Integrating Care to Improve Surgical Outcomes and Reduce Costs

Hospitals have an opportunity to improve clinical and financial outcomes by redesigning the way they care for surgical patients and by adopting an integrated, multidisciplinary model of perioperative care.

In a healthcare environment complicated by the ongoing shift of elective and lower-acuity surgical cases to outpatient settings, hospitals are treating a larger share of patients with high-risk, high-cost conditions, making surgical cases a prime target for any hospital looking to improve clinical outcomes, enhance patient satisfaction, and increase efficiency.

The majority of hospitals spend approximately 50 to 60 percent of their annual budgets supporting perioperative services—that is, the care of surgical patients before, during, and after their procedures—and these cases also account for up to 60 percent of a hospital’s operating margin. ^a Therefore, maintaining surgical volumes can be a make-or-break proposition for many facilities.

Challenging the Status Quo

Traditional perioperative care tends to follow a linear pathway wherein a sequence of clinical events occurs in a specific order, one at a time, as a patient moves from diagnosis to preoperative care, to surgery, and then to postoperative care and discharge. At each step, the patient’s care is determined by the individual clinical judgment and practice preferences of the physician or specialist managing that phase of care.

Although this historical model addresses surgical care needs, it can be inefficient and costly both to the facility and to the patient.

Consider the example of a patient with a hip fracture. The classic, linear perioperative care pathway for this condition might proceed as follows:

• The emergency medicine physician diagnoses the fracture and notifies the hospital medicine team of a patient requiring admission.
• The hospitalist admits the patient, conducts an assessment, and requests a surgical consult.
• The surgeon assesses the patient and determines whether he or she is eligible for surgery.
• The surgeon consults with the anesthesia department and schedules the procedure.
• The anesthesiologist conducts a preoperative risk assessment.
• The patient undergoes surgery.

This scenario can take up to 36 hours from the time the patient presents to the emergency department (ED) to the start of the presurgical process. During that time, the hospital and patient would incur more than a day’s worth of hospital costs while facing increased risks for infection and other complications that could be avoided with a more streamlined path to surgery and recovery.

New models of perioperative care instead bring together physicians from across the hospital—surgeons, anesthesiologists, emergency medicine physicians, hospitalists, and post-acute care specialists—to redesign care pathways and create more collaborative, efficient transitions of care.

Integrated Care Models

Coordinated perioperative care models have many names, such as enhanced recovery after surgery (ERAS) and fragility fracture programs. These models typically are single service-line-specific care models, whereas the perioperative surgical home (PSH) model encompasses a more robust, integrated, and multidisciplinary team-based approach to care.

The PSH model was developed by the American Society of Anesthesiologists, which defines it as a “patient-centric, team-based system of coordinated care that guides patients through the entire surgical experience, from the decision to undergo surgery to discharge and beyond.” ^b

The PSH model rethinks traditional surgical care pathways to identify areas for improvement that can accomplish the following:

• Increase adherence to evidence-informed guidelines
• Improve the quality and safety of perioperative care
• Reduce complication and readmission rates
• Reduce surgical costs and provide superior value
• Enhance patient safety and family experience

In short, the PSH model brings together multidisciplinary teams of clinicians—typically led by an anesthesiologist or surgeon champion—to implement standardized care pathways for surgical patients with the goal of providing better-coordinated and more efficient care that minimizes complications and speeds recovery. The model standardizes all routine processes and procedures for each relevant case type, driving out the variation that can create uncertainty or inefficiency around resource utilization and outcomes. Standardization of routine processes allows for easier identification of higher-risk or nonstandard care and allows essential resources to be reallocated to where they are needed most.

Integration in Action

The PSH model encompasses any number of diagnoses or comorbid conditions involving any kind of surgery. To illustrate, consider again a patient who presents with a hip fracture. In a hospital that has adopted a PSH model and reengineered the care pathway for patients with hip fractures, a patient’s experience may follow an order more like the following:

• The emergency medicine physician confirms a hip fracture and immediately consults with both the hospital medicine and anesthesia teams.
• The hospitalist admits the patient while the anesthesiologist notifies the orthopedic surgeon and schedules the surgery.
• The anesthesiologist conducts a preoperative risk assessment.
• The patient undergoes surgery.

