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Beyond the Preoperative Clinic: Considerations for Pediatric Care Redesign Aligning the Patient/Family-Centered Medical Home and the Perioperative Surgical Home

Ferrari, Lynne R. MD*†; Antonelli, Richard C. MD‡§; Bader, Angela MD, MPH*∥

doi: 10.1213/ANE.0000000000000627
The Open Mind: The Open Mind

From the Departments of *Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts; §Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts; and Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts.

Accepted for publication November 14, 2014.

Funding: Unfunded.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Lynne R. Ferrari, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave., BCH3216, Boston, MA 02115. Address e-mail to lynne.ferrari@childrens.harvard.edu.

The success of the specialty of anesthesiology in an era of health care reform will require alignment of future anesthesia practice models with the strategic goals driving care redesign. The vast majority of this effort has been centered on the evaluation of clinical practice and outcomes in the adult population. The measures for success in infants and children are different and will require consideration of the special needs and specific diseases that are relevant to pediatric patients. For example, the in-hospital mortality rate for pediatric patients is 1.1% compared to 2.0% in adults, and the 30-day readmission rates are 6.5% for children versus 19.6% for adults.1–4 The Patient/Family-Centered Medical Home practice model may be a guide to the care of pediatric patients when considering the implementation of the Pediatric Perioperative Surgical Home.

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ALIGNING ANESTHESIA PRACTICE MODELS WITH HEALTH CARE REFORM GOALS

The goals defined within the Affordable Care Act are the Triple Aim of high-quality care, a focus on population health, and reduced expenditures. Redesigning practice models represents a disruptive innovation in which the benefits offered are simpler, less expensive, and of equal or higher quality than current fee-for-service models.5 A key strategy for meeting these goals is the implementation of measureable, standardized activities that provide optimization of care coordination. High-performing care coordination addresses interrelated medical, social, developmental, behavioral, educational, and financial needs to achieve the best possible health and wellness outcomes.6 As these models evolve, it will be essential to monitor progress and performance by devising measures that will successfully gauge the value provided by the portfolio of care coordination activities and functions, as the provisions of the Affordable Care Act tie payment to provision of coordinated care of all providers in the continuum.7 This model considers a patient’s preferences and values in all health care decisions, which in other settings has been associated with better outcomes, decreased utilization of expensive tests and procedures, and decreased postsurgical complications.8

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THE PERIOPERATIVE SURGICAL HOME: EXTENDING THE CONCEPT TO PEDIATRIC POPULATIONS

Development and implementation of the Perioperative Surgical Home model is in its early stages. The current literature is scarce but continues to increase, as demonstrated by the issue of Anesthesia & Analgesia devoted to this topic in May of 2014. The anesthesia group at the University of Alabama at Birmingham has elegantly outlined the benefits of the model to patients, institutions, and the specialty of anesthesiology.9 The belief of this group, shared by many who embrace this concept, is that expanding the anesthesiologist’s scope of practice to function as the physician leaders of the new model will result in a more comprehensive and integrated approach to surgical care, promoting standardization and integration in perioperative systems that will improve clinical outcomes, ensure high-quality patient-centered shared decision making, and decrease inefficient resource utilization.

The literature on the concept of the Perioperative Surgical Home considers system development and implementation based largely on the needs of an adult surgical population in which the vast majority of the medical issues are cardiac in nature as well as the chronic conditions inherent to the elderly.10 Compared to adults, the reasons for readmission of pediatric patients within 30 days of discharge are significantly different (Table 1).2,4 There is currently no work outlining the application of the Perioperative Surgical Home model to pediatric surgical patients. This is in sharp contrast to the large body of literature on the successful development and implementation of the Patient/Family-Centered Medical Home, which has long been an accepted model for integrated, coordinated medical care for children.11–14 This model considers the unique components of pediatric health care which focus on developmental progress rather than prevention of adverse sequelae, dependency on adults and family members, and the return on investment over long-term life course.15 In contrast to the adult surgical population, a very small percentage of pediatric surgical patients requires transition to skilled nursing facilities after discharge.

