All right. We're going to go ahead and get started. I wanted to welcome you to this lecture topic today. This is an area within rehabilitation that if you haven't started to take a look at, you really should. When we're talking about hospital systems and health systems on a nationwide level, really pushing throughput through hospitals and also doing a lot of bundled care from a reimbursement standpoint on a national level, this is where PM&R can really step into this arena and really make a difference for us. Again, I'm John Aum, Chairman for the Department of Physical Medicine and Rehabilitation, coming from the Rockefeller Neuroscience Institute at West Virginia University, here to talk to you about perioperative medicine and the piece of the pie that we can take as physiatrists to help patients. Note of financial disclosures. So the objectives. I really want to give you a background to what perioperative medicine is. I don't know your familiarity with it, but kind of give you an overview of what that entails. Medical comorbidities and ways that we can optimize patient success before surgery, reduce complications and how we can improve those surgical outcomes, and then also look at how perioperative medicine can improve patient experience overall and satisfaction. So perioperative medicine. This is that umbrella of comprehensive care from a surgical standpoint that looks at the before, the during, which includes the hospitalization, the admission, the surgery itself, and that acute hospital stay, and then going into after surgery. Usually, as we know as physiatrists, we usually tend to pick them up after surgery, whether that's a consultative service, and then if we're doing inpatient rehabilitation, we'll catch them there. And so this, again, kind of focusing on what we can do beforehand. But the overall goal is to maximize your patient's outcomes, help our surgical partners, help your hospital and your health system on what we can do to help those patients. But again, this has got to be a very collaborative effort, and so we as physiatrists are very used to working in team environments, but we've kind of had those smaller teams where we're talking about therapists, our case managers, but now we need to look at it from a system approach of what that means from anesthesia, internal medicine, your surgical counterparts, and really expand what that team is going to do to help our patients out. The other aspect I want to really put out there is this is happening regardless if we're going to jump on this train or not. Perioperative medicine is a go. I've been involved with it now for a little while. I have, we have a guest speaker from Anesthesia Society of America. He's been doing patient safety home. If you haven't heard of it, we'll go through it a little bit later on when he gives his portion of the talk. But this is going on, but it's further evolving, especially now that reimbursement is getting involved, CMS is getting involved. This is going to happen whether the physiatry is going to be on board or not, and so this is where we really need to do, as a specialty, a look at how we can then help the group overall. So, preoperative care. This involves evaluating the patient. We look at their overall health, identify and manage any of the medical conditions, and we want to prepare that patient for surgery. And again, this isn't just about looking at medical comorbidities. We're going to look at things like nutritional status, mobility, their functional capacity. Imagine what you could do if you knew functional limitations prior to the patient ever getting into the hospital admission, making post-acute plans, DME plans, before the patient even enters the hospital for that admission. When you talk about throughput and reimbursements, how fast we can get a patient out the door versus if you have ever done consults, when you see a patient, you get consult, and they're saying they want to leave this afternoon. We know that that placement is not going to happen in the next 30 minutes. We know we're not going to be able to get them a wheelchair in 30 minutes of time. But let's say now, looking backwards, if we know that those patients' functional needs three weeks out, four weeks out, depending on the type of surgery, think about what you can do to optimize that patient, and then getting in the realm of prehabilitation to address those functional deficits ahead of time, and then see where we can go from there. So again, really looking at the overall preoperative period, working with our anesthesia counterparts, working with our internal medicine and our surgical counterparts on what we can do to help that patient. Then we have the intraoperative care. This is probably one area where we don't add a lot. This is really where the anesthesiologist is supporting the surgical team in the operating room, making sure that the patient survives it. But again, when you kind of start bundling that a little bit into the hospital stay, that's also where we can look at, say, for an amputation, what can we do? If we know a patient's coming in for an amputation, instead of waiting for a consult to come, have that part of the team so that we're there, ready to go, can do the patient education, what to expect. You know, a lot of times, if you've worked on consultative services, you know you get a patient who's post-op after an amputation, when am I getting my prosthesis? Am I going to get this before I leave? You know, then you have this entire education component, versus if that's done ahead of time and then reinforced when the patient is admitted, even preoperative, knowing that that care team is going to be there waiting for them when they come out of anesthesia, ready to go. So making those plans. But seeing where you can add value to that team. Again, there's going to be plenty of surgical cases that we can't be part of that intraoperative period, but try to imagine what we can do from that functional capacity to make that quality of life change in that intraoperative period and immediately afterwards. And then getting into the post-op care. And again, this is I think where most of us are probably very familiar with things, where we look at, you know, we get consulted on board, looking at what we can do for the patient, start making post-acute planning. But again, you know, trying to shift that paradigm and not just focus on the post-operative period, but really looking at it as an entire paradigm of care starting from the beginning. And I'll get into this, but, you know, looking at pain management. If you have somebody who's on neuropathic medications, and we've seen this too often, we know that their home dose is, say, whatever neuropathic medication is up here. A lot of times these get stopped and they don't get put back on until a lot of times they come to inpatient rehabilitation. Versus what if you had that plan ahead of time saying, once this patient is stable and is acceptable to the surgical team, we'd like to restart XYZ medications because we know this is going to be an issue. Or if they have pre-existing spasticity issues, we know that the post-operative period, a lot of times those spasticity issues can become worse. So we can start making plans of, we need to increase that dose. Even if they, say, have a back pain pump, we know we need to make adjustments from there because the body's going to respond. There's a physiologic response to surgery. So we need to identify that ahead of time and then continue that in that post-operative care period. So why is this important? In 2023, there were approximately 51.4 million elective surgeries. Elective surgeries. This isn't your traumas coming in. This isn't those emergency cases. These are surgical cases that we can make an impact because these are planned ahead of time. Now again, some of these are going to be your cholecystectomies and maybe we don't have a lot to offer if they're otherwise healthy. But imagine 51 million patients that have a physiatrist look at them ahead of time to look at what functional deficits, what impact to their life that's going to entail, and how we can help them. And so again, we get wrapped up in a lot of very traumatic cases. And sometimes these can be simple visits, whether you're involved in pre-surgical evaluation clinic, making simple recommendations of, we expect this patient to have some issues with pain, we would recommend this. We could look at getting them into ambulatory therapies following. And that could be it, the end of your recommendations. But at least there's a plan versus a patient going home and going, what do I do? This hurts. This is what's going on. I can't. I'm the caretaker. I do the cooking. Even if it's simple as they do the cooking at home, I can't reach my pots and pans or my glasses to get anything because I have this. This patient's going to need a reacher because they're going to have an abdominal binder because they had a cholecystectomy. That's the end of the recommendation. But again, the benefits that we could provide patients as a physiatrist moving forward. So again, going into the importance, we want to reduce risk of complications. Depending on