Perioperative Surgical Home Model Julie Sheedy DNP, MSN,

Perioperative Surgical Home Model Julie Sheedy DNP, MSN,

Perioperative Surgical Home Model Julie Sheedy DNP, MSN, NE-BC,RN Administrator March 9, 2019 Agenda Welcome Overview of TriHealth TriHealth Surgical Home Data Collection Lessons Learned Future state Closing TriHealth At A Glance

Four acute-care hospitals with 900 adult-staffed beds One short-stay surgical hospital Two free-standing outpatient surgery centers Over 140 outpatient service locations Over 150 physician practice locations Over 850 employed physicians Over 1,800 physicians on medical staff Over 12,000 employees TriHealth Awards for Clinical Quality, Technical Excellence and Employee Engagement TriHealth Awards for Clinical Quality, Technical Excellence and Employee Engagement Healthcare Information and Management System Society (HIMSS) Analytics Electronic Medical Record (EHR) Adoption Model Stage 7 Awarded to

TriHealth successfully TriHealth July 2014 recertified as HIMSS Stage 7 in December 2017 TriHealth Surgical Optimization Center Recognition Nationally Recognized by ASA as Industry Leading Innovator Award Nationally Recognized by Studer Group Whats Right in Healthcare Nationally Recognized by ASPAN as First Place Winners Local Problem

Increased LOS Patient outcomes were being impacted due to: Clinical variation Lack of coordinated care Patient disconnected from primary care provider Causing: Increased costs Inconsistent patient experience Surgery Delays /Cancellation s Increased Readmissions Preventable Complications Lower Patient Satisfaction

Higher Cost Per Care Perioperative Learning Collaborative Premier Learning Collaborative is physician-led that brings health systems and clinical leaders together to challenge perceptions and practices related to improvement solutions. Leveraging the power of peer-to-peer learning, data-enabled decision making and innovation to evaluate new cost and quality improvements. Over 80 hospitals are participating and sharing best practices TriHealth chose to participate in the National Perioperative Learning Collaborative and pilot a perioperative surgical home program. 8 What Is Perioperative Surgical Home? Surgery Decision Patient centered, team based model of care that guides the patient from the decision of

the need for surgery through 90 days post discharge PostDischarge Optimization Provides a care pathway for the patient with clinical processes and protocols throughout the episode of care Acute Care Pre-op Aligns with the triple aim to reduce cost and clinical variability while improving clinical outcomes Surgical Event Transforming Pre-Surgical Services Surgical cases account for

50% of readmissions Current state contributes to excessive expenditures (labs, cardiac clearance, productivity) Duplicate and unnecessary testing Fragmentation falls short of meeting patients needs PSH Perioperative Clinic Patient Reported Outcomes (PROs)* Identification of risk through screening Chronic disease Management Holistic Management of the patient TriHealth Surgical Optimization Center (TSOC)

Admission through a centralized clinic Early preadmission assessments/risk stratification Centralized systems to gather health information Prehabilitation programs Multidisciplinary team based care to coordinate/navigate complex patients prior to surgery Support healthy surgical candidate with a standardized process Solution Selection Process Colorectal as the Preferred Service Line Manageable volume (~3oo patients) Cohesive and collaborating group of physicians and team members Looking for an engaged service line that would allow us to stand up a successful model that could be extended and repeated across the enterprise. 13 Where We Started March 2016 February 2017

Average Length of Stay 8.2 Days Surgical Site Infections 21 Delayed Cases 9 % Readmission 14.00% Average Cost Per Case $11,693 Overall Patient Experience (Top Box) 72.50%

Governance and Clinical Decision PSH Core Group Making Dr. Matt Schantz, Dr. Elsass, Dr. Kirkpatrick, Dr. Guend, Mary Pat Gilligan, Julie Sheedy, Diana Smith, Judie Conley Surgery Decision Optimization Preop Day of Surgery Intraoperative PACU Acute Phase of Care Discharge Data Analytics Education Communication Anesthesia : Dr.

