Good morning, everyone. Thank you for logging in and joining us. So we're here to talk about academy efforts and value-based physiatry. We'll have several speakers today. We'll talk about what the academy is doing in this area, and we'll take some questions at the end. So if you all have questions that come up along the way, just type them in the chat, and we will get to them as we get time to at the end. So I am Chris Standard. I am at University of Pittsburgh School of Medicine at UPMC, and I'm going to start by talking about value-based care in general, and the theme being is physiatry going to be the windshield or the bug? Where are we going and why are we going there? So I don't have any disclosures to relate, no conflicts. So as we talk about this, you have to keep in mind, this is a medical healthcare is in a transition. We're transitioning to value-based care, and ready or not, it is here. This is what is happening. Things are changing, and I don't know that providers are all in the loop necessarily, but the current fee-for-service system really is unsustainable and ineffective for what our healthcare system needs. Payers of all stripes want better value for what they're paying for, and patients want better access and better health and lower costs than our current system gives them, all of which is going to require change. In that change, transparency, equity, and accountability, the accountability on us are all central to the transition to value. As we look at this, I think we have two basic choices here as our field, as a field of physiatry. We can be the windshield and try to drive change, or we can be the bug and get splattered. Those are our choices. You ask yourself, why would we be the bug? Well, let's go look at what's happening in the healthcare world. One, this is data from the AMA. They survey physicians every two years, and what has happened over the last eight years has been a dramatic shift in physician employment, where starting about 2016, we crossed from most physicians being independently employed to working for somebody else, being an employee. At this point, most of us are now employees, which means we are not totally in control of our destiny as much as we might be in private practice. If you look at how we get paid in a fee-for-service system, this is becoming less and less tenable, which relates directly to that idea of we're becoming employees. If you look at how we get paid, Medicare has a payment formula. We're all pretty familiar with RVUs for the most part, but payment is a math equation, essentially. It's RVUs times what's called a DPCI, which is a geographic modifier. It's generally around one for almost every state. Then CF is a conversion factor. That's the actual dollar number that Medicare uses to transfer or change, essentially translate RVUs into dollars. In 2020, that was $36.09 per RVU. This year, it is $34.89. They're proposing for next year, it is $33.58, down another almost 4%. There are other things happening in Medicare that at the moment might drop payment by 10% across the board next year. Even if we want to stay in fee-for-service, it becomes less tenable because the payments are going down. If you shift and say, okay, well, we'll look at bundled payments. That's one of the bigger Medicare interventions to save money and try and find an alternative payment structure. If you look at bundles, where does the payment savings come from in existing bundles? The largest existing bundle probably is a total joint replacement bundle. It's a mandatory bundle for Medicare. In a recent review of the whole program, the authors looked at the first three years of Medicare CMS and their joint bundle and their payment initiative and where savings came from. When you look at the data, the reduction in Medicare payments are driven primarily by reductions in post-acute care, meaning largely rehab. Are we the bug here? In the bundle, that's what's cut out. If you think about where they want to go and where the future may be, in 2019, shortly before the pandemic, we had a meeting or two with CMMI, which is the Center for Medicare and Medicaid Innovation. They're the ones who come up with system redesigns within Medicare and test them. At that meeting, they presented their initial proposal for a spine bundle, for bundling spine care, a bundle payment for spine care that would be triggered with a visit with a surgeon, meaning that the surgeons would then own and control and operate the bundle and we would not. We would be the bug because we would be out. For what it's worth, we did present an alternate suggestion at that meeting. We really talked about collaborative evidence-based non-operative care and what we said seemed to resonate in future meetings, so what will happen here, not totally sure, but the idea that that is what might happen is existentially threatening to us, I think. So if we decide to flip and say we want to be the windshield instead of the bug, how do we do that? One, I think relevance matters. You're going to try and be a windshield and drive change. You have to be in an area where people will pay attention and where there's a lot of concern. So if you go to the leading causes of early death and disability in high socioeconomic countries like ours, first is stroke, the next is low back pain, the next is stroke, oh sorry, heart disease, sorry. Heart disease is the first, then low back pain, then stroke, then lung cancer, then COPD. So in our scope of practice, two of our main areas of clinical focus are in the top three, which gives us relevance in areas where we can put some effort and gain some attention and some traction because it matters to people and payers. If you go to spine and say, okay, we can look at spine and value in spine, what drives the cost of spine care? We studied this for APNR. Our IPPM group put out a paper on this a couple of years ago. The prime driver of the cost of spine care is surgery. It accounts for 32% of the cost for all spine care events seen by physiatrists and about half of those seen by surgeons. It is a single biggest driver of cost followed by imaging and injections. When you add it all up, spine, back and neck pain have become the most expensive health condition in the United States, which is kind of astonishing. More than everything, more than heart disease, more than cancer, more than everything else you can think of. So what is the future of spine care? I was looking through things and I found this quote, which I really like. The ultimate opportunity comes in true musculoskeletal population health management. And this comes from the president and chief transformation officer of the healthcare outcomes