Recovery Is Now at Home. Is Your Team? (Strategies for Post-Acute Care Under CMS TEAM)

Episode Contents

• 00:00 Introduction and guest background
• 02:22 Redesigning surgical workflow around the patient, not the team
• 03:35 Why clinical workflows are built for the medical team, not the patient
• 05:02 Team-based and technology-enabled approaches to home recovery
• 08:24 How bundled payment models align incentives across the episode
• 09:55 Pre-habilitation and setting shared expectations before surgery
• 11:18 The counterintuitive reality: less utilization requires more effort
• 12:55 Achieving 90 percent same-day discharge for bariatric surgery
• 14:55 The year-long culture and buy-in effort behind protocol adoption
• 16:20 What it takes for digital health tools to move beyond a pilot
• 19:20 Redesigning the full surgical patient journey end to end
• 21:18 The burden of recovery shifts to patients and caregivers at discharge
• 23:24 Patient connection to the surgical team does not end at discharge
• 24:10 Patient-reported outcomes and the future of post-acute measurement

Key Takeaways

Drawing on his work leading the first randomized controlled trial of home hospital for surgical patients at Brigham and Women's Hospital, and an enhanced recovery initiative that achieved same-day discharge rates above 90 percent for bariatric surgery, Tsai makes the case that better outcomes require more coordination, not less, and that the infrastructure most hospitals rely on was built for the team, not the patient.

Transcript

Welcome to The Surgical Journey, a podcast about putting patients at the center of surgical care. From preoperative readiness to recovery at home, we talk about the real processes and data that shape outcomes. Each episode features conversations with health system leaders, surgical teams, and technology experts who are changing how patients move through surgery and recovery. At Novonav, we focus on making surgery easier for patients and their care teams.

That means clear communication, reducing administrative burden, and smarter use of data. In this series, you'll hear how that work plays out in real clinical environments. Let's get into the conversation with our host, Lisa Miller. So welcome to The Surgical Journey podcast, a podcast by Novonav.

I'm Lisa Miller, your host today. I'm really excited to have Dr. Thomas Tsai joining us. Dr.

Tsai, thank you for being on The Surgical Journey podcast. Great, thank you so much, Lisa. Great to be here with you. I want to give a little background and we'll jump into some questions.

So I have the privilege of sitting down today with one of the most influential voices in surgical quality and health policy in the country. Dr. Thomas Tsai is an associate professor of surgery at Harvard Medical School, an associate professor at the Harvard T.H. Chang School of Public Health, and the medical director of health policy research at the American College of Surgeons.

Dr. Tsai's work sits at the intersection of surgery policy and delivery innovation. At Brigham Women's Hospital, he led the first randomized controlled trial home hospital for surgical patients in the country and ran an enhanced recovery initiative for bariatric that resulted in same day discharge above 90%. He's also served on the White House COVID-19 response team and advised the Obama administration on implementation of the Affordable Care Act.

And he also works with the team bundle payment model and implications of CMS phasing out the inpatient only list and how that's shaping surgical programs across the country. So with saying all that, today we're talking about what it means to redesign the surgical patient journey, how policy and payment models are changing, where and how patients recover, what it actually looks like to, you know, build those reliable care pathways. It's the second time I've had the opportunity to speak with you, Dr. Tsai, so thank you again.

I'm gonna jump right in. You led the first randomized control trial, like I said earlier, of the home hospital for surgery patient at Brigham Women's. As more procedures moved to outpatient settings and patients recover at home, what needs to change about how surgical teams manage that recovery when they can no longer see the patient every day? Yeah, thank you, Lisa.

The work that we did on the surgical home hospital occurred while I previously served as the director of clinical care redesign at Brigham Women's Hospital. And we really thought of it as truly redesigning and transforming care. That means what are we designing to and transforming towards? And I think starting with that premise is the most important part.

And that premise is a more efficient and patient-centered experience for our patients undergoing surgery. So the key lessons from that work was that in order to have optimal recovery under a home hospital program, or even just in the home setting, is that we need both a team-based approach and a technology-enabled approach. And the real opportunity is actually rethinking our clinical workflow to match the optimal patient experience, as opposed to a workflow that's designed to suit the efficiencies of the surgeon, as opposed to the efficiencies and recovery of the patient. An example of this is we learned from the home hospital program is that we don't actually have to round at 6 a.m.

in the morning anymore when the patient is actually at home. We do that with the patients in the hospital because the team has to round, put in orders, see the patients in the pre-op area, and rush to the operating room by 7.30, which is the case at most hospitals. So you're waking up patients at 6 a.m., sometimes waking patients up at 5.30 a.m., for the interns and students to pre-round and collect vital signs. So all that workflow is geared towards the medical team, but not the patients.

