Julie Sheedy DNP, MSN, NE-BC,RN Administrator March 9 , 2019

1. Perioperative Surgical Home Model Julie Sheedy DNP, MSN, NE-BC,RN Administrator March 9, 2019

2. Agenda Welcome Overview of TriHealth TriHealth Surgical Home Data Collection Lessons Learned Future state Closing

3. 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

4. TriHealth Awards for Clinical Quality, Technical Excellence and Employee Engagement

5. 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 July 2014 TriHealth successfully recertified as HIMSS Stage 7 in December 2017

6. TriHealth Surgical Optimization Center Recognition Nationally Recognized by ASA as Industry Leading Innovator Award Nationally Recognized by Studer Group What’s Right in Healthcare Nationally Recognized by ASPAN as First Place Winners

7. Local Problem 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

8. 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.

9. What Is Perioperative Surgical Home? • Patient centered, team based model of care that guides the patient from the decision of the need for surgery through 90 days post discharge • Provides a care pathway for the patient with clinical processes and protocols throughout the episode of care • Aligns with the triple aim to reduce cost and clinical variability while improving clinical outcomes

10. Transforming Pre-SurgicalServices • 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

11. PSH Perioperative Clinic • Patient Reported Outcomes (PROs)* • Identification of risk through screening • Chronic disease Management • Holistic Management of the patient

12. 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

13. 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.

14. Where We Started

15. Governance and Clinical Decision Making

16. Intended Outcomes Reduce Cancels

17. Intended Outcomes Reduce Cost Reduce Cancels

18. Intended Outcomes Reduce SSI Reduce Cancels Reduce Cost

19. Intended Outcomes Reduce Readmit Reduce SSI Reduce Cost Reduce Cancels

20. Optimization Phase Surgeon referral to TSOC Nurse Practitioner identify for pre-risk screening Obtain anesthesia consults Perform H&P’s when necessary Determine course of treatment based on labs and EKG

21. 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

22. Optimization Protocols • Anemia Protocol • Anticoagulation Pathway • Diabetes Protocol • Enhance Recovery Protocol • Fraility • Nutritional Pathway • Obstructive Sleep Apnea • Smoking Cessation

23. 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 CollSurg 2010 Farhat J Trauma Acute care Surg 2012 Kim JAMA Surg 2014

24. Therapy order management

25. Referral for Diabetes Education

26. TSOC Communication Tools

27. Intraoperative Phase • Multi-modal pain management • Fluid management • Standardization of surgical technique

28. Postoperative Phase • Pain management plan of care • Early mobilization • Care transition to home • Discharge protocols • Multi-disciplinary approach with patient and family

29. 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

30. TSOC Inclusion

31. Flagging Patient As TSOC

32. Best Practice Alerts

33. Post-Discharge Documentation

34. TSOC Dashboard Reports

35. TSOC Dashboard Reports

36. TSOC Dashboard Reports

37. TSOC Dashboard Reports

38. Quality Outcomes Increased Overall Patient Satisfaction 76% to 83% No Case Cancellations 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

39. 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

40. Quality Outcomes *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

41. Overall Project Outcomes

42. Soft & Hard ROI for TSOC

43. Keys to Success

44. 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!

45. What’s Next • Expanding TSOC and Clinical Pathways • Additional service lines: • 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 Guide’s role • Refine and expand implications in addressing patients at risk for readmission to the hospital

46. QUESTIONS