where we get involved with the patient, you know, we can look at smoking. And again, all parts of the perioperative team are going to address a lot of these things. Obesity, poorly controlled diabetes. Again, kind of looking at how these affect life. Even if we're not necessarily adjusting, say, blood sugar medications for their diabetes, but what other functional deficits can we worry about so they don't end up with a fall and then get bounced back in the hospital for readmission. So again, looking at those functional issues going forward. Health. You know, a lot of times what we look at is what that means in the sense of wound healing. But going beyond that, we know there's going to be a certain amount of immobilization following surgery. What that's going to mean to their functional strength. We can address these ahead of time and start developing prehabilitation plans to bring up their functional capacity higher to when they were going in. Because we know that functional capacity is going to decrease once they're postoperative. So the goal would be to increase that. And we see this a lot in our cancer rehabilitation specialties where they're looking at this ahead of time. And so again, trying to adapt a lot of the research that's been done there and see where we can apply that elsewhere for our patients. Again, shorter hospital stays. Many in the country, we have issues with beds. I know hospitals around the country, we have patients in ERs waiting to come in. And so again, can we help our health systems by getting patients out the door quicker safely in a good way by allowing then more patients to get into our health system so we can take care of them. Again, sometimes these are simple needs where if they just had us ahead of time, we can get this taken care of so they're not just sitting on our wards. And enhanced recovery. Again, so it's not just functional. There's going to be a big emotional component to it. So you want to make sure that we're addressing the psychosocial aspect of it. Try to mitigate fears that come with surgery. So again, these are all the things that can impact a patient. Going back to muscle loss, functional weakness. It's even educating family. There's a lot of times where we see, well, don't let grandma get up. She's going to do this. Or don't let grandpa do this. Versus no, it's okay. We want them to do that. The longer they're laying around doing nothing, they're going to continue to get weaker. So again, that's where we as functional specialists can get involved. Educate not just the patient, but their entire family. So when we're looking at optimization, kind of said before, nutritional support. Again, this is going to depend on the team as a whole. We have a lot of anesthesiologists, a lot of internal medicine docs. They're very good at it. But there's also a lot that don't necessarily address it because a patient may have a lot of medical comorbidities and so they're worrying about other things. So again, we do this a lot in the post-acute care realm. In the rehabilitation realm, why can't we do this starting off before surgery happens? Physical conditioning. Again, this is where we look at their functional capacity. What they can do at home. What their needs are going to be. Identify assistive devices ahead of time and really maximize patient safety. Psychological support. And this is again where we're going into not only patient education, but family education. Some of that goes into also not just looking at code status, but talk to them about what their long-term wishes are. What that means for resuscitation. We know as physiatrists what that can mean if the worst case scenario happens in those outcomes. So the education component really becomes important for our patients. And again, that goes into the patient education. And ultimately, we're used to it. It's what we do all the time. It's coordination of care. This is where we really are great specialists at it. So involving yourself in the health system and getting beyond what our normal bubble of a team is and really expand out to other disciplines, other specialties. Physical conditioning. We'll go into it too much more. Pain management, as I said. This is really where we can benefit. We have a lot of patients around the country. Neuropathic pain, spasticity issues. How we can address that. But even start making therapy plans. Even in the acute hospital stay, we can develop plans on our preoperative notes to guide therapists saying, hey, these are going to be an issue. Can you also address this? Versus just doing range of motion. Because we always see that very generic therapy can get ordered while a patient is at the hospital. But why don't we give them a little bit more guidance to help that patient move along further? Functional assessments. Again, doing this. The longer you have, the better. There's been research that you can have statistically significant physiologic change in the human body by making changes at three weeks. So if you capture somebody more than three weeks out, you can make more significant changes. So again, trying to involve yourself in pre-surgical planning for patients. Patient planning again. Whether that's going to be like the patient would need IRF care, SNF level care, or even just ambulatory levels of care. Having those plans in place ahead of time. Especially if it is somebody who's going to be ambulatory. So they don't have to think about, oh, I need to call. I think there's a physical therapy down on 2nd Street. But have these plans in place so they know who to call. Maybe even check it out and visit it and make sure it's a good environment where they want to go ahead of time. And then the patient education component. The problems though right now is we're at a time where again cost saving is very big. So there's a lot of financial constraints on implementing these programs. So again, this is where you have to get creative. And there's working with the other specialties in your hospital and how this can be done. This is going to be conversations with your C-suite and why this is beneficial to the patients. And again, from throughput to cost savings to increasing access to patient beds. These are things you need to worry about. Lack of awareness and education. And so again, what that pre-surgical planning can offer a patient and how it can improve surgical outcomes. Prevent readmissions. These are the conversations you want to have. Organizational barriers. You're going to have to talk to others in your hospital and your health system. Even if you're a private practitioner doing some of this is knowing the other surgical specialties in your area and what you can offer and what those barriers for patients are going to be. Time constraints. It does take extra time. And so again, trying to manage your busy clinical times. Finding ways to do that whether you're a single provider, the sole physiatrist in your community or if you work for a large department. Our days are packed. And so again, trying to find ways where we can provide access to it. Sometimes there's cultural resistance to it as well. Whether that's from the hospital or just even the community or what that means of prehabilitation. It's a word that I think we're used to. This is something that we are aware of as physiatrists. But outside of that, even amongst other specialties within medicine, this may be a totally novel term for them. So again, trying to get past cultural resistance and where you're at. And then reimbursement issues. So this is where we're going to get into and this is where I'm going to let my colleague here get into a little bit more. But these are issues that are happening and a lot of politics involved in it when we're getting into how do we reimburse it so that everybody part of this care paradigm team is reimbursed for their services. These are my references. And so I do want to introduce Dr. Christopher Steele. He's an anesthesiologist. He's been working with the American Society of Anesthesiology for a number of years now for what used to be called a patient safety home. It's now evolving in more to perioperative medicine. As current institution at White River Health, I think you've filled every single role there. From taking charge of anesthesia there to CMO, Chief Quality Officer, is now serving as the interim president and CEO of the hospital there. So he's seen all aspects. Lucky for them, they have somebody at that level who's very involved with perioperative medicine. But again, he's had an immense amount of experience in dealing with the politics and how to push this effort forward. So I want to welcome Dr. Steele. Thank you so much. I really appreciate that. And thank you for the opportunity to chat with you guys. I've benefited a lot just being at the conference. As a CEO, it's been great seeing physiatrists and figuring out how they fit in the health system and how it works. That's been really eye-opening to me. So many opportunities I've learned just through these lectures, nerve conduction studies from our previous thing we've heard about. It was fantastic. And as an anesthesiologist, I don't interact a lot with physiatrists. And so