Journal of Clinical Anesthesia (2015) 27, 185–187
Editorial
The Perioperative Surgical Home: An Innovative Clinical Care Delivery Model ☆,☆☆,★ The Patient Centered Medical Home (PCMH) model was created to improve medical care of patients, in an effort to improve the widespread concerns of growing medical care costs and variable quality of care. While conflicting data are reported, overall the PCMH is recognized as an important tool to manage the health of a population while the patient is at home (REF). Once a patient is scheduled to undergo a surgical procedure, he or she exits the Patient Centered Medical Home (PCMH) clinical care model [1] or whatever existing clinical coordination arrangement exists, and enters a hospital-based, perioperative model of care. Current perioperative care model, however, is composed of clinicians practicing individually; preoperative evaluation is often inconsistent and is silo oriented. Currently, postoperative care is frequently disorganized, with no systems in place to minimize variability in care delivered. Overall, patients are subject to a system that is characterized by fragmentation, decreased patient satisfaction, and highly variable clinical quality [2]. With this backdrop, there is clearly an urgent need to improve the efficiency of the perioperative care, which may account for up to half of hospital admission expenses in the U.S. One of the potential solutions to this problem of disjointed healthcare is the newly proposed Perioperative Surgical Home [3] clinical care delivery model. The PSH model, recently proposed by the American Society of Anesthesiologists,1 calls for a patient-centered, physician-led multidisciplinary, team-based system of coordinated care. This model of coordinated and protocolized care guides the patient through the entire surgical experience from when the decision to operate is first made until 30 days after discharge. The PSH is somewhat similar to the Enhanced Recovery After Surgery (ERAS) program that was initially developed and implemented in Denmark and Scandinavia before being adopted in several European countries and especially in the United Kingdom [4–6]. ERAS is defined as “a multimodal ☆
Funding Source: No external funding was secured for this study. Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. ★ Conflict of Interest: The authors have no conflicts of interest to disclose. 1 American Society of Anesthesiologists Committee on Future Models of Anesthesia Practice Annual Report to the House of Delegates. August 18, 2013. ☆☆
http://dx.doi.org/10.1016/j.jclinane.2015.01.006 0952-8180/© 2015 Elsevier Inc. All rights reserved.
perioperative care pathway designed to achieve early recovery for patients undergoing major surgery”.2 While ERAS includes a set of 21 specific clinical items that are to be included, the PSH model includes all aspects of the perioperative management. Implementations of the PSH have begun in a few programs in the U.S. [7–9] Early data indicates that implementation increases patient satisfaction while reducing costs, minimizing complications, decreasing recovery times, and shortening the length of stay in the hospital. In this editorial, we highlight five major components of the PSH as they relate to key, essential elements of the existing PCMH model (Table 1).
1. Patient centeredness In the PSH, patient-centered care and shared decisionmaking – shared decision-making being a prime and tangible example of patient centeredness – would replace the current perioperative physician-centered care. This model takes into account the patients’ preferences and values in perioperative decisions, which have been shown to be associated with better outcomes, decreased utilization of resources, and better patient experience. An example of shared decisionmaking is the management of perioperative pain. Under the PSH, decisions about pain interventions will be brought up as soon as the decision to operate is made and will respect the patient and family preferences and wishes. Efforts will be made to consider all available modalities to manage pain throughout the post-operative period. To effectively consider the patients’ needs, the PSH team has to include anesthesiologists, surgeons, hospitalists, nurses, pharmacists, care coordinators, social workers, nutritionists, IT personnel and financial counselors. The framework for all these healthcare providers will be not only “what is good for the institution and efficiency” but also “what is best for the patient”.
2
http://www.erassociety.org. Last accessed August 11, 2014.