performance company. I think that's true, but you get into population health management, who's going to do that? Who's going to manage the musculoskeletal health of a population? Why would it not be us? If you go to stroke, the American Heart Association and American Stroke Association put out a joint statement in 2013, trying to assess future stroke needs and where we might want to be focusing attention as a society. And they estimated that in 2012, stroke costs were 105 billion for direct and indirect costs in 2010 dollars. In the same dollars, meaning 2010, they thought this would rise to 241 billion by 2030, which is a rather dramatic increase in that stroke would affect almost 4% of the US adult population. When they thought about solutions, and how do you address this as a society, they really felt there needs to be a greater emphasis on implementing effective preventative acute care and rehab services. Why not us? That is us. Why not us? Right? If we want to be the windshield and not the bug, that should be us. If we want to become the windshield, what do we do? How do we think about this? Right? We look at these things and say we want to be relevant. And we are important and what are what how we address patient care and our goals for our patients are important for them. Several things we have to do, we have to get to the table and join the conversation. You have to be there. We have to be there as a specialty. We have to provide an essential role and value based care and we have to be able to articulate and support that statement in that role. We have to come up with words and language and data that allow that. We need to keep the focus of care and the focus on outcome measurements and the focus on desired outcomes of care systems on long term function and health. That is what's important to our patients and what our field focuses on. Whatever we do, prevention, access, equity, collaboration and accountability are all baked into all these structures and we have to address them all as we do this. And we need a plan. We have to have a plan. So that's what we've been doing here. So we in our IPPM committee and across APMR are working on this and how do we get a plan to get to address these things and help ourselves be the windshield. That's what we'll be talking about. So Dr. Glassman is going to start talking about value, low back pain and APMR efforts. Dr. Zorowitz will then talk about capturing value and longitudinal care for stroke. And Dr. Slocum is going to talk about APMR's work with the perioperative surgical home. And with that, we will move on. So Dr. Glassman, the floor is yours. Great. Thank you, Dr. Standard. Good morning, everyone. I'm waiting to share my screen now. Okay. So Chris, if you stop your screen sharing, then I will start mine. There we go. Perfect. All right, everyone. So we're going to share. All right. So I'm Dr. Stuart Glassman, still somewhat part of Granite Physiatry in Concord, New Hampshire, and on the faculty of Dartmouth and Tufts. But I've recently started a new role as the Deputy Chief of Physical Medicine and Rehabilitation at the VA Greater Los Angeles Healthcare System. And for the first time, I do have an intriguing disclosure, which I'll get to. We're going to talk about improving awareness of the IPPM Spine Care Toolkit. We're going to enhance understanding of value-based decision-making in low back pain and spine care, and discuss methods for improving physiatry involvement in spine care programs and systems. So I have no financial disclosures, but it's the first time I've ever said this, so you get to be part of it. The views expressed in this presentation are those of the presenter and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. So there we go. All right. So this has been a 10-year journey for looking at spine care, spine models, and the Academy. It started back in 2011 with a Models of Care Initiative for what was then one of the four steering committees for the Academy, the Professional and Public Awareness Committee. Dr. Morton Lanoff was the chair at that time. I then took over in 2012. We continued to focus on the Models of Care Initiative. Myself, Dr. Benton Giap were very involved in looking at some of the financial and economic issues for spine care. Then in 2015, the Innovative Payment and Practice Model Workgroup came to be, and we started looking at what were the alternative payment models that members were doing for low back pain. And we surveyed members and tried to get examples of that. And there is an article from 2015 in the Purple Journal that Dr. Peter Esselman and I authored. All right. So 2015 and 2017, as we looked further through IPPM into this whole low back pain issue, and at that time, Dr. Standard was part of it, Dr. Thomas from Cleveland Clinic, Dr. Giap, Dr. Anthony Lee. We worked with a search firm and a research firm looking at low back pain costs. We actually sampled a 5% Medicare data grouping to try to find out how do we as physiatrists impact value in spine care. There have already been some articles about physiatry and low back pain. And eventually we found an intriguing issue, which was whether a surgeon got involved or a physiatrist got involved, the per member per cost dollar amount went up and stayed up for years just by having the presidiatrist or the surgeon step into the treatment plan which was somewhat surprising to us because we thought we would lower costs and actually we did not we actually raised costs not as much as the surgeons but that got us thinking there's definitely something else here going on a white paper was produced and then Dr. Standard myself Dr. Thomas had already signed up to give a presentation on a spine care model and we couldn't really talk about it much in detail because we were already writing the paper that we were going to publish so we do apologize to everyone that was there that day five years ago in the ones that you didn't get your money's worth but hopefully you find more about it today. Then in 2018 we proposed a spine care model through IPPM to one of the other committees for the academy QPPR and some of the information overlapped with the bold initiative for MSK issues that also was happening at that same time in 2017-2018. Eventually the article of Dr. Standard referenced I think it was published online in 2019 and hard copy in 2020 so that's the reference that I used and then over the last couple of years we said you know no model will work the same in every health care system and location so maybe it's better to think about a toolkit that members can pull parts out of it being me and that's how we shifted from the model and going from the model