it's really nice to just get my eyes opened. Sometimes you don't know what you don't know. And so that's really been fun. When I was getting ready to do this presentation, I was trying to think of a lot of ways that anesthesiologists and physiatrists overlap and what's complementary. And so hopefully you'll get to see a lot of that during this presentation. One thing stood out as a little bit different, and I was a little resentful of it. So I'm going to share it with you. But as a physiatrist, it's wonderful that you get to take a patient that isn't moving and you get to take a multidisciplinary approach to getting them from not moving to moving. And that's great for the patient. The win is celebrated by the whole care team. As an anesthesiologist, when I take a patient that's not moving and they start moving, for some reason the surgeon that's in the room at the time doesn't celebrate it the same way. And so I don't know why that is, but I might have to take some marketing advice from you guys. I may have to learn that over time. So just a little bit of difference there. But going through this, I want to, let's see here. From a financial disclosure, I don't have anything to disclose. I'm a consultant. I work with several organizations. I'm currently the interim CEO of White River Health and an anesthesiologist. From an objective standpoint, I'm going to share a little bit about the American Society of Anesthesia's journey on perioperative medicine over the last 10 or 15 years. I want, hopefully you'll be able to understand the different types of preoperative evaluation and then really consider reasons that now could be a great opportunity for you to engage in perioperative medicine at your respective organization. So those are the three things we're really going to focus on. The American Society of Anesthesia has been working in the field of perioperative medicine pretty heavily since 2010 with the passage of the Affordable Care Act. Really, the writing was on the wall at that point that we were going to be moving in this direction. And so the ASA created a committee on future practice models to get together and say, how does this affect anesthesiology as a specialty? And they drafted a white paper on a perioperative surgical home as a brief. And they partnered with some groups and set up these learning collaboratives. And so the ASA had three learning collaboratives where they took institutions from across the country. Over a course of about six years, over a hundred different organizations across the country from small rural organizations to large academic institutions came together and talked about how a pre-op clinic and perioperative medicine worked at their institution and really worked together to make it foundational of how it would work across really any system. And so I was fortunate enough to be a part of that through White River Health. And I was on the steering committee for the second iteration of the surgical home collaborative and I was the medical director for the third iteration, which was PSH 2020. I also led the implementation guide efforts in trying to get an implementation guide of all the information that we learned over those collaboratives so that other people could kind of benefit from what we learned, both the good and the bad. Sometimes you learn a lot more from messing things up in my experience than actually doing it right. And that's hopefully able to share some of that. The ASA recently has created an ad hoc committee on perioperative medicine and now a center for perioperative medicine that I'm going to share with you just a little bit. This is the pathway that we took through that. As you see, the learning collaboratives and the PSH steering committee all happened while the ASA also created that ad hoc committee on perioperative medicine. And then all of those have really come under one umbrella as a foundational platform for this center for perioperative medicine. And so it's really been a journey that we've been on and been a lot of fun. The ASA isn't the only organization that works in perioperative medicine in our space. There's a lot of other organizations that are involved at the American College of Surgeons have a lot of interest in this, obviously. Other societies, the Enhanced Recovery After Surgery, ERAS Society, Evidence-Based Perioperative Medicine, other acronyms, POCE, the American College of Perioperative Medicine is led by Zev, a fantastic anesthesiologist that's really a pioneer in this space, and so we really owe where we are to a lot of different people that have invested a lot of time into this, and a rising tide lifts all boats, and as you hear, we just see more and more people getting involved in perioperative medicine, and so it's really a fun time to be in it. So what is this Committee on Perioperative Medicine? The ASA in 2022 created this really as a long-term plan to kind of bring all these disparate efforts in the anesthesia world together. And the plan was to accelerate, address, and position themselves, and so accelerating the adoption of perioperative medicine as a distinct specialty of anesthesia, to address the needs of hospitals and health systems, and then to position the ASA as an authority in this, and so part of the reason we're talking at this meeting about this is because I do believe in it, and I do think the AAPMNR has great interest in all of us collaborating together to really center around our patients. And so with that, the steering committee for this Center on Perioperative Medicine really has four different parts, Dr. T.J. Gann, Andy Rosenberg, Niju Ravikant are all there, and then Dr. Canison, who's been involved in this for a long time, are all leading this steering committee. And the things that I really want you to get out of this steering committee, and probably one of the most important things, is how we define perioperative medicine, and we're gonna also briefly go over the mission, vision, and kind of the audience, but I'm gonna spend a touch bit of time on this definition here, a multidisciplinary approach encompassing the whole continuum of care for patients undergoing surgery, interventions, or invasive procedures. I'm gonna pause there because sometimes we think of this as a pre-op clinic or something like that. And so really we wanna change that mantra because, as you know, intervening in a patient before they get cut or have surgery is so important to outcomes. That's some of the biggest things we can do, is set appropriate expectations and plan ahead before just being reactive, and so knowing that it is the whole continuum is super important. The goal is to improve patient outcomes, so having the patient in the middle, reducing morbidity and mortality through the entire period. It's achieved through collaboration among healthcare providers, including anesthesiologists, surgeons, nurses, and all specialists to ensure well-coordinated and comprehensive care for the patients. I'm gonna stop because that's something that anesthesiologists haven't been involved in forever, is coordinating care. It's something you guys are experts in, care coordination, and it's something that we tend to be more episodic in, pre-op and intra-op, and a lot of times anesthesiologists don't even have the data of what their length of stay is or if they get readmitted, and so this is novel to us, but things that you guys have been intimately involved in throughout your entire training and practice, and so overall, the aim is to enhance the patient's overall health function, quality of life, and experience both during and after the procedure, and so that really is important and hopefully sets that standard for anesthesia, for surgeons, and for all of us to be able to collaborate and center around the patients. I'm gonna go over these a little more quickly, but the mission is to create widespread adoption of this interdisciplinary culture of collaboration, care coordination that advances anesthesia with the principles, and so again, you're gonna keep hearing those things, coordinating care, collaboration. It's fundamental, it's what we're talking about, and I think it's how we're gonna help our patients. This is our vision, briefly, creating this individualized, evidence-based care that's seamlessly coordinated for our patients, minimizing your complications, improving recovery, and transforming the perioperative period into a time of opportunity for changing lifestyle for better health, healing, and growth. You guys know that patients sometimes don't wanna change, surprisingly enough. You talk to them about something related to their diet or something related to their activity, and they don't wanna change. This may be our opportunity prior to having a knee replacement or a hip replacement that they wanna get this done, they're having pain, and this is that opportunity we can get could possibly change their lives forever, and so we may not get this opportunity again, so talking to them about things that aren't just pertinent to this specific surgery but to their whole lives are so important, and hopefully we can partner with ACOs and entire organizations about putting the patient in the