This rapid hip integrated pathway (HIP) features early and increased coordination among clinicians to allow for much faster time to surgery, often the same day the patient presents to the hospital. This path to surgery can result in a lower overall length of stay (LOS), which reduces risk for postoperative infection and the likelihood of a skilled nursing facility (SNF) stay—all results that are associated with lower costs, better outcomes, and improved satisfaction. ^c

Another service-line-specific example is provided in the ERAS model. These programs are designed to help surgical patients recover from surgery more quickly, safely shortening the patients’ hospital stays and helping them return more quickly to their normal routines. Under ERAS, the multidisciplinary care team again works together, following a set of evidence-based guidelines to speed recovery. Those guidelines include the following steps:

• Optimization of existing diseases such as anemia or diabetes
• Clear and consistent communication and education of patients and families about expectations regarding activity, diet, and pain management before, during, and after their hospital stay
• Minimal use of IV fluids, drains, and nasogastric tubes
• Minimal use of opioid painkillers
• Early reintroduction to diet, usually the same day as surgery
• Early ambulation

Because patients are almost always scheduled for their surgeries or procedures electively, anesthesiologists have an opportunity, unique among hospital-based physician specialties, to optimize patients prior to their admission—in other words, to ensure patients are healthy enough for surgery. A coordinated and streamlined perioperative process, particularly involving the services rendered prior to admission, allows patients to recover more quickly. ERAS pathways have been shown to significantly reduce length of stay, opioid use, and postoperative complications. ^d

Positive Results

Ascension All Saints Hospital in Racine, Wis., implemented both rapid HIP and ERAS protocols as part of its plan to reengineer perioperative care. The ERAS program was applied to the hospital’s elective colorectal surgery patients. After implementation of ERAS, this patient population experienced one-day reductions in LOS and time to ambulation, a 50 percent reduction in postoperative pain scores for the first two days after surgery, and a 78 percent reduction in total doses of opioids used in the postoperative period. Similarly, the hip fracture population experienced a 77 percent reduction in pain medication administration within the first 12 hours after surgery and a 51 percent reduction in postoperative pain scores within the same time frame.

In Portland, Ore., Legacy Good Samaritan Medical Center saw a significant three-day reduction in LOS (from 6.7 days to 3.7 days) by implementing ERAS for its patients undergoing elective colorectal surgery. The LOS reduction resulted in an estimated cost savings of $4,803 per patient. Despite reducing LOS, the organization saw no increase in the rates of postoperative complications or 30-day readmissions.

Kettering Health Network’s Grandview Medical Center in Dayton, Ohio, achieved a 51 percent reduction in postoperative surgical site infections with its surgical home and ERAS programs. With the typical postoperative site infection costing between $10,000 and $20,000, this reduction translates to significant savings for the hospital and higher quality ratings. ^e

Customized Success

At Summa Health System in Akron, Ohio, the anesthesia team has implemented a unique anesthesia care team model to take on integrated perioperative care. There, anesthesiologists cover an assigned care area during their shifts, dedicating themselves to all preoperative patients and block clinics, for example, or to the post-anesthesia care unit or a specific block of operating rooms. Certified registered nurse anesthetists (CRNAs) are instrumental in implementing and effecting performance improvement and patient care excellence. This model ensures there is an anesthesiologist present for all anesthesia care events. It also allows for more highly leveraged care team models than the typical national average of 1 anesthesiologist to 2.4 CRNAs. ^f

The facility medical director for anesthesia at Summa Health estimates his model saves the health system approximately $4 million per year in physician costs in comparison to typical anesthesia care team models.

To enable its model, the team has adopted smart electronic health record technology and standardized practices, protocols, and checklists for virtually everything it does, from anesthesia induction to patient education and perioperative care scripting. This approach eliminates the variation that comes with the traditional master/builder model of medical practice and creates a team culture where everyone agrees to follow the best practices that create the most efficiency and optimize outcomes.

One of those standardized processes is the regular use of nonopioid, regional anesthesia blocks for postoperative pain control. Summa Health uses the strategy for nearly half of its surgical cases, but the entire team is trained to perform blocks. This practice has allowed the organization to reduce its opioid load by approximately 95 percent while lowering LOS and enhancing satisfaction among patients, who are pleased to go home sooner with less pain. ^g

Additional Impact

This integrated approach to perioperative care also provides financial benefits in value-based payment models such as accountable care arrangements. If the healthcare industry continues to move toward payments for episodes of care that extend beyond the hospital, or that require managing the health of entire populations, hospitals will benefit when they can move patients through the inpatient experience more efficiently and set them up for optimal recovery at home, versus discharge to a SNF or a rehabilitation facility. By reducing their costs for episodes of perioperative care, hospitals can capture a greater share of episode-based payments and boost margins.

