Anesthesia’s Role in the Acute Care Continuum

Peter Nosé, MD

Peter Nosé , MD

Director of Operations, Anesthesia

Published January 20, 2015

Up until December 2014, my Partners and I at Group Anesthesia Services (GAS) maintained a successful, five-decade-long practice at Good Samaritan Hospital in San Jose, California.

Our highly respected practice benefited from an informed and engaged patient population, a favorable payer mix and talented and collegial surgical colleagues. We easily recruited from top residency programs and had great relationships with our facility administrators. Most importantly, we provided safe and efficient surgical anesthesia to some of the sickest and most fragile patients.

So, why did we choose to join an integrated acute care practice in which specialties such as emergency and hospital medicine could easily overshadow our own?

One simple reason: external forces threatened our practice model. As a medium-sized, single-specialty practice, we were missing clinical opportunities and risked becoming irrelevant in a rapidly changing environment.

Since its development as a specialty, the paradigm for anesthesiologists has largely focused on the provision of great intraoperative care. Though our skillset may extend into preoperative preparation and postoperative recovery, our job is largely considered “done” once the patient has safely emerged from the operating room. Our consultative interactions are more often in reaction to changes in a patient’s condition rather than through a well-organized and well-planned perioperative care plan.

The degree to which anesthesiologists work with other specialists to proactively coordinate perioperative care has largely reflected individual motivation. The process is dependent on the individual and not the system, resulting in variable outcomes and patient experience.

As an example, in the course of attending a frail patient who’s just undergone major abdominal surgery, nobody would argue with the anesthesiologist’s decision to transfer that patient straight from the OR to the ICU to be kept intubated and on a ventilator for a time until the patient has demonstrated the strength and stability to breathe on her own.

However, to the extent that anesthesiologists, intensivists and hospitalists are already familiar with the patient and have developed a coordinated postoperative recovery plan, that same patient might avoid postoperative intubation and thereby avoid secondary complications associated with immobility and prolonged mechanical ventilation.

As professionals, we all strive to do the best for our patients … but on an individual level. In today’s fee-for-service model, there is no financial incentive (nor disincentive) for efficacious or efficient care. The model only rewards more care. Physicians are compensated for every clinical episode, regardless of the patient’s meandering course from illness to health. Society has largely endured this expensive delivery model despite the fragmented, confusing and often inefficient manner in which healthcare is delivered.

It’s not surprising that public policy is now advancing a system that rewards the patient’s actual return to health. By leveraging global reimbursement models, payers are restructuring incentives, moving from a model where incentive rests on simply performing procedures to one where the financial reward reflects the ultimate health of the patient. Deriving value from this model depends on the degree to which a patient’s return to good health occurs efficiently, safely and economically.

As a single-specialty group lacking any formal relationship with other participants in perioperative care, my group sought a partner with whom we could satisfy these demands, while still preserving our professional and financial autonomy. Joining an integrated practice provided an opportunity to join a robust Acute Care Continuum that spans emergency medicine, hospital medicine and post-acute care. We believe this integrated model will lead the transition from narrowly focused patient interactions to a more collaborative and results-oriented system.

The addition of anesthesiologists, critical care medicine and other hospital-based specialists to the Acute Care Continuum enables providers to move from a reactive, sequential process of care to a more proactive, team-based approach to patient management. More than offering an opportunity for survival, the Acute Care Continuum offers community physicians, physician assistants (PAs) and nurse practitioners (NPs) an opportunity to lead fundamental changes in healthcare delivery.

For anesthesiologists, perioperative coordination should support:
  • Enhanced readiness for surgery, even weeks to months before elective operations (e.g., “prehabilitation” of nutritional status, cardiac and pulmonary function);
  • Developing a coordinated plan for management of underlying medical conditions pre-, intra- and post-op;
  • Developing an integrated plan for pain management
  • More efficient discharge and rehabilitation planning
My own professional organization, the American Society of Anesthesiologists, has recognized the need to broaden our role beyond the operating room through its introduction of the Perioperative Surgical Home. While the specifics of this new model deserve a separate discussion, the model aligns with the Acute Care Continuum in the common goals of shared decision-making, better multi-specialty integration, and increased value to the patient as well as healthcare facilities.

Assumed, but unproven in this integrated model is an improvement in the quality of care. Ultimately, the goals of increased operational efficiencies, decreased resource utilization, decreased length of stay and decreased morbidity need to be demonstrated. Yet, the ability to calculate the quality of that clinical service depends on resources that few practices possess and even fewer could afford.

Just as important as the actual delivery of care is our integrated group's focus on defining and quantifying the quality of that care. As members of a large national practice, we now have access to well-established resources to assess the quality of care and further guide refinements in its delivery. As hospitals and ambulatory care facilities all work to define their own answer for value-based services, these analytic resources will help to distinguish our group as a valuable partner.

I’m excited by the addition of anesthesiology to the Acute Care Continuum. From a strategic business perspective, I believe integration and coordination of care multiply the value provided by any one specialty on its own. More than a strategic solution, however, is the opportunity to provide more efficient, safer and perhaps more effective care by working as true partners.

Partnering to improve patient lives

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