middle and improving their overall health. Our audience, as you see, everybody's involved, it's a team-based effort. This is from somebody I really have a ton of respect for, Tom Vetter, and he put this in one of his articles, and we've shared this a lot, but the patient is in the middle of this, and all the rest of us need to center around the patient and coordinate that care, and this is, I think, a really good diagram of that. The current journey, as you guys know, hopefully the patient's in the middle, but we really tend to be siloed out a little bit, and care is getting more and more complex as we do sicker and sicker people with more and more complex surgery, and anesthesiologists and surgeons aren't trained as PCPs to optimize people, and so some anesthesiologists, a friend of mine, Gary Steer, actually is trained as an internal medicine physician, but most anesthesiologists don't have a background in that or the training, the surgeons don't either, and so we need other experts to come with us in the perioperative period to help optimize these people and take them on this journey. Again, sometimes we do our best, but we don't know what we don't know, so I think we have a siloed area where we send them to a specialist, and the communication isn't great between providers, surgeon, anesthesiologist, or any specialist, and really not great with the patients. Patients seem to be in the middle of all this, but they can't get all of us to get on the same page sometimes, and so that's certainly not ideal, and this can lead to bad things. Not great outcomes for patients sometimes. As you just heard from Dr. Alm, missing opportunities for billing. There are opportunities for billing. There's issues of first case cancellations, bad experience for patients, and unnecessary consultations that waste the patient's time and provider's time too. All that that could be fixed through coordinating ahead of time, and so those are things that we really have to break down these silos and collaborate and communicate to be able to do better in all of these aspects. Some of the reasons we run into these problems is simply aligned incentives. The surgeon gets a global profit, so for them to do their part, there's no extra reimbursement to really spend tons of time optimizing patients and getting them ready. They're paid that global fee, and they're not trained in some aspects in rehabilitation or optimization of the patient on the front end. Primary care providers, a lot of times, they don't even know their patient is having surgery. Their patient may have gone to a surgeon and been diagnosed with a problem and seen the surgeon, so some of them are out of the loop. A lot of them aren't really sure what happens when a patient gets put under anesthesia or what happens in that, and they aren't inpatient specialists, so they really don't know how to affect things like length of stay and throughput, and so they don't really know how to optimize a patient perfectly, and as we get more and more complex optimizing people, they may not know all the protocols involved. Anesthesiologists, I'm kind of biased toward anesthesia, just calling a spade a spade, but from our standpoint, a lot of times the anesthesia, H and P, is bundled into the whole thing too, so if you don't structure these arrangements properly, these visits, there's no incentive for anesthesia to spend a ton of time optimizing them out of their standard H and P as well, and then from a health system standpoint, if the health systems can't figure out a way to get paid for it, and it's hard for them to allocate resources and locations and all the time of setting up EHRs and throughputs in clinic because they may be able to make it more efficient. As an administrator, it's hard to get funding for things like that, and so it's these misaligned incentives that we're not clear on, and all of us are like, well, we might be able to get paid. We might be able to reduce length of stay or efficiency, but without that concrete of exactly how we do it, it's really hard to change people's minds and actually move this forward, so from our standpoint, what we would say is really having perioperative specialists that coordinate the care, that really work on evidence-based protocols that allow people in a structure that you can bill, not that you can't bill for every single one of these, but your high-risk patients, you can bill for this if it's structured properly, and incorporate more than just optimizing somebody pre-op, but optimizing them for surgery, but also for readmission to try and prevent that 30-day readmission rate, to be able to make sure your discharge disposition is appropriate, getting DME ahead of time helps them being able sometimes to do prehabilitation and other things, and setting the expectations for length of stay. All of those things can help, and all of those, again, are ways that we can align the incentives of all of our stakeholders and make it better for us to really help our patients, and so you can fix a lot of those problems that we solve. One of the really big keys that I think is way underappreciated is the governance model of how you do a clinic like this. It's really easy to say, oh, there's a clinic, and people come in, and they get taken care of, but when you collaborate, governance matters. Who's in charge? Who's not in charge? Who has a say? And from my experience, what you really need to do is identify who the stakeholders are, and then you need to sit them at the table and figure out what a win is for everybody, because you really need to know, how is this going to work? No one wants to say, well, this is great for them, and it hurts us, and it's more work for us, and it isn't good for us. They're probably not going to be the best supporter of that program, so you've got to figure out what matters, what's salient to each of your stakeholders. Sometimes it's a small clinic, and you just have a collaborating physician or a medical director. Sometimes it's led by an operating room, and the OR kind of runs it and has a lot of people they collaborate with, but most of the time, you'll see a customized model where you really identify those stakeholders and figure out who's involved at this institution, where are your strengths and weaknesses, who wants to help people, and how can we develop that? But I really think you need to talk about having a really good governance model for this pre-op clinic, and I really would encourage physiatrists to be at the table there, because I'll tell you, it's very, very needed, and you'll see as some of the new value-based purchasing things are coming along, some of the CMS Teams model that we'll talk about in a bit, really some good things that are a reason for you guys to be at the table, because again, a lot of times we don't know how to bend the needle in post-acute care as anesthesiologists or surgeons, and we need your help in that, and so really critical to be involved in the governance model, and that governance model then can meet on a regular basis and talk about what's working and what's not working, and look at outcome measures, and look at leading and lagging indicators, and make small changes to it, and achieve reproducibility of small protocols. Make sure you're adhering to the protocols. That's one of the biggest problems we see, is people have fantastic protocols, no one ever follows any of the protocols, adhering for age 20 or 30%, but boy, those protocols, we're gonna spend hours arguing the most minute detail that no one's following. So anyway, good to have these governance models in place, really critical for success. So I'm gonna kind of dive into the different pre-op evaluations you're gonna see, and the last one you'll see perioperative health clinic, that's gonna be more encompassing, but I don't wanna make it sound like that's the only thing you can do at your institution. I think doing anything is better than nothing, and I think the progression that you're gonna see is sometimes people just don't have any type of evaluation. Patients show up, they go to sleep, away we go. Most of the time though, that's gonna lead to some problems. They're gonna get an increased cancellation rate, communication is gonna be poor, patients won't have a great experience, and there's areas for optimization. So the first thing that institutions normally do is say, okay, we're gonna do this day of surgery encounter. And what they're gonna do is people are gonna show up, anesthesia, nursing staff, everyone will be involved there, and they'll basically just say, are you ready for surgery? That doesn't really help cancellations a lot, because if they're not ready for surgery, the answer is, you can't have surgery today. So that's a problem. Not really a lot of time to optimize somebody an hour before they show up to surgery. And so you're probably not gonna get the greatest outcomes, but you're gonna get your H&P signs, you're gonna do timeouts and some basic things, and a lot of people do this, and honestly, if you've got a really healthy population, and you can pull this off. There's problems with it, but I think it's not terrible, and a lot of people do this really