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How can the Perioperative Surgical Home be applied to pediatric anesthesia practice?

Traditional volume-based care for surgical procedures has the potential to result in fragmentation of care and a diminished patient experience. Too often, perioperative care plans are variable and disjointed. As the need for surgery disconnects patients from their routine medical care, lapses in care may occur for many surgical patients. Costs rise, complications occur, physicians and other healthcare team members are frustrated, and the patient and family experience a lower quality of care. The Perioperative Surgical Home is a patient-centered, innovative model of delivering health care during the entire patient surgical/procedural experience, from the time the decision for surgery is made until the patient has recovered and returned to the care of his or her Patient-Centered Medical Home or primary care provider. The modern concept of the Pediatric Perioperative Surgical Home renders the old practice 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. The goals defined for future health care are represented in the Triple Aim of high-quality care, a focus on population health, and reduced expenditures. The redesign of 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. A key strategy for meeting these goals is the implementation of measurable, evidence-informed, standardized activities that provide optimization of care coordination. The Pediatric Perioperative Surgical Home is a team-based patient-centered model designed to improve the delivery of health care and reduce the cost of care overall. These goals are achieved through continuity of care for surgical patients, shared decisionmaking with patients and family, and integration of care throughout the entire surgical episode of care. The components of this practice model include optimal preoperative testing and preparation, the right care, at the right place, at the right time, and evidence-based care principles which reduce unexplained variability, intraoperative inefficiency, complications, redundancy, and cost of care. A 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 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. 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. 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. A comprehensive Perioperative Surgical Home provides coordination of care throughout all of the clinical microsystems of care and embeds the above strategic principles into its framework. Tracking of patients’ progress through all of the stages of the episode of surgical care provides an overarching assessment that directs the clinical management and closes the loop to transition back to primary care and the medical home. The key elements of the Perioperative Surgical Home are to provide a portal of entry for perioperative care, ensure continuity, and stratify and manage patient populations according to acuity, comorbidities, and risk factors. Additional components of this process include the delivery of evidence-informed clinical care before, during, and after the procedure, the management, coordination, and follow up of perioperative care across specialty lines while maintaining cost efficiency. As these new practice models evolve, it will be essential to monitor progress and performance by designing measures that will successfully gauge the value provided by the care coordination activities throughout the perioperative episode of care. Physician leaders are drawn from the organization’s anesthesiologists, surgeons, and hospitalists to achieve the goal of consistent application of evidence-informed leading practices across specialty lines. The early identification of patients at risk for perioperative complications and subsequent readmission is an important concept so that these patients may be optimized preoperatively in an attempt to mitigate postprocedural morbidity. A mechanism to pay for health care which rewards providers for delivering superior value to patients while achieving better health outcomes at a lower cost is an alternative to a system of reimbursement that rewards the quantity but not the quality or efficiency of medical care. Value in health care is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. To determine value, providers must measure the cost of each condition or procedure by tracking the expenses in treating the patient over the full cycle of care. Providers must have information regarding the cost for each component of care and how that cost is related to the outcome achieved to move toward “value-based reimbursement.” This requires an understanding of the resources required, the capacity cost of supplying each DOI: 10.1111/pan.13222