186 Table 1 The five essential elements of the existing PatientCentered Medical Home model defined by the Agency for Healthcare Research and Quality (AHRQ) ‡ Patient Centered-Care: Relationship-based primary care that meets the individual patient and family’s needs, preferences, and priorities. Comprehensive Care: Primary care providers are accountable for meeting the large majority of each patient’s physical and mental health needs. Coordinated Care: Care that is coordinated across all elements of the broader healthcare system. Accessible Services: Enhanced access to primary care through a variety of means including expanded hours, email, and telephone communication. Committed to Quality and Safety: A commitment to safe, high-quality care through engagement in quality improvement activities and safety monitoring. Last accessed November 17th, 2014. ‡ AHRQ Website - Patient Centered Medical Home Resource Center. http://pcmh.ahrq.gov/page/pcmh-foundations.
2. Comprehensiveness The PSH clinical care model seeks to create a continuum of care for the patient beginning with a review of the appropriateness and timing of the surgery, and ending 30-days after discharge with smooth transitions back to the PCMH. The 30-days mark is chosen because of the CMS definition of re-admission for an inpatient episode of care. This detailed, standardized care pathways will be applied to most patients as recently described in our first report of a PSH model of care for joint replacement surgery [7]. The care pathway will include a preoperative risk assessment that optimizes co-existent conditions and also flags certain patients as “high-risk”, legitimizing deviations from the pathway to optimize their care [10]. Within this pathway, all issues related to any aspect of the care of the patient will be coordinated and handled by the team of healthcare providers.
3. Coordination The PSH model requires coordination between all phases of the perioperative process: from the surgeon’s office to the pre-admission testing process, through the pre-, intra- and post-operative periods in the hospital and lastly, the post-discharge process at a skilled nurse facility or at home. In the current system, healthcare providers in all these phases typically function independently. While establishing coordination between providers can be difficult, it can be aided by improvement methodologies, such as Operation Management, Lean and Six-Sigma [11], as well as the active participation of all of the personnel involved in the perioperative environment. Consequently, information technology is essential for coordination of the perioperative period so a proper interface between the general electronic
Editorial medical record (EMR) system of the hospital and the perioperative IT systems is extremely important. Finally, in the PSH, the anesthesiologists would be the natural leaders because of the strong culture of system improvement and patient safety that exist in this specialty. However, hospitalists or other management-trained leaders could step forward to lead or co–lead the team, and the leaders could vary depending on the type of surgery.
4. Accessibility Patients and their families must be able to contact PSH providers at all times. While the patient is in the hospital, PSH providers would coordinate all care and have access to high level IT and integration of the Anesthesia Information System (AIMS) and the electronic medical record (EMR) of the institution. Once the patient is discharged to a skilled nurse facility or home, close follow up will continue and a team-based approach will be activated if a patient presents to a clinic or emergency department with any medical problem potentially requiring re-admission within 30 days. After that time period, PCMH providers will insure the continuity of care.
5. Committed to quality and safety The new care model is based on standardizing protocols across the entire spectrum of the patient experience. This allows medical care to be based on a flexible clinical pathway. These clinical pathways, or protocols may optimize patient care throughout the perioperative continuum if widely applied. These evidence-based protocols might reduce variability and lead to higher quality and safety of the surgical episode. Where clinical evidence does not exist, or is controversial, the PSH team should develop trans-disciplinary agreements for standardization of care. Prevention of postoperative complications such as surgical site infection, venous thromboembolism and pneumonia are important outcomes of the care in the PSH model. One question that arises is the distinction between the existing precedent of co-management of patients between surgeons, internal medicine hospitalists, and anesthesiologists, and the PSH. Most of the co-management systems have been ineffective at achieving any meaningful improvement in outcomes and have had limited impact on cost. While co-management typically involves the postoperative period and ‘divides the work’ between these two physician specialties, PSH calls for an entire transformation of “how the work is done”. It calls for coordination between all services, protocol based care throughout the entire episode. In conclusion, this editorial provides an overview of the features of the PSH as an innovative clinical model aimed to transform the way surgical care is delivered. It highlights the difference between the PSH and existing models of
Editorial “co-management” between providers. Continuing to develop these standardized, evidence-based, interdisciplinary perioperative care pathways along with better coordination will reduce variability and lead to higher quality and safety of the surgical episode as well as increased patient satisfaction. The PSH model has the potential to transform the way surgical care is delivered in the US.