well. It's very logistically simple, there's very many moving parts, it's hard to mess up that process flow. Low overhead cost, again, your cons or patient optimization doesn't really occur, you got some cancellations and issues there. But if you've got an ASC and a lot of healthy people, it's possible that this could work. But a lot of people will start in some model like this and then say, all right, let's figure out, we're having a lot of cancellations, we're having some bad experience, what else could we do? And so the next step is, people typically get nursing to start making calls a few days in advance. And so the patient will be contacted prior to the day of surgery by the nursing staff, they'll go over some basic preoperative protocols, when do we need labs, when do we need EKGs, and honestly, this is probably the most common model you're going to see if you looked at all of the areas having surgery, this model is probably the most common. Because it kind of gets the benefit of both worlds, it's pretty straightforward, you'll get calls, you'll be able to explain it, you'll get the really easy cancellations to avoid, making sure labs are in place, making sure EKGs, making sure they're not having a heart attack when they walk in that day, all those kind of things. So that is very common, and it's better than not calling somebody ahead of time, got to give them credit for that. But there is cost involved in that, you're going to pay for a nursing staff to start making all these calls, and there's no revenue to generate that, it's just a pure sunk cost. And it's challenging for that nurse to coordinate between the surgeon, anesthesia, PCP, and a lot of people, and so it leads to a lot of silos, it's not reimbursed, and still, you don't have a clinician that's evaluating the patient, and it's really hard to anticipate future needs when you're not all collaborating and thinking ahead. But a lot of ASCs and HOPDs and small volume hospitals will be in this model, but usually the next step is, hey, we want to take it to the next level, what is that? And what that is, is your traditional pre-op clinic. And so this is where you're going to have a protocol that's going to say a fast track patient is going to get a phone call, and make sure they check all the lists, and they're just going to be told, show up to surgery this day, you're fine. The sick people are going to say, hey, come in and visit with us. And so these are very staffed different ways, sometimes you might have an AP in there, you might have a physician there, and they will see the really high risk patients, talk to them, and try and optimize them for surgery. A lot of times they're following protocols, and that's a good thing. And they're really focused on making sure they're not getting canceled, trying to reduce unnecessary utilization of consults for cardiac clearance and other things that they can just take care of while they're there. And it is good, and done in the right situation. This is something that you may be able to bill for, if done properly, but again, it improves optimization. This helps in your really sick people, the complex patients. It's going to make your cancellations even better than they were, and help with a little bit of coordination, because instead of having a lot of different people involved, one person can kind of own that. Now, again, you're adding another layer of cost, and if you can't figure out a way to bill for it, this is kind of where you start getting a lot of resistance from administration, because they're going to say, so now we're having another doctor or AP in that's involved. If we can't figure out a way to pay for this, this is going to be a problem, because your costs keep going up. And again, it's easy to say, well, we're making it back in efficiency, but it's just hard to see that, and hard to get buy-in on those. And so, again, really important you do that. The other thing this needs is geographic footprint. It's easy to find a place somebody can make a call, but for people to come in, you got to have a footprint. Some places are very packed in, and it's really hard to find places that patients can get in and out and park, and you might need to check in if you're going to try and do billing and those kind of things. It's very, it's a lot more logistically challenging to do that and coordinate, but again, I think it is a step in the right direction, and definitely better for our patients. This is what you'll see a lot in, as you get more high volume, moderate to high complexity, you'll see more people going to this. And then kind of that last step is, okay, we have this. We haven't either figured out how to bill for it, or we do, but what's next? What's next is really taking the decision from a pre-op clinic to this perioperative mentality, and so it's more than just talking about, are you ready for surgery? It's talking about, are we able to prevent readmission, and talking about things that may not just affect your specific surgery, but could definitely affect you afterwards, and so for instance, this is where you may not just talk about things in relation to their surgery and optimizing them. You might involve things like advanced care planning, and talking about code status. Code status is one of those weird things in the OR that is really challenging, because a lot of times, code status is actually revoked in the OR, because we do things, and lower their blood pressure, and we want to be able, if their heart stops, to pump on it and get it circulating again, because we're the ones that lower their blood pressure, because of medicines, but sometimes it's hard to explain all that to patients, and the surgeon doesn't want to say, well, you need surgery, and here's what we're going to do if you try and die on us. Probably not the best way to really establish great rapport with your patients. I'll tell you what's even worse to do with patients, is for me to come in about one minute before you go to surgery, and say, hey, everything's ready, we're doing good. One quick thing, if your heart stops after we get you back there, are you cool if we just kind of take care of it? Probably not the best way to really involve, get that confidence going with the patient, so again, probably not the best time to do that, so probably a good time to do that would be in a pre-op visit, so that you could explain, hey, you've got a lot of comorbidities, let's talk about congestive heart failure and how that was with you before surgery, it's going to be with you after surgery. If your surgeon tells you to drink a ton of fluid to hydrate properly, it's great for your kidneys, but it might fill your lungs up with fluid and you won't be able to breathe, so you've got to talk through those and let that balance out, so this is what those clinics are great for, and you can also start coordinating, how long does surgery take? I'll tell you, we had experience at White River where our length of stay for total joint replacement in about 2011 was about 3.1 or 3.2 days, which now in 2023, you're like, what are y'all doing? That's crazy. Well, that wasn't that crazy then, it wasn't good either, but the biggest thing that actually changed length of stay wasn't some amazing, oh, we found this awesome fast track pathway that's the smartest in the world, it was that we told the patients, you're going to have to leave tomorrow, like, you're going to have surgery, we're going to take great care of you, but just so you know, at the end of the day, after we rehab you, our plan is for you to go home, because what was happening is, they would tell them that, but if the patient didn't have a ride home or they're like, hey, last time I stayed two or three days, then they didn't want to go home, and for some odd reason, we didn't want to fight with them, and we're like, eh, it's okay. So actually moving that discussion up actually was our biggest change in length of stay, the orthopedic surgeons would tell you that. So I think starting to talk about not just optimizing, but what to do after is important. There's even codes involved called transitional care management codes. Now not everyone can bill for that, but done properly, transitional management codes are super important after surgery, especially for anyone discharged from a hospital observation stay, because you need to talk not just about how your wound heals, but all your comorbid illnesses. So for moderate to high complexity patients that are discharged from an inpatient setting, it's really important to have a discharge phone call within 48 hours, and to make sure you've reconciled the meds, they make sure they have the stuff they need. I mean, how silly is it that it's like, you need oxygen and it's not there, and if they don't have it, they're gonna come back to the hospital. So you gotta do your blocking and tackling, and then try and get them back in within seven to 14 days because the most common time for readmission is just a few days after their discharge. So those are things that we can start talking about and planning and scheduling before they even have surgery. So again, that's why that's really critical to have a