Schantz/Dr. Elsass Anesthesia : Dr. Schantz/Dr. Elsass Anesthesia: Dr. Burgess Anesthesia : Dr. Schantz/Dr. Elsass Surgeon: Dr. Kirkpatrick & Dr. Guend Surgeon: Dr. Maynard Surgeon: Dr. Kirkpatrick Surgeon: Dr. Guend

Surgeon: Dr. Kirkpatrick Clinical Lead: Lisa Hess & Lori Vernon Clinical Lead: BN/GS SDS Managers & OR Managers Clinical Lead: Carolyn Hoenicke Clinical Lead: Lisa Hess & Lori Vernon IT Lead: Mufaddal Frosh & Diana Smith Clinical Lead: Sue Sandsone

PSS/PAT RN: 2 BN & 2 GS SDS/OR RN: 2 BN & 2 GS PACU/IP RN: 2 BN & 2 GS Care Coordinator: Heidi Loughran Data Analytic Lead: Patrick Haney Marketing & Communications IT: Lindsey Satterfield & Chris Cionni IT: Shara Jenkins & Jennifer Grice

IT: Lindsey Satterfield & Chris Cionni IT: Thomas Hester IT: Lisa Sheppard & John Montavon IT: Lindsey Satterfield & Chris Cionni Clinical Informatics: Sharon Hafertepe & Meg Howes Clinical Informatics: Clinical Informatics

Clinical Informatics: Tracey Bracke & Beth Angst Sherri Chenault & Patti Burke Anesthesia : Dr. Schantz/Dr. Elsass Anesthesia : Dr. Elsass Surgeon: Dr. Kirkpatrick Educators: Patrick Bobst & Amy Orr Educators Intended Outcomes

Preoperative - Improved patient experience - Managed comorbidities - Reduce clinical variation - Transitional Care Planning Reduc e Cancel s Intraoperative - Reduce clinical variation - Operational efficiencies Postoperative - Right level of care

- Integrated pain management - Prevention of complications Long Term Recovery - Coordinated discharge plan - Educate patient and care givers - Transition to appropriate level of care - Rehabilitation and return to function Intended Outcomes Preoperative - Improved

patient experience - Managed comorbidities - Reduce clinical variation - Transitional Care Planning Reduc e Cancel s Intraoperative - Reduce clinical variation - Operational efficiencies Reduc e Cost Postoperative - Right level of

care - Integrated pain management - Prevention of complications Long Term Recovery - Coordinated discharge plan - Educate patient and care givers - Transition to appropriate level of care - Rehabilitation and return to function Intended Outcomes Preoperative

- Improved patient experience - Managed comorbidities - Reduce clinical variation - Transitional Care Planning Reduc e Cancel s Intraoperative - Reduce clinical variation - Operational efficiencies Reduc e Cost Postoperative

- Right level of care - Integrated pain management - Prevention of complications Reduc e SSI Long Term Recovery - Coordinated discharge plan - Educate patient and care givers - Transition to appropriate level of care - Rehabilitation and return to function

Intended Outcomes Preoperative - Improved patient experience - Managed comorbidities - Reduce clinical variation - Transitional Care Planning Reduc e Cancel s Intraoperative - Reduce clinical variation - Operational efficiencies

Reduc e Cost Postoperative - Right level of care - Integrated pain management - Prevention of complications Reduc e SSI Long Term Recovery - Coordinated discharge plan - Educate patient and care givers - Transition to appropriate

level of care - Rehabilitation and return to function Reduc e Readm it Optimization Phase Surgeon referral to TSOC Nurse Practitioner identify for pre-risk screening Obtain anesthesia consults Perform H&Ps when necessary Determine course of treatment based on labs and EKG

Optimization Phase Nurse Navigators obtain surgical referral Perform chart review within 48-72 hours Phone encounter to determine clinical needs Conduct Optimization protocols Perform optimization visit for education and necessary services Follow-up with surgical patients 6 days out Optimization Protocols Anemia Protocol Anticoagulation Pathway

Diabetes Protocol Enhance Recovery Protocol Fraility Nutritional Pathway Obstructive Sleep Apnea Smoking Cessation Implications of Frailty for the Surgical Patient - Frailty in non emergent surgery predicts: - 2.5 fold increased risk of postop complications 1.7 fold increase in LOS 20 fold increase in discharge to not home Frailty in emergency surgery:

11 fold increase in mortality Makary J Am Coll Surg 2010 Farhat J Trauma Acute care Surg 2012 Kim JAMA Surg 2014 23 Therapy order management 24 Referral for Diabetes Education 25 TSOC Communication Tools 26 Intraoperative Phase Multi-modal pain management Fluid management