Maxime Cannesson MD, PhD* (Professor of Anesthesiology and Vice Chair for Research) (Director of Cardiac Anesthesia) Zeev Kain MD, MBA (Chancellor’s Professor and Chair) Department of Anesthesiology & Perioperative Care University of California, Irvine Health *Corresponding author at: Department of Anesthesia & Perioperative Care, UC Irvine Medical Center, 101 The City Drive South, Orange, CA 92868 E-mail address: [email protected]
References [1] Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA 2009;301:2038-40.
187 [2] Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307:1513-6. [3] Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The Perioperative Surgical Home as a Future Perioperative Practice Model. Anesth Analg 2014;118(5):1126-30. [4] Knott A, Pathak S, McGrath JS, Kennedy R, Horgan A, Mythen M, et al. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ open 2012;2. [5] Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434-40. [6] Cannesson M, Kain Z. Enhanced recovery after surgery versus perioperative surgical home: is it all in the name? Anesth Analg 2014;118:901-2. [7] Garson L, Schwartzkopf R, Vakharia S, Alexander B, Stead S, Cannesson M, et al. Implementation of a Total Joint ReplacementFocused Perioperative Surgical Home: A Management Case Report. Anesth Analg 2014;118:1081-9. [8] Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The Perioperative Surgical Home as a Future Perioperative Practice Model. Anesth Analg 2014;118:1126-30. [9] Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Pittet JF. The Perioperative Surgical Home: How Anesthesiology Can Achieve and Leverage the Triple Aim in Healthcare. Anesth Analg 2014;118:1131-6. [10] Greenfield S, Billimek J, Kaplan SH. The total Illness Burden Index: A patient-reported summary measure of multimorbidity. In: PVaA RR, editor. Handbook of diseases burdens and quality of life measures. Heidelberg, Germany: Springer-Verlag; 2009. [11] de Koning H, Verver JP, van den Heuvel J, Bisgaard S, Does RJ. Lean six sigma in healthcare. J Healthc Qual 2006;28:4-11.
Editorial
The Perioperative Surgical Home: An Innovative Clinical Care Delivery Model ☆,☆☆,★ The Patient Centered Medical Home (PCMH) model was created to improve medical care of patients, in an effort to improve the widespread concerns of growing medical care costs and variable quality of care. While conflicting data are reported, overall the PCMH is recognized as an important tool to manage the health of a population while the patient is at home (REF). Once a patient is scheduled to undergo a surgical procedure, he or she exits the Patient Centered Medical Home (PCMH) clinical care model [1] or whatever existing clinical coordination arrangement exists, and enters a hospital-based, perioperative model of care. Current perioperative care model, however, is composed of clinicians practicing individually; preoperative evaluation is often inconsistent and is silo oriented. Currently, postoperative care is frequently disorganized, with no systems in place to minimize variability in care delivered. Overall, patients are subject to a system that is characterized by fragmentation, decreased patient satisfaction, and highly variable clinical quality [2]. With this backdrop, there is clearly an urgent need to improve the efficiency of the perioperative care, which may account for up to half of hospital admission expenses in the U.S. One of the potential solutions to this problem of disjointed healthcare is the newly proposed Perioperative Surgical Home [3] clinical care delivery model. The PSH model, recently proposed by the American Society of Anesthesiologists,1 calls for a patient-centered, physician-led multidisciplinary, team-based system of coordinated care. This model of coordinated and protocolized care guides the patient through the entire surgical experience from when the decision to operate is first made until 30 days after discharge. The PSH is somewhat similar to the Enhanced Recovery After Surgery (ERAS) program that was initially developed and implemented in Denmark and Scandinavia before being adopted in several European countries and especially in the United Kingdom [4–6]. ERAS is defined as “a multimodal ☆
Funding Source: No external funding was secured for this study. Financial Disclosure: The authors have no financial relationships relevant to this article to disclose. ★ Conflict of Interest: The authors have no conflicts of interest to disclose. 1 American Society of Anesthesiologists Committee on Future Models of Anesthesia Practice Annual Report to the House of Delegates. August 18, 2013. ☆☆
http://dx.doi.org/10.1016/j.jclinane.2015.01.006 0952-8180/© 2015 Elsevier Inc. All rights reserved.