clinic that can think through it in a multidisciplinary manner like that. So this is where you're gonna see, this is where probably your highest risk people would benefit from things like that. You're going to hopefully be able to coordinate what the surgeon wants, what the anesthesiologist needs specifically for the case, what their PCP wants. Also coordinate that with an ACO. How do we reduce the total cost of care for this patient? Those are things that matter, and we don't need to just be focused on this episode, but also in general. How do we stop from readmission? How do we prevent ER visits? All kinds of things. Done properly, I believe, and we'll talk a little bit more about it, this is a fantastic framework for bundle payment programs like CMS Teams because they tell you, we want you to coordinate care for a surgical episode throughout the entire episode. So you've gotta get the stakeholders together, and you might as well talk about it at the decision to have surgery rather than after surgery. And so this is your opportunity to be able to do that. And so this is kind of that more complex model. Again, there's increased complexity, but done properly, this has a great opportunity to build and collect above and beyond what the others were, and a great way to take care of your patients, and a great way to start screening people for more than just surgical things. A lot of people that get readmitted actually have depression. And a lot of times it's like, are we screening people for depression when they come in for surgery? Well, we screen them for obstructive sleep apnea, we do strop bang screening because it affects them perioperatively, and it could affect readmission, but are there other things that we need to screen for? Having a committee that can come and talk about it, can look at your outcomes and say, you know, mental illness is a big reason we've had a couple of these readmissions. What can we do ahead of time to help those people before they have problems? And so you really need that iterative PDCA cycle going, and you've got to have all your stakeholders there to pull it off. And when you do, you can have a lucrative way that pays for itself and kind of lets you do that. So I wanted to share with you, I think we've got a burning platform to pull this off. And so the burning platform is a phrase that's been used for probably overused, but I'm gonna go ahead and do it. It's over 10 years. It's what makes you actually do this? What is this crisis situation that's causing you to move now and not a week from now? And that's really critical, because I think so many times as clinicians, we're like, eh, it's better for patients, let's do it. And as an administrator, you're like, there are a lot of things that are good for patients, and I've only got a limited amount of money, and I've got to divvy it up. So how do we say it's better to do this now? We don't need to wait till next year. We need to do it now, and I think we've got that. And so what I wanna share is this CMS team program. We're gonna talk quite a bit about that coming up, but it's something by CMS. I don't know if you guys have heard about it, but you certainly will. A lot of your organization, it's gonna be mandatory for, and it's a mandatory bundled payment for certain surgical episodes. This isn't the government's harebrained idea that, oh, let's try bundled payments. This is something that they've been doing for a long time. They started with the BPCI program, Bundled Payment for Care Improvement program, and they did this many years ago and had a lot of different episodes that you could choose from. They did BPCI and then BPCIA, which was their advanced program. You had tons of different episodes, medical episodes, surgical episodes, and they were voluntary, so you got to choose from it. And my organization participated in BPCI, and we did it for DRG 469 and 470, which was total joint replacement lower extremity. And we actually did really, really well in it. And we enjoyed that program, but the problem was, and this is gonna shock you, the hospital systems that weren't very good at that didn't elect to participate in it. And I know that's a shock, so I'm gonna let that kind of sink in for everybody. That was one of the issues is you had the people that weren't quite as strong that were not in it. And so also total joint replacement lower extremity was one of the ones that saved a lot of money. Now our organization reduced total cost of care and made outcomes a lot better through some of the things we've talked about. So CMS kind of learned from BPCI and BPCIA and said, hey, maybe we should focus it down to just a small number of episodes and then make it mandatory. So they did that in CJR. That was comprehensive care for joint replacement. Obviously CMS is notorious for eliminating waste, so instead of calling it CCJR, they called it CJR and eliminated that C. So that really impressed everybody. We were all really excited, and they were just a model of efficiency with that. So anyway, but that unfortunately was mandatory, but it didn't really affect that many places. But again, they saw benefit, improved quality, reduced total cost of care. And so then with this new CMS team program, what they've done is they still made it mandatory, but they're moving it out to five episodes and to a lot more places in a lot more metropolitan districts. And so my hospital's one that's involved. A lot of your hospitals are going to have to do this mandatory CMS team program. And so it's an evolution. It's not going away. So it's something that I think we all need to be familiar with. But again, from where we're sitting, what a great opportunity. And it's just a good way of saying it. So this is, it's consistent with this constant fee for service to value-based care. We talked about it going from voluntary, more pilot to this quality-driven, comprehensive, mandatory solution. And the CMS team program is this transforming episode accountability model. And what you're gonna see is there's five episodes. Cabbage, lower extremity joint replacement, major bowel, surgical hip fracture treatment, and spinal fusion. So basically hip fractures, total joint, spine fusion, column resections, and cabbage. Those are your five. So if you did those, if you do those, and you're in that district, you're going to have to do this program. And it's gonna start January 1st of 2026. That's great news because that means we get like a year to get ready for this. So that's a running platform. It's probably too late if you're already in it and you don't have a plan. Conversely, if we've got a year, this is the time where you've got time to set a program up, a clinic to take these cases, create, get all your stakeholders, figure out what your leading and lagging indicators are, and really measure what your baseline is and how to get better, and all work together. And so to me, this is the time that you can really dive into this. And so I think this is your opportunity to go to your organization and be an expert. So I'm gonna give you some details about CMS team and some ways that physiatry really can be on the leading edge. A lot of your hospital administrators may not be fully aware of this program. As hospital administrators, sometimes we're always like, well, maybe it'll change, maybe it won't be there. So I think you coming and saying, hey, this is legit, it's coming, and here's what I know, and here's what I wanna be a part of, I think would be great. It's gonna look for financial accountability, target prices, there's different tracks we're gonna talk about, and then it does a performance assessment. So you're gonna have to reduce the total cost of care, you're gonna have differing amounts of risk, upside and downside risk. The downside is gonna be what motivates people. Typically, human beings are more motivated by fear of loss than the opportunity for gain. So if you're trying to change somebody's mind, emphasize what they could lose, not what they can get, just a tip for life. And then performance. You're gonna have quality gating that's involved in this. And so you can't just do terrible care and reduce the cost, that's not gonna work. So these are the tracks we're talking about. Track one is upside only risk, but it's for the first year of this program. Then you're gonna see, for years two through five, you're gonna start seeing either track two or three. And track two is gonna be this 10% risk adjustment, and then you're gonna have 20% adjustment for track three. And so again, if you look at it, this is on the payment for total joint replacement, hip fractures, colon resections, cabbages, and spine. That could be a lot, because we're not talking about the surgical pro fee. We're talking about the whole episode cost for an organization. And that's in the tens of thousands of dollars on a lot of these episodes, or significant, even more that for cabbages. It's a lot of money. So 10 to 20% of that payment is remarkably significant. And so that will get people's attention, and it's not tough math to figure out what the average DRG payment is for a lot of these inpatients, and multiply times your number of cases