to the toolkit we think is going to help more of our members over time. All right so why should we care about value remote back pain? Well there's a lot of reasons and mostly it's because of how many people have it and how much it costs so in 2016 and this came out of a JAMA network article that Dr. Standard mentioned low back and neck pain were the highest healthcare spending 135 billion dollars in spending most of which was paid for by private insurance then public and then out-of-pocket payments and then globally about seven and a half percent of the entire population of earth have low back pain which is about 577 million people. So what were some of the goals of the toolkit? We wanted to demonstrate a positive impact on patient outcome and satisfaction and decrease cost and increase value over time. Establish a multidisciplinary team of clinicians with coordinated care with physiatry hopefully being a team leader. Identify the framework of a spine care pathway with the appropriate diagnoses components duration of treatment and oversight. Ultimately tangible decreases less opioids less emergency room utilization decreased advanced imaging studies decreased spinal injections if not indicated and decreased surgical intervention if it can be avoided and then of course develop recommendations for patient outcome measures such as potentially utilizing the AAPMNR registry and then create resources that academy members can use to educate themselves and their hospital health system leadership concerning some of these spine care models. So considering value-based spine care you have to understand your pattern of utilization local versus national understand what's the payment model that really matters in your community. Are alternative payment models accepted accountable organizations? Are you part of one or more than one? Is fee-for-service still the main way that people are getting paid? What's the structure of the team? The patient's always the center. What about the clinicians? What about administrators? Can you coordinate with payers? Anthem as a health insurer, Home Depot as a national employer, Kaiser Permanente as a healthcare system. Although here in California about 30,000 employees are about to go on strike next week for Kaiser Permanente but then they have some challenges. Risk one and two-sided risk obviously you know risk on the upside or risk on the downside or both. And what about innovation? New treatment pathways, new technology, new options. All right so engaging senior leadership considering this type of spine care program because unless you have your own clinic in your own center if someone else is going to have to buy in to do it. Understand the variability of the administrative structures and I want to thank Dr. Mitra from the University of Kansas who was part of helping create some of these ideas. Identify the departments, individuals, and stakeholders to be involved in the discussions. What are the techniques you have to use for essential conversations? Create a concise and evidence-based message such as physiatry like spine care is a team-based program that has been shown to improve value and decrease cost. One sentence that gets the message across. Align with future payment initiatives, how to transition from people service to APMs, and objective evidence that physiatry led spine model lead to cost savings. That's what all administrators want to know. Show me the money as Jerry requires. All right so what makes up an effective organizational team? Balanced representation, know the relevant stakeholders, who's the convener to bring everybody together? It might be you. Who are the physician champions? The 10th person is the person that doesn't go along with everyone else. That's the person that challenges everyone to think differently. Financial input data outcome is crucial. You need to know that it's effective and it's working. Who's the program director and coordinator? It probably won't be you. There might be another clinician but you know maybe a nurse case manager and the administrator obviously. All right so this is my favorite diagram that you're going to want to remember no matter where we go from here. This is the SWOT analysis and the environmental assessment. You have to understand who's around you. What's your competition? Who are your allies? So strength, weaknesses, opportunities, and threats. Now below that is the symbol from Led Zeppelin IV which came out 50 years ago this week and I think that's what they were actually diagramming was a SWOT analysis of rock and roll in 1971. So put that in there for some reason. But the reality is who can you rely on? Some options and know who also leads your competition. The global spine care initiative is looking at this issue of spine care in a global manner. Many different countries are involved with that. Now some of our threats and competition UnitedHealthcare that our academy spoke to a couple years ago created a program where patients could have direct access to physical therapy and chiropractic care and have no co-pay as long as they didn't have to see a doctor first. And we were all concerned about patients would probably possibly not be receiving the best care because there was no physician involved. Hinge Health is a home-based health care and physical therapy program which is a digital musculoskeletal solution for corporate clients including Home Depot. So no one even thought about this a few years ago obviously. OptumLabs, you know Optum works along with UnitedHealthcare looking at tens of millions of patients outcome data and they are focusing also on a non-physician initial care for low back pain. I'll show you a slide in a second that it's closer than you think and the link is there. We can collaborate with surgeons, primary care physicians on future spine care needs. I've worked a lot with one of the medical directors for Anthony in New Hampshire and he's a family physician and they are very interested in the physiatric model of spine care. And actually in northern New England they're working with Andy Hay in Vermont for exactly this issue. And then what about resistance, fee-for-service providers, interventional pain management physiatrists who maybe are working for big multi-specialty groups and they're concerned about their revenue because of their contracts. So some of our own members may actually be resistors as well. All right so Equinox is a pretty well-known health care club in different parts of the country and right next to the Equinox where I work out every week is Optum. So I'm going to break in there one day and see what's actually going on there because that's where the non-physician