Furthermore, the fact that an integrated care model requires coordination and communication among clinicians breaks down the silos that have traditionally separated departments to create a more team-based culture with smoother transitions through the acute care episode. These changes can translate into reduced clinician turnover, saving on recruiting costs, and into better payment due to enhanced patient satisfaction scores. ^h

Getting Integrated

Because integrated perioperative care requires participation from all clinicians who treat patients in the perioperative continuum, hospitals must secure participation and buy-in from all relevant departments, including clinicians in the ED, hospital medicine department, anesthesiology, surgery, and post-acute services. Multispecialty team representatives from these departments can begin to identify the specific cases or diagnoses that would benefit most from reengineered care pathways, such as patients who have hip fractures or who are undergoing colorectal surgery, and begin designing and implementing new protocols.

Moving to a new perioperative model can be a challenging process on several levels. Such a dramatic process change typically requires dedicated physician leaders who will champion the new approach to care. The new care processes must become part of the hospital’s formal policies and procedures. And when it’s time to operationalize changes, formerly independent departments and physicians must collaborate in new ways.

Because many physicians are used to practicing independently, these changes may require some adjustment. Hospitals and integrated care champions must emphasize that physicians have an opportunity to shape the new integrated and standardized processes to ensure they meet their high clinical standards, and although there may be some additional legwork on the front end, establishing the new processes will allow all parties to work more efficiently and be more productive over time. This increased efficiency can allow physicians to spend more time with patients and use resources more effectively for patients who require additional care.

Integrated perioperative care models can have a positive impact on a hospital’s operational, financial, and clinical outcomes. For hospitals that can effectively collaborate across service lines to redesign care processes, the PSH can help lower costs, improve outcomes, and enhance patient satisfaction and care transitions for surgical cases.

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Sonya Pease, MD, 
is chief medical officer, TeamHealth Anesthesia, Palm Beach Gardens, Fla.

Footnotes

a. McDermott, K.,W., Freeman, W.J., Elixhauser, A. “ Overview of Operating Room Procedures During Inpatient Stays at U.S. Hospitals, 2014,” Healthcare Cost and Utilization Project, December 2017; Dahl, R., How Hospitals Can Increase OR Profitability , Surgical Directions, 2013.

b. American Society of Anesthesiologists, “ Perioperative Surgical Home: Learning Collaborative Overview,” 2018.

c. Friedman, S.M., Mendelson, D.A., Bingham, K.W., et al., “ Impact of a Comanaged Geriatric Fracture Program on Short-term Hip Fracture Outcomes,”Archives of Internal Medicine. Oct. 12, 2009; Kates, S.L., Mendelson, D.A., Friedman, S.M., “ The Value of an Organized Fracture Program for the Elderly: Early Results,” Journal of Orthopedic Trauma, April 2011.

d. Kash, B., Cline, K., Tomaszewski, L., “Developing a Financial Model of the Perioperative Surgical Home (PSH),” American Society of Anesthesiologists, May 2015.

e. Ellison, R., “ The Cost of Surgical Site Infections,” NEJM Journal Watch, May 2014.

f. TeamHealth data

g. The Advisory Board Company, “Cost and Quality Impact of Multi-Modal Pain Regimens,” Executive Research Briefing, Nov. 24, 2014.

h. Helfrich, C., Dolan, E., Simonetti, J., et al., “ Elements of Team-Based Care in a Patient-Centered Medical Home Are Associated with Lower Burnout Among VA Primary Care Employees,” Journal of General Internal Medicine, July 2014; Bodenheimer, T., Sinsky, C., “ From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider,” Annals of Family Medicine, December 2014; Griggs, A., “ Collaborative Clinical Culture at UCI: Exploring Teamwork in the Department of Anesthesiology and Perioperative Care,” University of California, Irvine, 2014; Reid, R., Coleman, K., Johnson, E., et al., “ The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout for Providers,” Health Affairs, May 2010.