that are CMS, that are Medicare cases, and voila, you got a big number times 20%, and it's gonna get people's attention. So with this, your limited risk or for tier one is gonna be like we talked about. Most hospitals can only do this for year one, except some exceptions, but most of them can only do year one. And it's just getting you started that first year in 26 with just a upside and no downside risk. So it kind of eases you into this, and then this is more information about this. And again, eligibility requirements is how they really determine who can do what, and more than what we need to go through on details, but do know for each of these episodes, there are quality implications that you've gotta do and meet. And this is coming on the heels too with total joints. Total joints, you're gonna have, the organizations are gonna have to be doing these patient reported outcome measures that are now mandatory. And so that's another thing your hospital's gonna be concerned about, and something that looks at the whole outcome over a whole year for these joints. And so the hospital's already trying to figure out how do I get out of this episode where they're only here a day or two, and now I've gotta worry about their care for a year. So I think you're providing a solution that you could not only take care of teams, but also incorporate some of this PROM tracking for your ortho cases and really do a great service to some of these providers and patients. So how does this apply to you specifically? And so one of those is getting a seat at the table. I really think if you guys aren't involved, this is still gonna happen, and it's probably not gonna happen as well for the patients, and you're not gonna be involved in it. And that's just not good for anybody. So I think you going to your administration and saying, I'm really interested in this, I think I can bring a lot of value to it. I can tell you as administrator, the answer's yes. I don't know how to do this. A lot of surgeons and ortho doesn't. Somebody has to take leave. Surprisingly enough, as a hospital administrator, I'm not overwhelmed by providers coming to me and saying, you know, I've never really liked the whole healthcare thing. I just wanna try and lead meetings and help on things that don't generate any revenue. Like, no, they don't typically like meetings, and they don't really like trying to figure out data and looking at it. So if you are interested in helping, thank you, and this will be really super helpful. The other part that I think, outside of helping patients and helping your specialty, is the downstream provider arrangements, and I'm kind of reading this out, but this model allows participants to engage in financial arrangements to encourage the success of the program. Participants will be allowed to share their reconciliation payments or repayments with providers and suppliers, including ACOs, which contribute to the participant's performance, the sharing required documentations. So why it matters. This, participants will ultimately be responsible for the cost of an episode that it may not have significant authority over, and so financial arrangements allow incentives to downstream providers to focus on optimizing care patterns. So in the end, for BPCI, the original BPCI, a lot of times hospitals just partnered with orthopedic surgery and said, okay, ortho, how do we do this? This, they took this into consideration through feedback and said, you can participate and encourage financially multiple people, and it's not all about the money, but it is going back to, it's a lot easier to talk one of your partners into showing up to a meeting if they might get paid for it. I mean, it's great to take care of patients, it's great to provide great care, but again, if there is financial incentives, it's good, and it's the right thing. It shouldn't, it isn't just about the orthopedic surgeon doing the joint. There's a lot of people involved, and it's not just the hospital, and so I think this is a great way, again, to create this governance model to where you can take the stakeholders that have a significant, that can create value for the patient, and let them work and create cutting-edge, evidence-based care to reduce the total cost of care and improve quality, and it's possible. We did it in a rural town in Arkansas for a total joint, and we got our length of stay down to one. Our readmission rate was 10% on total joints, and that wasn't good, that's really not good, and, but that was a long time ago, and we got that down to about two, and we take care of some sicker people, and it happened through optimizing people. It happened through having meetings every month and looking at the people that got readmitted and kind of scratching our heads and saying, how can we reduce the readmission? What was special about this one? You know, this patient continued smoking the entire time through. Maybe we need to be more serious about not smoking. Maybe this patient had, wasn't very healthy prior to surgery, and we could have asked them to adjust their activity habits before surgery to do certain things that might make them lower risk. We looked at how to get people home sooner, and what we found is the number one, after setting expectations, as we got more mature, the number one thing that, of whether they went home post-op day zero or post-op day one was if they had physical therapy post-op day zero, and our physical therapy department didn't ambulate a significant percentage of them because they were really busy. I get it, but our orthopods kind of put a little pressure on them. Orthopods are known for doing that sometimes. No offense, I've got some good friends that are orthopods, but they're doing it because they're advocates for their patients, but guess what? After they, in a meeting, were very clear that this was important in their own unique way, we got our rate from about 60 to 70%, up to 98 to 100% every month of that, and guess what? Our patients went home a lot more, but that was multidisciplinary. I wouldn't have made a big deal about it as an anesthesiologist, but the orthopod did, and so again, having a physiatrist there to help us with discharge disposition, there were decisions we made that we didn't have you guys' expertise on of when is it really helpful? We were like, well, we're above benchmarks in using inpatient rehab. We're above our benchmark using home health, so we just need to reduce it, but it's kind of like taking a chainsaw to a, it's some great analogy. We just, we did too much. Taking a bazooka to a mosquito or something. Like, we overdid it, I don't know, and we need that precision that you guys can offer, and so I would love to collaborate with you guys on things like that, so we were able to make a difference, but man, it would be helpful to have extra people to collaborate, and they've done it in this model and allowed us all to have incentives, so just to give you guys some tips, things that I've seen, and again, most of the things that I recommend are things that I've totally messed up many times, not just once, but it's common barriers, failure to identify and gain buy-in with all the stakeholders. This is one where if admin doesn't think it's legit or you don't ask admin what a win is and you go do it, you may reduce length of stay, and they don't care, because some hospitals don't care about length of stay as much because they're not full anyway. Some hospitals are all about length of stay because they're totally full, and it's a whole nother case they can bring in. You've gotta talk to them and ask. If you don't ask what's important, you'll never know, so getting buy-in from all the stakeholders, not just admin, but your surgeons, physiatrists, nursing, pharmacy, a lot of people are involved in this, so lack of clear leadership. This is a problem in things like this because if everybody is responsible for it, nobody's responsible for it, so you really need administrative support, but you need a clinician champion, and you guys can be that champion. There's no doubt in my mind. I've seen anesthesiologists be that champion. I've seen medicine docs be that champion. I've seen the, I've seen physiatrists do this, and I've seen surgeons do this, so you need that leadership, though, and then collaboration with the leadership to say, I'm gonna lead this, but I need everyone's help, and that's what you really have to see. If you don't, again, it just, it causes problems long-term. Anesthesiologists, I hate to say it, but sometimes we're the problem. A pre-op clinic that anesthesia doesn't want to collaborate with, and it's ours, and we're not gonna talk to other people, we're gonna do it because we can do it, can lead to problems, and we have to break down those barriers. The perceived threats to PCP. Well, the PCPs are gonna hate it. They're gonna be threatened by it. That means you gotta engage them. You don't wanna do it in a silo without them. You wanna say, hey, the reason we're doing this is because we care about this entire episode of care. We're gonna take great care of your patient. We're gonna optimize them. We're gonna take great care for the next 30 