low back pain adversaries sit. So it is in our backyard at least here in California that's for sure. But was not seen in New Hampshire. All right so key clinical team members in their roles, primary care referrals, ER physician referrals, physiatrist as a team leader, PT behavioral health. We know that chronic low back pain patients are going to have a high overlay of mental health issues. Nursing, dietitian, nutrition, case management, spine surgeons, part of the team members and down the road you can think about our chiropractors relevant. Occupational therapy, acupuncture, massage and pain management. So ultimately what's the pathway? Patients with low back pain can be referred from the emergency room or primary care. Hopefully they're seen within a week from the time of the referral. Conservative care management directly supervised by a physiatrist likely for up to 12 weeks of treatment. Although this is not a specific model but these are just general concepts to keep in mind. You want the physiatrist to complete a comprehensive consultation evaluation, look for red flags, figure out the diagnosis, consider if there's any imaging to be done, look at past treatments, consider referrals for other therapies, have a follow-up in one to two weeks which could be a telehealth visit and then as needed over the next few months. The duration of care is based on maximizing patient outcomes and improving value, decrease costs, set up your exit criteria based on outcomes and pre-set goals and then consider reassessment at six months, nine months in a year with data collection. Here are some recommendations for quality clinical financial outcome metrics. The academy registry, the link is there to track data. Although some health systems they wouldn't keep the data themselves, they don't want to share data with anybody else. So you'll probably run into that. They may not want to use the academy registries tools. They may want their own collection of data. Promise 29 patient reported outcomes, document outcomes in the record, document the diagnosis, quality care, important clinical outcomes, financial outcomes as well because you have to remember this is creating value and value is related to cost savings and transparency with data analysis. How do you then increase program awareness once it's up and running? Grand rounds, board presentations, speak to chief medical officers, online articles and hospital newsletters, local media, county and state medical societies, talk to your local payers, medical directors or CMOs at your health plans, talk to the case managers for the employers, workers compensation because a lot of workers compensation injuries are spine related. This kind of a toolkit can help create a program for those patients. Work with our academy for social media resources to highlight the toolkit and the options, webinars, CME, academy talks here, AAP and also at health insurance national meetings that happen annually as well. You have to reassess the program, make sure everything is going well. Again, reported outcomes for the patient, satisfaction, functional activity change, decreasing opioid use, healthcare utilization and lower costs, value of the program, are you getting people back to work, are they not applying for social security disability and satisfaction from the stakeholders and the team members. Here are some references, our IPPN paper that we published. There will be references in the toolkit that will be published online on the member website. There is an example of a different toolkit which is for post-acute care and you will see as an example what it will look like when it is ready. Thank you and I look forward to answering any questions afterwards and on to Dr. Horowitz. Thank you. Okay, share that, and then we are all set there. Thanks very much Stu, appreciate it. So what I'm going to be doing is going to talk about the same thing with stroke. So I'm Bruce Zorowitz. I'm an outpatient physician who does neuro rehab with a focus in stroke. As you can see I'm also chief medical informatics officer at MedStar National Rehabilitation Network as well as at Georgetown University School of Medicine. There are my disclosures just research that we happen to be doing, but nothing with related to this. So what I want to do is to start with a little bit of background. Chris actually talked a little bit about this earlier but I'll update this. So basically total cost of stroke in the United States was again over $100 billion according to 2016 US dollar values. About two thirds of it is accounted for by indirect costs from underemployment and premature death. So that's pretty pretty significant. What's really interesting though is since everybody thinks that, you know, stroke is a disease or condition of the elderly, the age group 45 to 64 also accounted for the greatest stroke related direct costs. So that's just something to keep in mind because these are people, largely, who will be under commercial insurances as opposed to Medicare. So what we're doing and I preface this by saying, I'm going to talk a little bit. I'm going to focus a little bit because I think a lot of what Stu talked about before is going to be talked about again but our work group, and being a little bit behind, is working on the development of a physiatrist-led post-stroke rehabilitation model. Again, hoping that outcomes improve. We try to reduce costs through consistent and direct involvement of physiatry in post-stroke rehabilitation care. So, again, like what Stu talked about, we're going to talk about a positive impact on clinical outcomes and satisfaction, decreased costs and increasing value. We try to optimize prescriptions because we may not necessarily be able to get rid of everything. Hopefully, decreased emergency department utilization and hospitalizations. We also want to, again, create educational resources for our members so that we can educate hospitals, healthcare systems, in other words, concerning alternate payment models for post-stroke rehab. So, again, the summary of our goals were very, very similar to spine with some differences. Developing recommendations for patient outcome measures such as using the registry. Establish a good interdisciplinary team of clinicians that are involved with patient care so that we can provide good quality treatment support and care coordination. And then identifying the framework of a pathway including the components, duration of treatment, and involvement and oversight. So, I'm not going to go through everything that Stu talked about because some of these are very, very similar, but what I want to try to focus on are things such as the description of