Table 1

Table 1

Over 20 years ago, the American Academy of Pediatrics defined the Patient/Family-Centered Medical Home in policy statements as care that is accessible, patient and family centered, continuous, comprehensive, and culturally sensitive. Although the Patient/Family-Centered Medical Home model began in pediatrics as an approach to caring for children and youth with chronic conditions, it has evolved into the standard for optimal primary care delivery for all children.16 The mission of the Patient/Family-Centered Medical Home is to provide coordinated, compassionate care directed by physicians in partnership with the child and family by forming strong links among the primary care provider team and other health care facilities where patients access services with their family/caregivers and community providers.17 Likewise the perioperative physician coordinates with other members of the primary medical team, surgical and subspecialist teams, nurses, social workers, and other hospital-based teams using best available evidence to improve quality and cost effectiveness of care while enhancing the patient experience. These handoffs and communication regarding individual patient assessment and planning among caregiver are an essential component of this new process.

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INTEGRATION OF THE PATIENT/FAMILY-CENTERED MEDICAL HOME WITH THE PEDIATRIC PERIOPERATIVE SURGICAL HOME

As the U.S. health care system is being redesigned to deliver higher value care, simply strengthening the primary care setting is not sufficient to provide optimal outcomes.18 As care delivery entities are configured to become accountable for meeting the demands for cost reduction and improved quality, the imperative to coordinate across specialties becomes critical. In delivery models lacking purposeful attention to integration strategies, the care experienced by patients and families is fragmented which results in uncoordinated, inefficient, low-value care.19 The Patient/Family-Centered Medical Home model, which strives to achieve this integration, cannot ensure delivery of optimal value outcomes unless there is a corresponding Pediatric Perioperative Surgical Home counterpart for those pediatric patients requiring surgical and procedure-based care. This provides a strategic framework supporting the alignment and coordination of professional efforts throughout the surgical episode irrespective of institutional, departmental, or community-based organizational boundaries. The American College of Surgeons National Surgical Quality Improvement Program pediatric subsection measures risk-adjusted outcomes to improve the quality of surgical care during the intraoperative phase. In contrast, however, the anesthesiologist-directed Pediatric Perioperative Surgical Home must address the continuum of care throughout the entire surgical episode.

The care coordination and integration within primary care pediatric practice is associated with a decrease in nonurgent emergency room visits, enhanced family satisfaction, reduced unplanned hospitalizations, lower out of pocket expenses, fewer school absences, and less impact on parental employment.20 Based on the success of the Medical Home models and the proposed benefits of the Perioperative Surgical Home in adults, appropriate application of these concepts to the pediatric surgical population would be expected to generate the same benefits to patients, families, health systems, and payors, utilizing the particular skill sets of the anesthesiologist to provide overall coordination.21–23 As in the Patient/Family-Centered Medical Home, the Pediatric Perioperative Surgical Home model must organize around each patient’s condition rather than each physician’s medical specialty and allow successful transition for the patient between outpatient care and episodes of procedural care. Care must be integrated across specialties and facilities, with the patient and family positioned at the center, so that the shift from volume to value may be achieved.24 This is especially important in the population of children with chronic conditions, an important segment of the population for whom care delivery is often fragmented.

The prevalence of children in the United States with special health care needs, defined as physical, developmental, behavioral, or emotional conditions requiring health services beyond those of the general population, has increased by 18% between 2001 and 2010 and now represents 15.1% of the total population <18 years of age.25 Anesthesiologists who develop and direct Pediatric Perioperative Surgical Homes, as well as Perioperative Surgical Homes caring for mixed adult and pediatric populations, will require additional pathways for children with congenital and acquired chronic disease, and associated special needs which will differ from those in the adult population. These elements must be considered when resources for Pediatric Perioperative Surgical Homes are negotiated, acknowledging that each of these patient populations requires a “health care micro system” which is defined by the Institute of Medicine as a small organized patient care unit with specific purpose, set of patients, technologies, and practitioners, which is aligned to their specific health concerns.15,26 Resource utilization and personnel costs have been evaluated for a number of Patient/Family-Centered Medical Home practices; similar strategies will need to be employed when negotiating resources to apply these concepts to the surgical episode.27,28

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NEED FOR DEVELOPMENT OF METRICS

