Security Health Plan
Marshfield, WI

As surgical techniques have evolved, more procedures can be safely performed on an outpatient basis and in settings other than hospitals. Today, more than half of all surgeries performed in the U.S. do not require an overnight hospital stay, and many are done in ambulatory surgery centers (ASCs), which provide same-day surgical services.

Some studies show that ASCs on average provide higher quality care for outpatient procedures than hospital outpatient departments, at lower cost.1 According to the Ambulatory Surgery Center Association, Medicare pays ASCs 58 percent of the amount paid to hospital outpatient departments for the same procedures, saving about $2.6 billion per year.2

“The kind of collaboration you need to foster innovation is only possible when there is a strong working connection between the delivery system and the health plan. Security Health Plan is willing to pilot innovative care and payment models, and that benefits the overall system and the patients we serve.”

Heather Kurtz, Director, Business Intelligence, Security Health Plan

Marshfield Clinic Health System and Security Health Plan went a step beyond the ASC model in 2015 when they opened Comfort and Recovery Suites to support ASC facilities in three locations: Marshfield, Eau Claire and Wausau, Wis. While some patients undergo same-day surgical procedures in the ASC, returning home without an overnight stay, others who require post-surgery care stay in Comfort and Recovery Suites, private recovery rooms that can also accommodate family or guests who wish to stay overnight.

The Comfort and Recovery Suite units, licensed as skilled nursing facilities and fully staffed by physicians and nurses, are operated by Grace Lutheran Communities, a nonprofit organization that also specializes in rehabilitation, assisted living, memory care, adult day facilities and other services.

Clinicians Integral to Change Design

In 2015, clinical leaders reached out to surgeons and other specialists for help designing new processes that would support an alternative patient journey through surgery. A clinical workgroup that included surgeons, anesthesiologists, nurses and others involved in surgical care created new order sets for pre-op, post-op and Comfort and Recovery Suites admission. Because the new methodologies were created by clinicians, the changes they represented were more readily accepted by fellow physicians, and their implementation was relatively smooth.

Consistent Evaluation of Patients

The list of surgical procedures that can be appropriately and safely performed in an ASC, with or without a short-term stay in the Comfort and Recovery Suites, continues to grow with the advent of new techniques and medications. Currently, joint replacement surgery and spinal surgery are the most common procedures performed in Marshfield’s ASCs, but the facilities can also accommodate hysterectomies, prostatectomies, bariatric surgery, cholecystectomies and other procedures.

Newer surgical methods and medications have greatly reduced recovery time and the need for emergency follow-up procedures—such as blood transfusions—that are typically done in hospital settings.

Marshfield Clinic Health System formed a perioperative surgical home to more rigorously manage care, costs, patient experience and outcomes for surgical patients. The records of all surgical candidates are reviewed by a team of nurses and physicians, including anesthesiologists, who use algorithms to determine if a patient is an appropriate candidate for surgery in the ASC. The team looks at the patient’s co-morbidities, lab results, cardiac function and other factors, including whether the patient’s insurer will cover their procedure in the ASC, which varies across payers and procedures.

The team then recommends to the surgeon the best setting for the procedure. The goal is to bring as many cases into the outpatient setting as safely possible.

Enhanced Recovery Protocol

Marshfield Clinic Health System clinicians use an evidence-based protocol called Enhanced Recovery After Surgery (ERAS), designed to support early recovery from surgery. The ERAS care pathway, which is promulgated by an international scientific organization that gathers and shares data, provides guidance to the care team and promotes partnership between the surgical and anesthesiology teams. Using multiple non-narcotic alternatives for pain management enables patients to emerge from surgery more awake, more alert and more astute, and with minimal pain.

This is especially important for older adults, who currently make up the majority of patients in the ASC, since joint replacements are the top surgical procedure performed there. Minimizing post-surgical cognitive impairment that can inhibit recovery and unsteady the gait is critically important to a smooth and swift recovery. The ERAS protocol is a key reason so many patients are able to undergo their surgical procedures in the ASC.

Results

More than 1,000 surgical procedures were performed in Marshfield Clinic Health System ASCs during the first 24 months after Comfort and Recovery Suites were opened. Clinical outcomes are the same as or better than those for patients who undergo surgery in hospital inpatient settings and who are admitted to a traditional skilled nursing facility for recovery. Moreover, patients who recover in the Comfort and Recovery Suites are less likely to be admitted to the hospital after their surgery than if cared for in the traditional skilled nursing facility.

Measure MCHS C&RS* Wisconsin Average**
Percentage of short-stay residents who were re-hospitalized after a nursing home admission. 2.1 20.7
*This figure is a combination of readmissions directly after surgery in Marshfield Clinic Health System Comfort and Recovery Suites and after a stay in a skilled nursing facility.
** This figure is updated quarterly and represents data current in Sept. 2018
Sources: Security Health Plan and Medicare Nursing Home Compare 3

Analysts compared the cost of procedures in the outpatient setting against the cost of the same procedure in a hospital, and during the Comfort and Recovery Suite’s first 24 months the health plan saved $4.7 million.

The Comfort and Recovery Suites have consistently performed at a high level, with two of the three facilities achieving 5 Star ratings and the third a 4 Star rating per the Medicare rating of skilled nursing facilities. Press Ganey patient satisfaction surveys show a 98 percent satisfaction rate with care in the ASC/Comfort and Recovery Suites.


Sources

1. Munnich, EL; Parente, ST. Returns to specialization: Evidence from the outpatient surgery market. Journal of Health Economics 57 (2018) 147-167. https://www.sciencedirect.com/science/article/pii/S0167629617310743

2. Ambulatory Surgery Center Association. Ambulatory Surgery Centers: A Positive Trend in Health Care. http://www.advancingsurgicalcare.com/advancingsurgicalcare/aboutascs/industryoverview/apositivetrendinhealthcare

3. U.S. Centers for Medicare and Medicaid Services. 2018. Nursing Home Compare. Retrieved from https://www.medicare.gov/nursinghomecompare/

 

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CASE STUDY: Speed Recovery & Improve Safety of Outpatient Surgery

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