economic considerations, which, again, are going to be relatively similar. Recommendations for quality clinical and financial outcome metrics and data analysis. I'm not going to go through the senior leadership, the SWOT analysis, because basically those are very similar and we need to develop those a little bit more. We also want to talk about considerations in care pathways such as duration of care, scope of care, how do you get in and out of each of those levels of care that we're going to be talking about, and then also reassessing our program as we've talked about before. So, as Chris very nicely talked about, are we going to be the windshield or the bug? So we really do want to be the driver. And we don't have to go that much further than looking at the European colleagues that published an article in the Blue Journal back in 2009. What they basically did was to really define what we do in terms of the continuum of care. And so what they talked about was that a physiatrist was called within 48 hours of the stroke event in centers, and PT, of course, was a little bit more because they had to get the therapies done. But the interesting thing here is that physiatrists tended to be more of team coordinators after 48 hours than somewhere like PT. So again, what we want to do and emphasize as we do this is, number one, start from acute care, literally from the time that that patient is admitted to the hospital all the way through the continuum. What we want to do with those consults is not just be the take my patient consult, because that really is not something that we necessarily need to be doing. We can be looking at the things that are going on in acute care and also grease the skids and help figure out where things are going to go in terms of triage. So what they did was, again, to look at the distribution of help during the rehabilitation phase. And what I want to really focus our attention on is the coordination of care here from pathways to home or from hospital to home. As you can see, in Europe and all these different countries, a little over two-thirds of physiatrists actually participated in that. And what's even more important is the fact that the head of the team and a little bit more than that were also physiatrists. So again, there is good reason for us to really take the helm as the driver of those kinds of things. The other thing I want to make sure of is that as we go through the continuum, to look at really what's out there. So my late colleague Alex Dromrich published this just very recently, posthumously, about looking at clinical trials for the optimal time in motor recovery after stroke in humans. And interestingly, although this is a very relatively small study that was done here, what they found was that there was an optimal period between 60 and 90 days after stroke with Lefser effects less than 30 days and no effects six months after a stroke. So the idea that we have to watch what we're doing because timing is everything. So where are these patients going and when do they go there are going to be very, very important. In the economic considerations, what Stu talked about is again very important. How resources are utilized, the payment model that is utilized. Is this going to be per episode or is this going to be post-acute, which has been a big controversy recently. The structure of the team. Also, how do you coordinate the model with the payer. So the models can be very, very different. I'm working on a project through the American Stroke Association where we're looking at stroke rehab in skilled nursing facilities in Montana. So where they may have only one inpatient rehab facility for the entire state. So how do you use all these things and make for the best potential model. We're not going to go one and two sided risk because we're going to have to be somewhat accountable for that. So what's really important in developing all of this stuff is really what do we do both upstream from rehab and acute care and downstream whether that's going to be whether that's going to be home care, whether it's going to be skilled nursing, whether it's going to be outpatient. So we spelled some of this out in an update that we published about two years ago, again, in the American Stroke Association on systems of care. And what we actually talked about in this is that number one, a stroke system should periodically assess its level of available services and resources. So again, we have to have a good understanding of what's out there so that we can make the best use of it. And then making sure as we will do this as physiatrists that the stroke system ensures that we are referring our patients to the setting most appropriate to the clinical need and whenever that is going to be necessary. The issue here is that for quality, then you have to consider how do we do this. Do you do CARF? Do you do joint commission? Do we do accreditation for these things so that you can raise the standards of what's going on? Because if you want to cut costs, you want to give the best levels of care to patients, you've got to make sure that they meet certain standards. So in terms of the care pathways, I want to spend a little bit of time on that. What we tend to do again in acute care to start from that side is to basically have everybody take a look at that patient and then get a treatment plan, which is reviewed by the team members. And then basically that care plan goes through that continuum of care. Of course, reevaluating depending upon the level of care, whether it's weekly as we do in team conferences in IRFs, biweekly say in SNFs and maybe monthly in visiting nurse and outpatient. But the big hole here is completing that comprehensive consultation and evaluation, looking at diagnoses, anything that may be a problem potentially down the road for that patient, assessment of physical limitations and treatments. And what's very interesting about that is that what we want to try to do, as I've alluded to, is that we're going to try to use ideal best practices and all that. And then make sure that the scope of care is delivered by competent professionals with their license. But the interesting thing is, is where do we find these things? We're going to find those in some of the clinical practice guidelines that are out there, again, to make sure that we're going to get good quality. And then again, looking at entry and exit criteria to make sure that we are sending patients to the appropriate level at the appropriate time. And then also determining when those patients are ready to move on to the next level of care. And then looking at reassessment again at six months, a year or even further down