Although data on the returns achieved relative to the cost involved are limited in part due to the absence of well-defined metrics, there is evidence of benefit in children with higher medical complexity.2 Although there are currently over 644 National Quality Forum–endorsed measures of quality, it is unclear that these will accurately reflect the positive impact on outcomes and resource utilization that the Perioperative Surgical Home seeks to provide.29,30 Of these endorsed measures, only 123 are related to a surgical patient population and 11 are specifically applicable to both pediatric patients and adults. Of these risk-adjusted measures, those that are applicable to both adult and pediatric surgical patients include: average length of stay, postoperative renal failure, prolonged intubation, surgical re-exploration, increased mortality for neonates undergoing noncardiac surgery, timing of prophylactic antibiotic administration, transfusion reactions, and ventriculoperitoneal shunt malfunction.31 In addition, capturing the impact on the patient and family experience will be vital. The available evidence would suggest that the measurement and interpretation of patient experiences can provide meaningful indicators of health care quality.32 Experience with the Patient/Family-Centered Medical Home and defined care coordination metrics can be potentially translated into metrics for the Pediatric Perioperative Surgical Home.33 In addition, a tool to measure clinical, cost, functional, and satisfaction outcomes at the level of the patient/family, primary and specialty care points, and institutional/community perspective has been proposed that may be translatable to the Pediatric Perioperative Surgical Home model.13 High-value organizations will use these metrics to demonstrate value to payers and regulatory agencies as well as for internal process control, target setting, and performance management.34,35

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CONCLUSIONS

The Value Proposition

The new concept of the Pediatric Perioperative Surgical Home renders the old concept of asking the primary care pediatrician to “clear” the patient for surgery and anesthesia obsolete. Instead the patient is evaluated in the context of an overarching perioperative episode which integrates the care provided by the perioperative care team with the patient’s ongoing providers for the benefit of the family, patient, and health system. Demonstrating the value of the Pediatric Perioperative Surgical Home to surgical colleagues, administrators, patients, policymakers, and payors will be needed to justify implementation of this new model; this will require rigorous evaluation. In addition, it is likely that the type of Perioperative Surgical Home developed will vary based on institutional needs, payment structures, and patient base. In all cases, however, the commonality of patient- and family-centered care and optimizing value are essential.36 Specific elements inherent to the preoperative, intraoperative, and postoperative phases that reflect the added value can be identified. In addition to the development of outcome metrics and institutional assessment tools, health information technologies and methodologies for comparative effectiveness research will be needed to validate the impact of the Pediatric Perioperative Surgical Home on the patient-centeredness, evidence-based practice, quality, safety, and value of patient care.37,38 Data collection tools will need to be developed to determine resource use based on complexity level in children. Mechanisms for financing will need to be presented to institutions and payors, and the potential value becomes a part of overall negotiations for clinician reimbursement. High-value health care organizations that deliver quality care at a reduced cost should incorporate common elements that will make these efforts achievable. These include successful specification and planning, infrastructure design, measurement and oversight, and self-study. In this context, specification refers to separating heterogeneous patient populations into clinically meaningful subgroups by disease subtype, severity, or risk of complications, each with its own distinct pathway.33 In addition, information technology infrastructures will need to be designed and modified to reflect the increased level of care integration and ensure that information is transferred securely throughout the episode of procedural care as well as to the primary care pediatrician via integration with the Patient/Family-Centered Medical Home.39

The literature has outlined quality and safety variables that can be applied to assess the effect of the adult Perioperative Surgical Home model; similar work will be needed to modify these variables to reflect the pediatric surgical population.21 As discussed above, the cost of care coordination is not insignificant, but the belief is that comparative effectiveness research and institutional outcome metrics will demonstrate that the value added warrants the investment. Establishment of the Pediatric Perioperative Surgical Home will require innovative ways of determining resource utilization and the return on investment.

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DISCLOSURES

Name: Lynne R. Ferrari, MD.

Contribution: This author helped write the manuscript.

Attestation: Lynne R. Ferrari approved the final manuscript.

Name: Richard C. Antonelli, MD.

Contribution: This author helped write the manuscript.

Attestation: Richard C. Antonelli approved the final manuscript.

Name: Angela Bader, MD, MPH.

Contribution: This author helped write the manuscript.

Attestation: Angela Bader approved the final manuscript.

This manuscript was handled by: Peter J. Davis, MD.

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