days, coordinate their care, keep them out of the hospital. What can we do to make this a win for you other than take great care of your patients? Do we need to make sure you get the notes in a better way? How can we help you? So bringing them to the table, engaging them. I've seen that blow up, and I've seen it work. And then lastly, competing priorities can slow it down. There's a lot, you gotta go back to the burning platform. You gotta make sure that people have allocated funds and time, and you're gonna have your meetings and have your support. If admin's like, oh yeah, yeah, kinda do whatever you want, be really, really careful. Like, ensure that you've got support because if they tolerate you doing it, they're gonna have a really low threshold for not funding it or just finding something else to do. So really, you've gotta make sure you've got support from all those stakeholders, and it's a priority. And some groups, I think Gary Lloyd did a fantastic job. Wait, Saeed Assef had it where one of his administrators, it was part of their performance evaluation was how the perioperative surgical home did. So I mean, aligning those incentives are critical. With that, I think the question to you is, what do you offer your patients at your organization, and how would the journey change if you were involved from the beginning with your patients here? And so that's what I want you to take home. Hopefully we covered what the ASA's doing, a little bit about periop, and how you guys can get involved. So if you have any questions about it, your society has a awesome health policy department, and this is their email, and you can ask them about the TEAMS program or anything else, they're fantastic. My name's Chris, I love talking about this stuff. I love talking about periop and business stuff all the time, so this is my email or phone if you're ever interested to call. I'm happy to talk about these things and reach you on. So with that, I will leave it for any questions. Thank you guys so much for your time. Thank you. Any questions out there? I know it's the end of the day, and that's why we want to make sure we have a health policy website. Again, if you think of anything tonight, tomorrow, or any point, or just want to learn more about it, you can reach out to us and we'll get back to you. Yes? My question is a little bit direct. Is there a physiatrist involved in your perioperative clinic in your system? No, we don't have any physiatrist in our whole health system. We're in Arkansas, and actually that's why I was here. I was talking to Dr. Alm about it, because I was like, we need physiatry. We have to make do with certain people in doing different things. We have an inpatient rehab department that we would love to have that in, and so there's a big shortage, and it's something that we would love to do that. So if you have any people interested in physiatry, you've also got my physiatry practicing in Arkansas. Wonderful place. That's my number and email, but it would be awesome. Now, the American Society of Anesthesia actually partnered with the AAPMNR in the perioperative surgical home, and so we were able to work in the collaborative with physiatrists who were doing things like this at their organization, so we've had it. We're just, sometimes recruiting is a challenge for us. and an interesting design? We would, we've seen it and we would love to work in a model like that, so yes. I mean, we're working on optimizing our clinic to do that and so it's different, I do, full disclosure, we live in a town of, a smaller town in Arkansas, so it's about a 220 bed hospital and we do about 7,000 surgeries a year, so it's not a high volume university or anything, but I do have clients at universities that do models like this and are constantly growing their perioperative programs, so yes, on every level, but again, every organization based on their size has a certain capacity of what they need and a certain degree of complexity that they take care of, but yes, we would love it to whatever we could do at our health system. And it has been a challenge throughout, and so I serve as the Academy's liaison to the ASA and that's how we met, but the ASA is very interested in getting physiatry more involved. The problem is, we are a small specialty and we tend to be conglomerated around larger metropolitan areas or academic centers, but we do know that there's a lot, there's more than just him that wants it out there. But what I heard is that you consult for some centers and they have a model like this, correct? Yes, everybody, if you've seen one, you've seen one. That's why they're trying to standardize it is because some organizations have pieces of what we talked about. It's not on the PowerPoint, it looks really nice to put it into four categories. I'll tell you, it's more of a spectrum that everybody lays in and some people have the billing figured out and some don't and some have it siloed, some collaborate with medicine or surgery department or other ones. So everyone kind of looks a little different, but the answer is, I believe, I've seen physiatry's involvement and I know that it would be an awesome partnership at most institutions there. It's just some of them aren't educated enough to know what role physiatry would play in that. Yes, ma'am. At the risk of instigating another lecture, what medical problems have you noticed made a difference in terms of length of stay versus early enough discharge? What specific medical problems had you noticed? For length of stay specifically, the biggest factor is talking ahead of time and setting expectation. Number two, for some of the organizations I was involved with, anesthesia actually didn't help sometimes because sometimes we didn't do motor sparing peripheral nerve blocks and so they weren't able to emulate post-op day zero. So those are some of the really basic things to get them out. As far as other things for length of stay, it's specific to total joint replacement of lower extremity. Anything at all, like even cardiovascular, neurologic, et cetera, or pulmonary. So as you get more complex, actually planning ahead with getting DME scheduled if that's needed and knowing that it takes a certain amount of time, planning ahead makes a big difference there. As far as total joints, some of them are being done outpatient now and again, that has to do with, that requires collaborating with physical therapy on the front end. As far as other disease processes, I'm trying to think. The reducing blood loss in the OR makes a really big difference, so giving them iron therapy prior to surgery is really important. I've seen organizations do PO iron and IV iron and you can raise their CRIT several points and ironically, if they're really anemic, that can cause, that causes weakness and then this, do I, I hate transfusing, if I give them more time, they won't, and that wondering really causes a problem and so those iron, anemia clinics on the front end, they've been done in a lot of places and that makes a massive difference in my opinion, especially on more complex. I'm trying to think of other conditions. And sometimes it hasn't been the most medically complex. A lot of times, what I've seen, where we're at in West Virginia, sometimes it's also just the social dynamics because the most medically complex, and a lot of times we'll qualify for inpatient rehab or skilled nursing facilities, sometimes it's the ones that don't qualify for that and now we're just sitting there because it's needing DME that wasn't identified ahead of time. So it's really more coordination of services and services and other necessities. Right. Big ones, I'll add two more because I had time to think. One is renal issues and that interoperatively, a lot of times you can have hypotension or you can have fluid imbalance and renal issues are a big reason for length of stay increase because you can't send them home with trending up kidney function, it's a lagging indicator, that keeps them in for a long time and there's a lot of things you can do on the front end for kidney function and also cognitive dysfunction and so that's one that actually in the pre-op setting, doing a mini-cog on the front end, a mini-cog allows you to identify somebody with cognitive dysfunction, dementia, before because what happens is a patient had dementia but we never tested for them and then they wake up confused and then they're like, you know, this person isn't the way they used to be. Well, we don't have any clue, we didn't know what they used to be but now it's an anesthesia problem. And so by doing it, now we can immediately know, is this delirium or dementia and there are different treatment mechanisms for it and that workup can really hinder people and so again, I think mental status is a really, really big one. Thank you very much. Yes, sir. Well, it's the end of our session. Thank you all for showing up and again, if you have any questions, feel free to email us. Thank you.

physical medicine

rehabilitation

perioperative medicine

patient outcomes

surgical process

healthcare systems

bundled care

preoperative care

multidisciplinary approach

care coordination

patient recovery