the road. So for care pathways, I can refer you to these two articles, again, both of which we published one in 2010, which was Nursing Interdisciplinary Care of the Stroke Patient back in 2010. And the Guidelines for Adult Rehab and Recovery published by us in 2016. And by the way, endorsed by AAPMNR at that time. So the interesting things in the care pathways that we should make mention of in terms of stroke systems is, again, making sure that we have a good screening evaluation during initial hospitalization to determine what is that first jump that that patient is going to make. And then down the road, making sure that long-term primary care and specialist care, including us, should be arranged to identify any residual impairments that these patients receive. Again, continued rehabilitation. The thing that drives us, again, very carefully is that, as I love to emphasize, acute stroke care is the first 24 hours. Rehab and recovery is the rest of their lives, which is where we should be. So along with that, again, the reason for getting that initial evaluation is because patients often are assessed for TPA and thrombectomy with the National Institutes of Health, the NIH Stroke Scale. And there is good evidence out there to show that patients with NIH Stroke Scales of zero still, even though they don't score on this scale, still may have significant handicaps, likely things like cognitive issues, down the road at 12 months. So again, we need to be able to identify those things. So how do we do that? Well, again, there is time for us to take the bull by the horns and work on that in acute care. So again, what we published with Pam Duncan earlier this year is this whole time for a paradigm shift, which basically says that comprehensive stroke centers, which have everything under the sun, provide comprehensive management of acute complex patients, but don't really include rehab. And so the idea is that we have to note disabilities as part of that comprehensive evaluation and do something about it. So what we basically said, there's an urgent need to shift paradigms and expand the quality metrics to include rehab-ready comprehensive stroke systems or stroke units to be able to expand scope of work and metrics. And again, in addition to functional things, we have to assess and refer patients for all the other things that are necessary, which include food, financial, and other social determinants of health. So again, these are things in terms of building quality and cutting costs are going to be very, very helpful. Finally, in terms of outcomes, what we want to do is look at things such as patients who do get the transition of care and then are following through with those, measuring patients that go to each type of rehab facility to make sure that it's the appropriate thing, and then making sure, again, to cut costs down the road, that you have patients that are referred to lifestyle management programs if they need smoking, if they have diabetes, hypertension, making sure all those things are being taken care of. Again, things that are important, mortality, disability, and then quality of life, as Stu mentioned before, promise is going to be important, as well as maybe something like the stroke impact scale at 90 days, blood pressure control, and things along those lines. And then from a financial standpoint, it's going to be important that we take a look at 30-day hospital readmissions because that's something that Medicare does look at. Healthcare utilization, what's the cost for care, as we talked before? Return to work status, again, because we saw that those younger patients are the ones who have the higher costs, and then looking at satisfaction of patients, stakeholders, and team members to make sure that we're providing good care at the best cost. In terms of inpatient care, there is an article that was published earlier this year by Joel Stein and others that look at clinical performance measures for stroke rehabilitation during acute and inpatient stays. In summary, post-acute care matters, and I love this quote from the article that we published with Pam Duncan, that now is the time to honor the patients and caregivers' strongest act, better access and improved secondary prevention, stroke rehab, and personalized care, and along with that, to make sure that we are optimizing costs so that we get the biggest bang for the buck. I know this is not exactly the way we want things to go, although this would be really, really nice, but again, optimal care is going to be very important for our stroke survivors, and we are the ones who can provide that care probably best of anybody and any specialty. Uh, so that completes that. Um, so I'm going to stop sharing and, uh, turn it over, uh, to, uh, Chloe for her talk. Thank you so much, Dr. Zorowitz. Um, let's see here. Okay. Can you guys see my, my slides? Yes. All right. Let's advance. Um, so I have no relevant financial disclosures. Um, I do receive research support from the Nielsen Foundation, um, and serve on, um, the Quality Measure Alignment Task Force for Massachusetts, um, as a volunteer. Um, I'll be talking about the Perioperative Surgical Home, um, which is an AAPM&R collaboration with the American Society of Anesthesiologists. Um, so I am the Associate Director of Quality at, um, Spaulding Rehabilitation Hospital, um, and I'm also the Director of Health Policy, um, at Harvard Medical School Department at PM&R, um, which I should have mentioned at the beginning. Um, but, um, the Perioperative Surgical Home is an interesting model. I'm just going to touch on it briefly, and if anyone has questions, we can get to it in the Q&A as well. But, um, the, the PSH Steering Committee, um, has been working together for a few years. Um, there were, um, several, um, learning groups and learning communities, um, that preceded the Steering Committee, um, that, as some of you know, Dr. Adair was involved in, um, as part of the IPPM Committee. Um, but the, the PSH Steering Committee, which was formed in 2020, uh, was tasked with coding the, or codifying the principles and components of the PSH model, um, which is a patient-centric, team-based model of care, um, spearheaded by the ASA, but with input from, um, organizations such as the, um, American Academy of Orthopedic Surgeons, as well as the, um, American Urological, Urologic Association. Um, and, um, it's tasked with meeting the demands of a rapidly approaching healthcare paradigm, um, which is a value-based paradigm, um, that will emphasize gratified providers, improve population health, reduced costs, and satisfied patients. So, really, they have sort of everything from the quadruple aim