June 3, 2019

A Look Beyond the Curtain – Bringing Post-Op Recovery Home

If you’ve had surgery, often the first thing you remember after going under anesthesia is waking up in the recovery room. You likely spent several hours there while the anesthesia wore off, feeling groggy and maybe a little nauseous. And if it was an “inpatient” procedure you were probably wheeled to another room, where you might have had to stay for a day, a week, or even longer. And that’s not including any trips to the emergency room or a re-admission to the hospital post-discharge should any complications arise.

For many patients, this post-operative period is not only monotonous, it’s expensive. In 2017, the average cost in the United States for an inpatient stay was a staggering $2,233 per day. To address this antiquated equation, clinicians at Partners HealthCare hospitals are working together to re-imagine post-operative care in a way that puts the focus back on the patient, and helps keep costs contained. What if – they asked – you could extend the benefits of our existing Home Hospital program by bringing post-operative care into a patient’s home.

The original Home Hospital program, which started as a pilot in 2016 at Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital (MGH), supported by Partners Population Health and Partners at Home, focused on caring for patients with acute medical problems like infections or complications from chronic illnesses like heart failure or chronic obstructive pulmonary disease (COPD) in the comfort of their own homes.

Since that pilot, the BWH team published their results in the The Journal of General Internal Medicine showing that the average direct cost for acute care episodes for home patients was up to half of the cost of the control patients cared for in the hospital. The pilot study’s primary outcome was direct cost, but the researchers also looked at other, secondary measures. They found that the “Home Hospital” model also decreased utilization (specifically, fewer laboratory orders [median per admission: 6 vs. 19; p < 0.01] and less often received consultations [0% vs. 27%; p = 0.04]) and improved physical activity (median minutes, 209 vs. 78; p < 0.01) without noticeable changes in quality, safety, or patient experience. The initial results have been so positive, the program has even garnered attention on a global scale.

“Applying Home Hospital to different contexts and clinical conditions is paramount to the success of the home hospital movement and a natural next step,” says David Levine, MD, MPH, MA, Internist and Home Hospital lead at Brigham and Women’s. “I’m excited to see how teams across the system are helping it evolve.”

Adapting Success for Surgical Patients

“Previously, patients who have had surgery or who suffered complications from surgery were not eligible for Home Hospital,” says Kyan Safavi, MD, an Anesthesiologist and Surgical ICU Attending who led the creation and implementation of the surgical branch of the Home Hospital at MGH. “This new program is building the ground work to enable Home Hospital to serve surgical patients at Mass General.”

To build this program, a multidisciplinary team was convened to think through the care pathways of these patients and how to safely and effectively deliver care in the home equivalent to what they would receive in the hospital. In close collaboration with the Home Hospital physicians and nurse practitioners, surgeons at MGH created detailed care plans for common post-operative complications. Together, they ensured that there were clear inclusion and exclusion criteria for selecting the right patients for the program and standard mechanisms to keep the surgeons updated on the patient’s progress. This was especially important since surgical patients have a markedly different set of problems and challenges compared to the original population of Home Hospital patients.

In the initial rollout of the post-op program, the team chose to focus on three surgical units:

  • The Colorectal Section in the Division of General Surgery for patients experiencing ileostomy dysfunction (a surgical procedure to create an opening in the small intestine for waste products to move out of the body and into a medical-waste bag).
  • The Orthopedic Trauma Unit in the Department of Orthopedic Surgery for patients with pain and wound care issues.
  • The Center for Gynecologic Oncology within the Department of Obstetrics and Gynecology (OB/GYN) for patients experiencing nausea, vomiting, dehydration, and deconditioning (a physical and/or psychological decline in function).

One of the most interesting aspects of this program was not related to how patients were cared for, but who was providing the medical care. Home Hospital physicians and nurse practitioners, many of whom are from internal medicine backgrounds, deliver the care to the patient in their home while working in close collaboration with the surgeons at MGH. This multidisciplinary approach to deliver home-based care is unique and highly innovative.

“One of MGH’s greatest strengths is the expert, multidisciplinary care that we can provide patients,” says Dr. Safavi. “By working together, we provide excellent care. We designed this program with that in mind and expect that patients will benefit greatly from the teamwork across departments.”

Happy Patients Heal at Home

Rocco Ricciardi, MD, a colorectal surgeon, was one of the first physicians to enroll a patient in this program. Dr. Ricciardi was particularly interested in the program since certain colorectal patients have a very high risk of being re-admitted to the hospital within 30 days—about 10 percent. His patient, a woman in her thirties, received a robotic proctectomy to remove her rectum following treatment for cancer. In addition to the proctectomy, Dr. Ricciardi also performed an ileostomy to protect her new pelvic bowel connection.

Post-surgery, her ileostomy had an obstruction, which can happen if the patient is dehydrated or eats too much fibrous food. Under normal protocol, he would have re-admitted his patient for observation. However, she seemed to be a good candidate for the Home Hospital post-op program.

“She was very excited that she didn’t have to go back into the hospital,” says Dr. Ricciardi. “Obviously she had been to the hospital a lot for the treatment of her rectal cancer with chemotherapy and radiation. The potential of not having to be back in the hospital was really good for her.”

She spent four days enrolled in the program recovering from her bowel blockage. Patients admitted to the Home Hospital are visited at least once a day by a member of the care team. The care teams can take physical exams, monitor patients’ vital signs, administer medications through an IV, and even take on-site diagnostic tests or imaging.

“The staff is very good about reporting back through email or phone exactly what they are seeing during patient evaluation. I think that’s the best strength of the program is the feedback you get,” says Dr. Ricciardi, “It’s almost like rounding in the hospital.”

A Look Beyond the Curve

The early results of this program are promising for the pilot team, though they understand that in order for it to scale to more patients across Partners, surgeons will need to feel comfortable with this new approach to co-managing a patient in the home setting.

“I think there’s a potential to really open it up to a lot of different patient populations,” says Dr. Ricciardi. “We’ve really limited the patient selection to pilot it, but obviously there are a huge number of potential patients that would benefit from these services.”

 


 

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