"Setting [a] goal as cost containment, rather than value improvement, has been devastating to healthcare reform efforts. A focus on value, not just costs, avoids the fallacy of limiting treatments that are discretionary or expensive but truly effective."
—Michael Porter, PhD, in "What is the value in health care?," New England Journal of Medicine, 2010

The perioperative surgical home (PSH) is a patient-centered, physician-led, team-based model of care coordination created by the American Society of Anesthesiologists (ASA). The PSH guides patients through their complete surgical experience, from their decision to undergo surgery, through surgical care, and concluding with planned discharge and return to function. It is a model of care designed to increase the value delivered by surgical procedures.

The PSH accomplishes the following:

• provides a portal of entry to perioperative care and ensure continuity
• stratifies and manages patient populations according to acuity, comorbidities, and risk factors
• delivers evidence-informed clinical care before, during, and after the procedure
• manages, coordinates, and follows up on perioperative care across specialty lines
• measures and improves performance and cost-efficiency of care

After strategic consideration and endorsement by the Council on Research and Quality, the AAOS Board of Directors endorsed a statement on "Physician-Led Team-Based Care" in December 2016 and appointed two AAOS representatives—Jeffery D. Angel, MD, and me—to the PSH Collaborative Steering Committee. The Steering Committee is composed of participants and representatives from endorsing organizations, including the AAOS.

Forty-four healthcare organizations participated in the first phase of the PSH collaborative initiative in 2014–2015. During this time, 64 pilot programs were undertaken, many in orthopaedic surgery.

Currently, 57 organizations from across the country are participating in the second PSH Collaborative (PSH 2.0). Of these, 25 organizations are planning, launching, or expanding orthopaedic PSH efforts, 6 are in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) program, and 11 are in the CMS Episode Payment Model for Acute Myocardial Infarction and Coronary Artery Bypass Graft program. Other specialty areas within the Collaborative include colorectal, pediatrics, urology, and vascular care. Teams of champions from anesthesiology, surgery, and administration lead these efforts.

Case study
Dr. Angel's team made a significant impact at White River Health System (WRHS) through its efforts to implement a PSH model. WRHS, which participates in the CMS Bundled Payments for Care Improvement (BPCI) Initiative, took part in PSH 1.0 and PSH 2.0 Collaboratives from 2013 to 2016.  During this time, WRHS had the following results:

• Length of stay (LOS) decreased from 2.9 to 1.65 days for total knee arthroplasty (TKA).
• LOS decreased from 3 days to 1.6 days for total hip arthroplasty (THA).
• TKA readmissions decreased from 6.3 percent to 3.7 percent.
• THA readmissions decreased from 11.6 percent to 1.9 percent.
• Home self-care increased from 28 percent to 67 percent.
• Inpatient rehabilitation decreased from 9 percent to 1 percent.
• Pain satisfaction increased from an average of 3.3 to 3.8 out of 4.
• Average total savings were $3,200 per case for BPCI patients.

Based on the positive outcomes achieved at WRHS through these PSH efforts, Dr. Angel has been asked to assist other surgical and medical services at the hospital to achieve similar coordinated care benefits.

Expanding the PSH footprint
More than 100 healthcare professionals participating in PSH 2.0 attended two national meetings (spring and fall, 2016) at the ASA headquarters in Schaumburg, Ill.  At each of these meetings, AAOS representatives spoke or made presentations in general sessions or in breakout sessions. In addition, more than 20 educational webinars and calls have been offered through the Collaborative to both first-time participants as well as advanced cohort participants. Through 2016, more than 800 registered Collaborative users visited the PSH Community website nearly 20,000 times. In addition, seven organizations have submitted data on more than 18,000 surgical cases to document value improvements.

As more organizations learn about the PSH model and experience its value first-hand, increasing numbers of patients will benefit from the coordinated, high-value surgical experience it provides. As a result, participating organizations will likely find it easier to participate in bundled payments and other value-based reimbursement programs within the Merit-Based Incentive Payment System.

Peggy L. Naas, MD, MBA, is a member of the AAOS Committee on Evidence-Based Quality and Value (EBQV), EBQV liaison to the Performance Measurement Committee, and an AAOS representative to the PSH Collaborative Steering Committee. She can be reached at peggynaas@gmail.com