perioperative care pathway designed to achieve early recovery for patients undergoing major surgery”.2 While ERAS includes a set of 21 specific clinical items that are to be included, the PSH model includes all aspects of the perioperative management. Implementations of the PSH have begun in a few programs in the U.S. [7–9] Early data indicates that implementation increases patient satisfaction while reducing costs, minimizing complications, decreasing recovery times, and shortening the length of stay in the hospital. In this editorial, we highlight five major components of the PSH as they relate to key, essential elements of the existing PCMH model (Table 1).
1. Patient centeredness In the PSH, patient-centered care and shared decisionmaking – shared decision-making being a prime and tangible example of patient centeredness – would replace the current perioperative physician-centered care. This model takes into account the patients’ preferences and values in perioperative decisions, which have been shown to be associated with better outcomes, decreased utilization of resources, and better patient experience. An example of shared decisionmaking is the management of perioperative pain. Under the PSH, decisions about pain interventions will be brought up as soon as the decision to operate is made and will respect the patient and family preferences and wishes. Efforts will be made to consider all available modalities to manage pain throughout the post-operative period. To effectively consider the patients’ needs, the PSH team has to include anesthesiologists, surgeons, hospitalists, nurses, pharmacists, care coordinators, social workers, nutritionists, IT personnel and financial counselors. The framework for all these healthcare providers will be not only “what is good for the institution and efficiency” but also “what is best for the patient”.
2
http://www.erassociety.org. Last accessed August 11, 2014.
186 Table 1 The five essential elements of the existing PatientCentered Medical Home model defined by the Agency for Healthcare Research and Quality (AHRQ) ‡ Patient Centered-Care: Relationship-based primary care that meets the individual patient and family’s needs, preferences, and priorities. Comprehensive Care: Primary care providers are accountable for meeting the large majority of each patient’s physical and mental health needs. Coordinated Care: Care that is coordinated across all elements of the broader healthcare system. Accessible Services: Enhanced access to primary care through a variety of means including expanded hours, email, and telephone communication. Committed to Quality and Safety: A commitment to safe, high-quality care through engagement in quality improvement activities and safety monitoring. Last accessed November 17th, 2014. ‡ AHRQ Website - Patient Centered Medical Home Resource Center. http://pcmh.ahrq.gov/page/pcmh-foundations.
2. Comprehensiveness The PSH clinical care model seeks to create a continuum of care for the patient beginning with a review of the appropriateness and timing of the surgery, and ending 30-days after discharge with smooth transitions back to the PCMH. The 30-days mark is chosen because of the CMS definition of re-admission for an inpatient episode of care. This detailed, standardized care pathways will be applied to most patients as recently described in our first report of a PSH model of care for joint replacement surgery [7]. The care pathway will include a preoperative risk assessment that optimizes co-existent conditions and also flags certain patients as “high-risk”, legitimizing deviations from the pathway to optimize their care [10]. Within this pathway, all issues related to any aspect of the care of the patient will be coordinated and handled by the team of healthcare providers.
3. Coordination The PSH model requires coordination between all phases of the perioperative process: from the surgeon’s office to the pre-admission testing process, through the pre-, intra- and post-operative periods in the hospital and lastly, the post-discharge process at a skilled nurse facility or at home. In the current system, healthcare providers in all these phases typically function independently. While establishing coordination between providers can be difficult, it can be aided by improvement methodologies, such as Operation Management, Lean and Six-Sigma [11], as well as the active participation of all of the personnel involved in the perioperative environment. Consequently, information technology is essential for coordination of the perioperative period so a proper interface between the general electronic
Editorial medical record (EMR) system of the hospital and the perioperative IT systems is extremely important. Finally, in the PSH, the anesthesiologists would be the natural leaders because of the strong culture of system improvement and patient safety that exist in this specialty. However, hospitalists or other management-trained leaders could step forward to lead or co–lead the team, and the leaders could vary depending on the type of surgery.
