Perioperative Surgical Home Model Moves Forward

By: Peter Pollack

ASA-developed initiative shows positive results; plans expansion

The Perioperative Surgical Home (PSH) is a patient-centered, team-based model of care coordination designed to guide patients through the complete surgical experience, starting with the decision to undergo surgery and concluding with discharge and return to function. In a time of increasing emphasis on bundled payments, such as the U.S. Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) model, the PSH, an initiative developed by the American Society of Anesthesiologists (ASA) and Premier Inc., may assist physicians in the transition to bundled payment systems while retaining an emphasis on value, patient satisfaction, and reduced costs.

Following a series of literature reviews to outline and develop the process, the first phase of the PSH initiative ran from July 2014 through November 2015. During Phase One, 44 healthcare organizations from across the United States worked together to develop and evaluate the PSH model. Of those, 73 percent successfully launched a total of 64 pilot programs covering thousands of completed cases. Orthopaedics was one of the key areas of study.

“At the Fall Meeting, the Council on Research and Quality (CORQ) held a strategic discussion about the PSH and enthusiastically endorsed it,” said Roxanne E. Wallace, MD, a member of CORQ. “In December, the AAOS Board of Directors upheld the CORQ recommendation and endorsed the PSH program.”

The PSH model consists of the following key aspects:

  • A portal of entry to the perioperative care pathway
  • Stratification and management of patient populations according to risk factors
  • Evidence-informed, integrated clinical care before, during, and after the procedure
  • Ongoing measurement and improvement

Skepticism, then buy-in
Arkansas-based White River Health System participated in Phase One of the PSH initiative and quickly saw positive results.

“I was very leery about healthcare reform and alternative payments due to the ongoing administrative burdens they place on physicians” said Jeffery D. Angel, MD, the Arkansas representative on the Board of Councilors. “I was even more concerned when our local anesthesiologist recommended a new patient care model developed by ASA. Then I became the codirector and saw the PSH in action. I saw firsthand what bundled care and alternative payment methods can achieve. White River Medical Center [in Batesville, Ark.] has just three general orthopaedic surgeons, but we made remarkable strides in increasing pain satisfaction, while decreasing readmissions, length of stay, and costs in our total knee and total hip services.”

“One of the most popular new models of payment from CMS, commercial payers, employers, and state Medicaid plans seems to be bundled payments,” noted Peggy L. Naas, MD, MBA, a member of the Committee on Evidence-Based Quality and Value. “The Perioperative Surgical Home Collaborative offers orthopaedic surgeons, as well as their colleagues and health systems, the opportunity to hone their skills in creating, leading, and managing a continuum bundle with successful outcomes. Developing these skills will help ensure orthopaedic success in the 21st century.”

“We used the PSH to set up protocols for optimization of patients before surgery,” Dr. Angel explained. “The processes during the hospital stay were standardized, and metrics were followed in near real-time. By implementing the PSH model, we decreased the need for intensive inpatient postoperative care through the use of preoperative education, stratification, and more frequent monitoring. Under the PSH we now have a system at our local, rural hospital to ensure that we can provide the Institute for Healthcare Improvement’s ‘Triple Aim’ of increasing patient satisfaction and outcomes, decreasing per capita costs, and improving the health of our population. Providers in any size or style of practice can come together through the PSH and standardize processes that make a difference in the lives of patients.”

Second phase starts soon
Phase Two of the PSH is scheduled to begin April 1, 2016. At its December meeting, the AAOS Board of Directors endorsed the PSH model. It also appointed Dr. Angel and Dr. Naas to participate on the ASA oversight panel.

“We need to ensure that orthopaedic voices continue to be part of the ongoing leadership process,” said Daniel K. Guy, MD, a CORQ member. “In addition, the Board is encouraging AAOS members to participate in the second collaborative.”

“We are excited to present this opportunity to our fellows to assist them in improving outcomes, adding value, and decreasing costs of orthopaedic care,” Dr. Wallace said.

In order to participate in the PSH Learning Collaborative 2.0, interested parties must complete and submit an application by March 15, 2016, followed by a PSH Learning Collaborative Participation Agreement by March 31, 2016. Applications and more information can be found at

The PSH Collaborative fee structure for new members is as follows:

  • Core group: year 1—$25,000; year 2—$22,500 ($47,500 total)
  • Advanced group: year 1—$40,000; year 2—$36,000 ($76,000 total)

Discounts are available to continuing members and to organizations that choose to pay in advance for both years.

For answers to queries about the timeline or participation in the PSH, please contact Roseanne Fischoff, PSH, executive at ASA, at 847-268-9169, or via email at; or Ashley Perry, director of population health at Premier Inc., at 202-441-4944, or via email at     

Note: Two informal PSH discussion groups will be held Thursday, March 3, during the AAOS Annual Meeting. To participate, go to Academy Hall C across from the Scientific Exhibits and look at the sign on the table reserved for PSH discussion. Experts will be available at the following times:

  • 11:00–11:30 a.m.—Jeffery D. Angel, MD
  • 3:00–3:30 p.m.—Peggy L. Naas, MD, MBA