Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:
- Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;
- Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;
- Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or
- Implement processes to ensure effective communications and education of patients’ post-discharge instructions.
ObjectiveParticipate in a Perioperative Surgical Home (PSH) model to improve coordination of patient care through the acute-care episode, recovery, and post-acute care.
Evidence of participation in a PSH model that provides a patient-centered, clinician-led, interdisciplinary, and team-based system of coordinated patient care. Include at least one of the following elements:
1) Coordination with care managers/navigators in preoperative clinic – Documented conversations with care managers/navigators (e.g., electronic health record note) to plan and implement comprehensive post-discharge plan of care that could take into account patients' post-discharge environment and support system out of the hospital; OR
2) Perioperative care process improvements – Documentation of evidence-informed perioperative clinic and care processes implemented to standardize care across the spectrum of surgical patients (e.g., workflow diagrams, word document of written policies and procedures); OR 3) Patient education and improvement – Implement processes to ensure effective communication of and education on patients' discharge instructions, taking into account patients' literacy level, language and communication preferences, and cognitive or functional impairments.