4. Accessibility Patients and their families must be able to contact PSH providers at all times. While the patient is in the hospital, PSH providers would coordinate all care and have access to high level IT and integration of the Anesthesia Information System (AIMS) and the electronic medical record (EMR) of the institution. Once the patient is discharged to a skilled nurse facility or home, close follow up will continue and a team-based approach will be activated if a patient presents to a clinic or emergency department with any medical problem potentially requiring re-admission within 30 days. After that time period, PCMH providers will insure the continuity of care.
5. Committed to quality and safety The new care model is based on standardizing protocols across the entire spectrum of the patient experience. This allows medical care to be based on a flexible clinical pathway. These clinical pathways, or protocols may optimize patient care throughout the perioperative continuum if widely applied. These evidence-based protocols might reduce variability and lead to higher quality and safety of the surgical episode. Where clinical evidence does not exist, or is controversial, the PSH team should develop trans-disciplinary agreements for standardization of care. Prevention of postoperative complications such as surgical site infection, venous thromboembolism and pneumonia are important outcomes of the care in the PSH model. One question that arises is the distinction between the existing precedent of co-management of patients between surgeons, internal medicine hospitalists, and anesthesiologists, and the PSH. Most of the co-management systems have been ineffective at achieving any meaningful improvement in outcomes and have had limited impact on cost. While co-management typically involves the postoperative period and ‘divides the work’ between these two physician specialties, PSH calls for an entire transformation of “how the work is done”. It calls for coordination between all services, protocol based care throughout the entire episode. In conclusion, this editorial provides an overview of the features of the PSH as an innovative clinical model aimed to transform the way surgical care is delivered. It highlights the difference between the PSH and existing models of
Editorial “co-management” between providers. Continuing to develop these standardized, evidence-based, interdisciplinary perioperative care pathways along with better coordination will reduce variability and lead to higher quality and safety of the surgical episode as well as increased patient satisfaction. The PSH model has the potential to transform the way surgical care is delivered in the US.
Maxime Cannesson MD, PhD* (Professor of Anesthesiology and Vice Chair for Research) (Director of Cardiac Anesthesia) Zeev Kain MD, MBA (Chancellor’s Professor and Chair) Department of Anesthesiology & Perioperative Care University of California, Irvine Health *Corresponding author at: Department of Anesthesia & Perioperative Care, UC Irvine Medical Center, 101 The City Drive South, Orange, CA 92868 E-mail address: [email protected]
References [1] Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA 2009;301:2038-40.
187 [2] Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307:1513-6. [3] Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The Perioperative Surgical Home as a Future Perioperative Practice Model. Anesth Analg 2014;118(5):1126-30. [4] Knott A, Pathak S, McGrath JS, Kennedy R, Horgan A, Mythen M, et al. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ open 2012;2. [5] Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434-40. [6] Cannesson M, Kain Z. Enhanced recovery after surgery versus perioperative surgical home: is it all in the name? Anesth Analg 2014;118:901-2. [7] Garson L, Schwartzkopf R, Vakharia S, Alexander B, Stead S, Cannesson M, et al. Implementation of a Total Joint ReplacementFocused Perioperative Surgical Home: A Management Case Report. Anesth Analg 2014;118:1081-9. [8] Kain ZN, Vakharia S, Garson L, Engwall S, Schwarzkopf R, Gupta R, et al. The Perioperative Surgical Home as a Future Perioperative Practice Model. Anesth Analg 2014;118:1126-30. [9] Vetter TR, Boudreaux AM, Jones KA, Hunter JM, Pittet JF. The Perioperative Surgical Home: How Anesthesiology Can Achieve and Leverage the Triple Aim in Healthcare. Anesth Analg 2014;118:1131-6. [10] Greenfield S, Billimek J, Kaplan SH. The total Illness Burden Index: A patient-reported summary measure of multimorbidity. In: PVaA RR, editor. Handbook of diseases burdens and quality of life measures. Heidelberg, Germany: Springer-Verlag; 2009. [11] de Koning H, Verver JP, van den Heuvel J, Bisgaard S, Does RJ. Lean six sigma in healthcare. J Healthc Qual 2006;28:4-11.