there. Um, they're really looking to improve population health, reduce costs, um, and importantly, I think, um, really have satisfied patients, as well as, um, providers that are happy, um, in that model. Um, so, as I said, the APMNR has representatives, um, as, and I'm the liaison for that, um, as well as, um, um, folks from the administrative side at APMNR, um, but we collaborate, um, and we also advocate for meaningful inclusion of rehabilitation into the perioperative surgical home model. Um, so, anytime the opportunity for, uh, rehabilitation or rehabilitation input comes up, um, we are there at the table. Um, as, um, Dr. Zorowitz mentioned, we are, we're both interested in, um, the acute care, um, sort of part of this paradigm within the perioperative surgical home, um, as well as, um, you know, even sort of pre, pre-perioperative, pre-surgery, um, but then also, um, in terms of after someone has, um, surgery looking at their rehab, um, and any sort of post-acute care or even sort of further down the line outpatient care that they may need afterwards. Um, this culminated in the release of an implementation guide, um, which was actually released, um, they had sort of a soft release, I think, in October and then formally released in November 2021, um, when they had their, um, annual meeting, um, and they had, um, uh, uh, essentially what is, uh, also an interactive module online that's available to ASA members, um, as well as, um, a sort of, uh, a lengthy PDF that involves sort of all these things in terms of, um, stakeholder analysis, um, engaging with leadership, um, and really sort of rolling out, um, a PSH model at your institution, um, and really customizing it to your institution, um, regardless if you're working at a small community hospital or a large academic medical center, um, and things that you may want to keep in mind as you are, um, going about, um, trying to cultivate this, this model of care, um, and also assess, assess outcomes and do sort of a, um, a, a PDSA cycle on it. Um, so it focuses on the components of the PSH, um, as well as strategies for developing a successful PSH model, um, within sort of diverse settings, um, and, um, it also has beneficially, um, CME credit and maintenance of certification, um, and anesthesiology for, um, learners who are available to complete this activity, uh, within the sort of the ASA, um, website, website domain. Um, we've successfully advocated for the role of PM&R in implementing a PSH model. I think we focus a lot on engaging, um, with physiatry colleagues, um, as part of this model, but, um, it also extends into, um, you know, our input in terms of which outcomes, um, we advocated for including, um, in terms of, um, looking at, you know, when, when someone is, um, both perioperative and when they're immediately, uh, postoperative, um, what kinds of things, um, are being assessed, um, and really having function, um, be, uh, a component of that. Um, and, um, like I said, we've really been highlighting the role of physiatry and collaborating with physiatry across the care continuum, um, in these models, which, um, as I said, don't, don't just involve anesthesia, even though this is, um, sort of anesthesia centric, um, as a something that's spearheaded by the ASA, but, um, also something, um, that involves, um, surgeons, um, you know, and has representation from the AOS and the AUA. Um, so next steps, so like I said, in July 2020 was when the PSH steering committee was convened, um, and we released the implementation guide for wider ASA membership in November 2021, um, and we're hoping to continue to collaborate, um, with the ASA regarding novel models of care, um, and, um, the future evolution of sort of, um, different, um, PSH, um, models and, um, learning tools for their membership. Um, so in closing, uh, we do hope to continue to collaborate broadly, not just with the ASA, but also with various stakeholder organizations to promote value in clinical care, um, and future work of the IPPM committee will continue to focus on value-based models of care delivery, um, advocacy for PM&R across the care continuum, um, so it doesn't matter if you're a frontline provider in an inpatient setting or an outpatient setting, um, or subacute rehab, um, but I think that also we want to focus, you know, as I underlined in my, um, uh, talk about the, the goals of the PSH model, um, is that we also want to focus on, um, things that enhance provider satisfaction. Okay, all right, I'm going to stop sharing, and then hopefully we can take some questions. I think we're back on, yeah? So, uh, the first question I saw was this question about frontline physicians, any recommendations on, on how frontline physicians can help? I'll give my two cents first. I think that this is the wind, seal, and the bug thing, right? If you, if we are passive, we're going to be bugs. We're going to get squished. Um, by being the windshield, this means show up. If your organization has organizational meetings, go. If they have work groups on restructuring care, go. If they have grand rounds, go and talk. If they have meetings of surgeons talking about spine care, show up. If they have neurologists talking about, about stroke care, about stroke care, show up. Get yourself to meetings, get yourself to tables, talk about value, talk to the people who look at financing your structure and say, I'd like to look at how we might be able to address care to improve financial finances here, how we improve long-term outcomes and return on investment on our care models. And just start these conversations in your system, and don't be passive. If you start talking, people will listen to you. We have a lot to offer, and genuine concern about the patient, genuine concern about better care, and concern about long-term financial viability of the structures around you really do resonate in most healthcare systems. So show up and talk to people. That's how you can help. Other people have other comments in there on that one? Yeah, I couldn't agree with you more. I think part of what I've done in the past, at least from a clinical standpoint, you know, from stroke is to talk to the neurologists, talk to the neurosurgeons. If you have, if you have rounds, if you have interdisciplinary rounds, show up to them, be the team leader. So you can, and then as I said before, don't make those consults, you know, just the take my patient consult. They don't need us to do a take my patient, but they need us to look at things that will help medically get that patient moving. So we want to show value and show that we're really, you know, worth our salt. And it's important to, as to paraphrase, you know, as to