Better outcomes and lower costs: The perioperative surgical home

Better outcomes and lower costs: The perioperative surgical homeWhether it’s a knee replacement avoided for years or an urgent life-saving tumor removal, when the decision for surgery occurs, too often the patient begins a journey into a complex system of fragmented medical care. Perioperative care, which generally refers to the three phases of surgery — preoperative, intraoperative and postoperative — can be variable and fragmented. Patients can experience lapses in care, duplication of tests and preventable harm. Costs rise, complications occur, physicians and other health care team members become frustrated, and as a result the patient and family may experience an overall lower quality health care experience.

The perioperative surgical home (PSH) is an innovative practice model that has been proposed by the American Society of Anesthesiologists (ASA®) as a potential solution to improve the quality and safety of the patient experience of care, and to decrease cost.

The PSH is a patient-centered delivery system that aligns with the National Quality Strategy to achieve the triple aim of improving health, improving the delivery of health care and reducing the cost of care. These goals are met through shared decision-making and seamless continuity of care for the surgical patient, from the moment the decision to have surgery is made, all the way through recovery, discharge and beyond. Under this model, each patient will receive the right care, at the right place and the right time.

As a specialty that is constantly focused on performance improvement, the PSH model should address limitations of our current system. The surgical experience today is characterized by significant variability of care, driven by the number of patients and individual surgeon and physician anesthesiologist preference. One way to reduce variability is to treat the entire episode as one continuum of care. This continuum can be achieved by having one perioperative team that coordinates and manages all aspects of care from the minute the surgeon decides to operate until 30-days post-discharge. Under the PSH model, patient-centered care and shared decision-making at each step of the process would greatly improve our current system.

The patient may enter into the PSH through a “virtual portal” by electronic access to his or her own medical record and educational materials or a more “physical portal” where the patient can communicate with clinicians in person or electronically, or some combination of both virtual and physical entry. When the patient enters into the PSH, the physician anesthesiologist ensures that specific risk factors are assessed during the preoperative period for every patient prior to surgery. The central idea is not to “clear the patient for surgery” but rather to optimize the patient for surgery based on risk factors and evidence-based protocols. Standardization of anesthetic/nursing/surgical protocols is a critical component of the PSH, with all protocols determined in advance. Similarly, nutrition management, a recovery plan, rescue from medical complications and smooth transition of care are all part of the PSH pathway.

The ultimate goal of the PSH is to create an evidence-based “road map” for health care organizations to spread knowledge and best practices of the PSH model. To do so, ASA has selected Premier, Inc., a leading health care improvement company, to develop a first-of-its-kind learning collaborative for the PSH model. The collaborative will proactively pursue care redesign strategies seeking to enhance the surgical patient’s experience, improve quality and outcomes and reduce costs. This includes better care coordination to reduce length of stay, readmissions and complications among patients.

In May, ASA invited health care organizations to apply to the PSH learning collaborative. With more than 51 million inpatient procedures performed nationally each year, surgical services represent a major component of health care expenditures and a sizeable opportunity to reduce costs and improve outcomes. This innovative new model, with the help of health care organizations across the country, is an opportunity to transform surgical care in the U.S. and ensure every surgical patient has a quality care experience.

Jane C.K. Fitch is president, American Society of Anesthesiologists.

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  • John C. Key MD

    Oh! I get it! The Patient-Centered Medical Home has been such a great success the surgeons will now jump on board! Sheesh. Another professional organization now wades into the soft mush of twenty-first century groupthink.

    • Dr. Drake Ramoray

      The cafeteria will become a patient and employee centered nutritional home. It is a system that aligns with Natiknal Quality Standards. It can be accessed via a portal. From the moment you decide to eat, it will be a seamless experience…….

    • PrimaryCareDoc

      Exactly what I was thinking!

    • Steve

      Agreed- I thought this was satire until I saw it was signed by the president of the ASA. So now that anything called a “patient centered _____ home” gets higher reimbursement, we want to get on board with it. Can I open a freestanding ED, call it a “patient centered emergency home” and get higher reimbursement too? Here’s another solution- how about the PCP does their job with “medical clearance”, the OR staff (as a whole) does their job, and the discharge planners do their job- problem solved. No medical homes, no wasted money- just good patient care.

  • DeceasedMD1

    Please, pass me the barf bag.

    • Arby

      Do you mean the emesis basin? Sure, right away after I’m done with it. I don’t think I could stomach any more hype.

      • DeceasedMD1

        Yeah that thing. I tell you I was seriously nauseous reading this Arby. Couldn’t stomach it. Definitely we can share the emesis basin and maybe give it back to the author to analyze its contents.

        • Arby

          You’re kind of a sick individual aren’t you? And, quite possibly and insomniac like me depending on which coast you’re on.

          In all seriousness, there is a big push for integrated homes going on, and the author is writing to their audience. It is not convincing to me as a patient, but perhaps it reaches a few of MDs.

  • guest

    You have got to be kidding me.

  • dontdoitagain

    Uh oh. You aren’t planning on making the patient “experience” one in which the patients (maybe) have no memory of the event ala Versed are you? “Patient centered” is anything but in my experience. Sort of like the “patient advocate” at the hospital actually being the “lawsuit mitigation” person. (rolling eyes) The phrase “evidence based” also makes me roll my eyes. “Evidence” is something so subjective as to be worthless if not actively harmful to patients.

    My peeve is Versed, it’s a marvy drug as “evidence-based” medications go, except for the fact that the drug had a really bad effect on me and many others which has been tossed in the pile of anecdotal “evidence” which doesn’t have any place in “evidence-based” scenario you describe. So evidence isn’t evidence unless it goes along with what you guys want to put forth as “evidence”. Anything “evidence based” is a farce.

    Spare me the perioperative surgical home. Looks like just one more expensive stand alone rip-off. One more layer of medical care, buildings and personnel in order to charge more for some nebulous “patient centered” care.

    I cynically wonder if this whole scheme isn’t made up by anesthesia doctors who want to use crna’s with themselves as the “supervisors”. Of course the crna’s claim that they are autonomous and without supervision, except that in order to rip off the government and by default, me through taxes, they need to specify a supervisor which was never there in order to bill medicare. Is that what this is all about?

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