he comments.
The PSH's "expected deliverables"—the concrete ways in which it can provide value—include improved coordination of care; reduced complication rates and readmissions; improved overall satisfaction among the surgeons, anesthesia providers, nurses and patients; reduced costs of care and hospital length of stay; standardization of practice using evidence-based practices and guidelines; and provision of quality and performance improvement measures demonstrating success.
Dr. Kain describes the PSH according to its preoperative, intraoperative, postoperative and post-discharge dimensions. Preoperative care includes optimization of underlying diseases, prehabilitation (e.g., smoking cessation, exercise) and risk stratification—identifying those patients most likely to experience postoperative problems. Preoperative care is essentially the same in the PSH as in traditional care delivery models, except that the model aims to optimize patient care by beginning much sooner before surgery. Intraoperative care emphasizes evidence-based protocols, goal-directed therapy and operations management along with strategies to reduce variation and the use of enhanced recovery after surgery protocols (ERAS). Postoperative care also uses evidence-based protocols, as well as team-based management, and a focus on complication prevention and variation reduction.
According to Dr. Kain, the most cost-effective approach to postoperative care is likely to involve the anesthesiologist in supervising the nurse practitioner and/or the hospitalist. Post-discharge care emphasizes transitioning the patient to the appropriate level of care (e.g., home or a skilled nursing facility), patient and caregiver education, rehabilitation and return to function, and again, reduced variation. For every patient who goes home, "we do a 'handshake' with a primary care provider to close the circle," he adds. In addition, the PSH at his institution has created a system in which the hospital's urgent care center continues to see patients who return with complications following discharge; however, a member of the PSH team sees the patient in urgent care to reduce the likelihood of a readmission.
One of the biggest challenges to implementation is hardwiring all of the evidence-based protocols and other strategies used in the PSH into the electronic medical record from the start "so it's part of the way you do business," notes Dr. Kain.
New Research
Data is beginning to emerge in support of the PSH. A two-year follow-up study of 328 total knee and total hip arthroplasty patients by Dr. Kain and his colleagues at the University of California Irvine in the July issue of Anesthesia & Analgesia showed positive results in length of stay, pain control, discharge to home rather than skilled nursing facility, readmission, transfusion rates and complications.
A PSH implemented for patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis resulted in a significant reduction in hospital length of stay and a reduced perioperative transfusion (Anesthesia & Analgesia, November 2016). A study of PSH implementation for total knee arthroplasty at a large integrated delivery system found significant simultaneous reductions in hospital length of stay and skilled nursing admissions among patients assigned to the PSH pathway compared to the Fast Track (T-Fast), although 30-day readmission rates did not differ between the two groups (Anesthesia & Analgesia, September 2016).
"There is a big part of the surgical patient's journey that we're not involved in," Dr. Kain adds. "We need to add more value to the hospital and to patients to remain viable and to remain relevant as bundled payments come and as all these movements happen around us. We really need to be part of the team and not get siloed. We need to be part of the care system. We need to adapt to change overall."
ASA offers comprehensive resources and information on the PSH here.
For more information from ABC about the PSH, please contact info@anesthesiallc.com.
With best wishes,
Tony Mira
President and CEO