California Leads in Perioperative Surgical Home Initiative

  • Sibert, Karen, MD, FASA
| Aug 11, 2014

California led the way in the number of participants at the ASA’s kick-off meeting of the Perioperative Surgical Home (PSH) Learning Collaborative, held on July 25-26 at the beautiful new ASA headquarters in Schaumburg, Illinois.

A portion of the historical wall at the new Schaumberg building.

Seven California healthcare organizations (HCOs) sent representatives to the meeting, along with 36 others from across the country, including academic medical centers, community HCOs, pediatric hospitals, and ambulatory surgery centers.

The PSH Learning Collaborative brings together HCOs who pay to participate in order to develop, pilot, and evaluate the PSH model.  The goal is to improve care for surgical patients from the moment surgery is planned through recovery, discharge, and post-acute care.  The participants pursue care redesign strategies to reduce length of stay, hospital readmissions, and complications of care.  They will pool knowledge and study successful practices.

More than 140 physicians and executives taking part in the Learning Collaborative met Friday evening for an introductory session led by ASA President Jane Fitch, MD, Vice President for Professional Affairs Stan Stead, MD, MBA, and Celeste Kirschner, the ASA’s executive for the PSH.  Members of the collaborative agreed to share information and outcomes data freely, and not to publish results individually until the collaborative is ready to publish them as a collective effort. 

“We’re looking at new ways to do this, and new ways to get paid for it, “ Dr. Stead said.  “We come from different points of reference and different points of readiness, but we’re all part of the same team.”

On Saturday, the Learning Collaborative heard presentations from ASA members who have already begun to implement the PSH model, including Art Boudreaux, MD, who spoke about the ongoing PSH experience at the University of Alabama at Birmingham, and Zeev Kain, MD, MBA, who leads the multidisciplinary PSH development at the University of California, Irvine.

Mike Schweitzer, MD, MBA, who chairs the ASA Committee on Future Models of Anesthesia Practice, told the group that the six weeks before surgery are critical for patients, because that’s when we have the opportunity to correct problems such as anemia, congestive heart failure, and nutritional status.  “These are the problems that often bring people back into the hospital,” he said.

“A lot of people are doing the intraoperative piece very well,”  Dr. Schweitzer said.  But as we’ve decreased the length of stay in the hospital, Medicare growth in spending on post-acute care has more than doubled since 2001.  Half the cost of perioperative care is incurred outside the acute episode of care, Dr. Schweitzer explained, and this constitutes a big opportunity for the PSH to demonstrate value.

“Variations in post-acute care cost are huge,” Dr. Schweitzer told the audience.  “There’s a difference of $15,000 over the first 90 days after discharge in sending patients home with home health assistance versus sending them to a skilled nursing facility.”  Smooth navigation from the primary care physician to the PSH and back to primary care will be the key to success, Dr. Schweitzer said, but that’s where lapses in care and failures in communication often happen.  “Who calls the patients after surgery to check if prescriptions have been filled, and if they need a ride to physical therapy?” he asked.

The PSH Learning Collaborative is coordinated by Premier, Inc., a leading healthcare consulting firm.  Joseph Damore, Premier’s Vice President for Population Health Management, told the group, “Everybody makes more money from complications in a fee-for-service world.”  But today, he said, the government and insurance payers want to change that model and pay people to improve quality and keep patients healthier. “This is not going away!” he declared.

At the same time, Mr. Damore explained, care redesign must not outpace changes in payment.  “If you do all this and don’t change payment, who gets all the money saved?  Insurers do,”  he said.  This is the reason why new models of payment must accompany changes in delivery of care. 

After the morning’s presentations, the Learning Collaborative participants split into groups to study three major topics:

  • Clinical protocols and operating practices
  • Measurement and performance improvement
  • Payment models:  the business case and value proposition for the PSH.

California representatives to the PSH Learning Collaborative include: 

  1. Keck/University of Southern California: 
    • Edward Kwon, MD
    • Earl Strum, MD
    • John Ziegler, MD
  2. Loma Linda University:
    • Gary Stier, MD
    • Michael Wettstein, MD
  3. Meritage ACO:
    • Keith Chamberlin, MD, MBA
    • Sabrina Kidd, MD
    • Marcy Norenius, MPH
  4. Stanford University:
    • Ronald Pearl, MD, PhD
    • Anita Honkanen, MD
    • Samuel Wald, MD, MBA
  5. University of California, Irvine:  
    • Leslie Garson, MD
    • Zeev Kain, MD, MBA
    • Kathryn Komaki, BA
    • Ran Schwarzkopf, MD
    • Shermeen Vakharia, MBBS
  6. University of California, Los Angeles:
    • Victor Duval, MD
    • Aman Mahajan, MD, PhD
    • Jure Marijic, MD
  7. University of California, San Francisco:​​
    • Lee-Lynn Chen, MD
    • Rachel Eshima McKay, MD
    • Michael Gropper, MD, PhD
    • Seema Gandhi, MD

For more information about the UC Irvine experience with implementing the PSH for the orthopedic service line, see their article in the May 2014 issue of Anesthesia & Analgesia:   

"Implementation of a total joint replacement-focused Perioperative Surgical Home: A management case report."

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