paraphrase Chicago elections, you know, consult early and consult often, you know, make sure you get open door to, you know, to say, Hey, you know, don't wait for them to say, I want you to consult on that person, say, I need to see that patient. And this is why. So I think, you know, again, being involved is going to be the only way to get yourself, you know, to really show value for us. Yeah. And certainly know your audience, understand, and your colleagues know what's important to them, know your strengths. And I think, you know, because I just have to understand the economic and patient outcome values of what we do. So if you always think about those issues, I think you'll have some of the ones to hear what we have to say. So it's important. Yeah. I would say too, when you talk about an implementation guide, so definitely getting a team together, and sort of having a, having a team, understanding the environment, and then, you know, also scaling things. So, you know, you're, you're not going to tear down the whole house and rebuild it all in one day. You know, you're going to start with something that is achievable, and move on from there. So I think all of those are good. Yeah. Last thing I'd say is that from having been on lots of committees, and most committees, 20% of people do 80% of the work, be in that 20%. And people will listen to you. Don't be in the 80%. All right. Next question for Dr. Glassman. How does the spine care, how does a spine care model sort of deal with this conflict of biomedical sort of focus in a fee-for-service structure, where we go after everything, to a more comprehensive structure on behavioral change? I believe that's roughly the question that Dr. Smith is trying to get at. Right. Exactly. So if you tell someone something often enough, they might actually start to believe it. So a lot of our patients have probably heard over and over from whoever treated them, you know, that they need medication, they need to not do certain activities, and they need surgery. And, you know, patients will often believe what is being told to them by physicians that, or nurse practitioners, or PAs that they trust. So part of this toolkit, and if you remember back on one of the slides, was the components of who are the team members, there was a behavioral health component and a case management component. So yes, we may be bringing ideas that are somewhat new for these patients, but remember, they got into the toolkit system by a referral from either their primary care doctor, or the emergency room. Other people are already starting to buy into that belief that there's a different way, maybe a better way to treat spine care. So that being said, this patient who had the belief of the whole, you know, biomedical surgical model, will have to probably taught new ideas. And to understand that they don't have to, you know, take an oxycodone or run to the ER every time they have a fat clean flare up. It's going to take education, it's going to take some behavioral modification. But again, that's part of, you know, what may work in the community, you know, there may be some things that are added in California that would never be added in Minnesota, who knows. But I think it's going to be part of the education component of this toolkit and program. That may not be done by the physiatrist, although you may remind the patient of some of those strategies, but there may be somebody else in the team that's really going to focus on this, discussing a new way of looking at recovery from spine pain and problems. Other thoughts? No, we have another question for, just so we don't run on a clock here. Question to Dr. Zorovitz, I'm going to combine the questions from Dr. Pichica and Dr. Schenk into this idea of, so working on this toolkit about how to think about and structure and present ideas of comprehensive stroke care over time and rehab, and will the toolkit idea, will the structures, will there, how do you present information on people on how to really integrate physiatry into care? And Dr. Pichica is asking about people who are more freestanding and not connected. How do we, as a society and as individuals, get to where you were talking about in the end of your talk about that physiatry has to be involved in the long-term care of this patient, and we need to think about longer-term trajectories and function, not end stroke units or stroke centers at sort of transfer to rehab. That's the beginning of the journey for the patient at that point, not the end. How do we get there? So, know your system. I think that was kind of the interesting, I think that's one of the things, know your system. What you can do is, I mean, this is education largely, so I think one of the things you do is you go to your bigger referral sources and talk, you know, get yourself, you know, again, you have to, if you want to be the driver and you want to be the windshield, you know, say, hey, I want to do a grand round, so you can talk about the value of PM&R, so that they get to know you. Then, if there's the possibilities, you know, of doing more than just, you know, maybe having a nurse liaison and being able to get out, and again, this is, there's a lot involved in this because it would mean getting credentials in the hospital, also getting the buy-in of your own rehab hospital. I mean, if you can start bridging those gaps, you know, those are all, I think, very, very good steps, but I think the major thing is get people to know you and what you do and show that, you know, what you do has value. All right, thank you. I think we're nearing the end. I think I would add to Richard's statement, this idea that, like, we have to be useful, right, as a society. People ask me for years, how do you survive in a value-based world, and I said two things. One, either own a population or solve problems, right, so stroke, we can own the population. Back then, we can own, but in so doing, we take care of difficult problems for our patients, for our colleagues, for our health systems, for payers. These are complex patients that we have skills, we have skills that help with them and make ourselves useful so that we're actually making things better, and then people will find us essential. Any other comments from the group before we let people go? Thank you so much. Thank you all for your time and attending, and great talks from everybody. I really appreciate it. You are phenomenal colleagues and collaborators. I appreciate it. Thanks.

value-based care

physiatry

proactive

interdisciplinary teams

rehabilitation

patient outcomes

collaborate

evidence-based interventions

healthcare professionals

changing landscape of healthcare