Standardization of surgical technique Postoperative Phase Pain management plan of care Early mobilization Care transition to home Discharge protocols Multi-disciplinary approach with patient and family Post-Discharge Phase Nurse Care Guide established to care manage patient 90-days post-discharge Developed registries to identify patients Utilized EMR documentation to standardize follow-up care

Patient Experience Survey at day two and day 10 TSOC Inclusion TSOC Inclusion Patient Flagging BPAs Clinical Workflow Optimization Clinical Pathway Pathway Review Physician Workflow Optimization Documentation Reporting Tools

Flagging Patient As TSOC TSOC Inclusion Patient Flagging BPAs Clinical Workflow Optimization Clinical Pathway Pathway Review Physician Workflow Optimization Documentation Reporting Tools Best Practice Alerts

TSOC TSOC Inclusion Inclusion Patient Patient Flagging Flagging BPAs BPAs Clinical Clinical Workflow Workflow Optimization Optimization Clinical Clinical Pathway Pathway Pathway Pathway Review

Review Physician Physician Workflow Workflow Optimization Optimization Documentation Documentation Reporting Reporting To Tools ols Post-Discharge Documentation TSOC Inclusion Patient Flagging BPAs

Clinical Workflow Optimization Clinical Pathway Pathway Review Physician Workflow Optimization Documentation Reporting Tools TSOC Dashboard Reports TSOC Inclusion Patient Flagging BPAs

Clinical Workflow Optimization Clinical Pathway Pathway Review Physician Workflow Optimization Documentation Reporting Tools TSOC Dashboard Reports TSOC Inclusion Patient Flagging BPAs Clinical Workflow

Optimization Clinical Pathway Pathway Review Physician Workflow Optimization Documentation Reporting Tools TSOC Dashboard Reports TSOC Inclusion Patient Flagging BPAs Clinical Workflow Optimization

Clinical Pathway Pathway Review Physician Workflow Optimization Documentation Reporting Tools TSOC Dashboard Reports TSOC Inclusion Patient Flagging BPAs Clinical Workflow Optimization

Clinical Pathway Pathway Review Physician Workflow Optimization Documentation Reporting Tools Quality Outcomes Response rate: 84% 218/260 returned survey Compliance with IT Tools: 100% of Colo-rectal patients followed the TSOC clinical pathway Total volume: 260 cases Increased

Overall Patient Satisfaction 76% to 83% No Case Cancellations Quality Outcomes 67% overall reduction in SSI Source: HDM Clinical Quality Dept 5.8% overall reduction in ALOS Source: TH TSOC Dashboard & Decision Support Financial Data Warehouse Quality Outcomes Column1 Pre-Pilot

Post- Pilot Cost Savings Case Volume 248 260 % Readmit 14 8.2 Cost/Readmit $ 13,347.00 $ 13,368.00 $ $ $ Total cost 453,798.00 280,728.00

173,070.00 *Pre-Pilot: Mar 2016 Feb 2017 *Post- Pilot: Mar 2017 Feb 2018 **TH average cost per readmission/all readmissions SOURCE: TH Decision Support Financial Data Warehouse Overall Project Outcomes 2017 2018 Length of Stay 8.2 4.8 Surgical Site Infection 21

8 9 0 14% 8.2% Patient Experience Survey 72.5% 83% Financial $11,693 $10,586 Delayed Cases

Readmission (Average cost per patient) Soft & Hard ROI for TSOC Reduced Readmission $173,070 Reduced SSI Cost $14,365 Cost Avoidance for Canceled Cases1 $66,960 Reduced Cost Per Case $287,820 Total ROI $542,215

Keys to Success Team Member Engageme nt Culture of Partnershi p Keys to Succes s Informatio n System is Seen as Part of the Care Team MultiDisciplinar y care

team 43 Lessons Learned Establish a steering group to oversight of the program. Keep the scope tight and cohesive. Select strong operational team members. Ongoing meetings to identify progress, barriers and challenges. Collaboration and team work respect and appreciation for all perspectives. Delivering a product that is a patient centered and a multidisciplinary approach. Celebrate wins! 44 Whats Next Expanding TSOC and Clinical Pathways Additional service lines: o o o o

Ventral Hernias went live November 2018 Spine scheduled late spring Urologic Gynecology Urology Future Increase patient engagement via MyChart questionnaires Improve patient experience through text-messaging Enhance data collection Integrate Clinical Pathways into the Discharge Care Guides role Refine and expand implications in addressing patients at risk for readmission to the hospital QUESTIONS 46

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