And one of the opportunities for home hospital was to reconfigure the care around the patient so we could actually let patients have a sound night's sleep, which is important after surgery, and round at a reasonable time. So I think that's one very small, but a very real example of redesigning the workflow. But the team approach is also important, too, because as the patient leaves the hospital, is recovering at home, you're depending on a broader team of providers to manage the patient. So we did a lot of collaborative workshops with our internal medicine colleagues, our advanced practice provider colleagues, our paramedics, to educate them.

Our initial trial was on bariatric surgery, so educating them on the expected recovery, the opportunities to watch for complications and how to manage them. And then the technology becomes important. The technology is meant to enable the new workflow, focus on the patient, and not just replace the old workflow. So I think that team-based approach, tech-enabled approach, but focused on the patient are the real opportunities.

So that's probably one of the most practical answers I've had on something similar. I mean, these questions were geared towards you, but you've answered so practically. I love the specificity, so thank you. Because the rounding, you know, like everybody, we've all had family members in the hospitals and either we've stayed over a night or we're rushing to get back, right?

Because like my mom, for instance, like, you know, I want to hear what the doctors say and I got to get there at 6 a.m. or something, and, you know, like, or I'm staying over. And that's a really good point, because at home, probably too, the family members can be part of that conversation easily. Like you said, designing around family care as well as the patient care.

So I love that point. And I just want to make, I have one quick follow-up question. You mentioned collaborative workshops. So can you just speak a little bit to that?

Because that's really interesting, because you're saying that you had all these, you know, different teams and now you've got a workshop. I would imagine, like you said, you're probably teaching paramedics what to look for, but that had to be met new, right? You had to design those workshops too, right? Yes.

Yeah, so, you know, when we, in the hospital, patients are managed by either our resident teams or our advanced practice providers. Now hospital is mostly physician associates or PAs, but they have been working as part of our teams for years. Residents are part of our training programs for five years, you know, under the supervision of the attending surgeons. So that's been the paradigm of how we pass on the knowledge of how to manage our patients post-operatively.

So this required actually a new paradigm of how we actually very quickly build the trust and rapport and also the collaboration with our other medical specialty colleagues. So again, the example of the Bariatric Home Hospital Program, we designed custom presentations, again, focused on the patients, like this is what the patient experiences, these are the symptoms, these are the expected diet, these are the warning signs we look for. So both from a patient's perspective, as well as the surgeon's perspective, these are the important things we watch out for for complications, you know, whether it's a sign of dehydration, a sign of infection, a sign of bleeding. A lot of our patients are actually medically complex.

That's why they're getting the metabolic bariatric operations not just for obesity, but because they have diabetes or heart disease or pulmonary disease, really working with our colleagues to learn together how we can provide the best care in this sort of new patient-centered, home-centered way. Yeah, thank you for that follow-up. I spoke with Fred Nice yesterday, and he talked a lot about the patient experience and how the clinical workflow should to be thinking about patient experience as well. So, and I love the learning together, which is so important.

So question two, your work on the team bundle payment model ties surgical outcomes directly to episode spending. How should surgical programs be thinking about the pre-op, post-op window as a lever for both better outcomes, better performance under bundle payments? It's a lot there, but I think you're very, very work-versed in the new team bundle payment to respond. The idea of the team bundle payment program, and actually all the bundle payment programs, is how do we actually align the incentives together for the care the patient's receiving during the inpatient phase, the hospital phase of care, along with what they're experiencing in the post-operative, post-acute care phase when they leave the hospital, whether it's at home or they leave the hospital or a nursing home or rehab facility.

The goal is, can we provide more efficient care, higher quality care, if we are able to align the incentives of all the providers that patient encounter along the way? So in particular, as you mentioned, there are important opportunities or windows to be able to improve that experience for patients. Pre-operatively, it's important to think about pre-habilitation. How do we actually get patients, especially for elective surgical procedures, in the best shape possible?

I often explain to my patients, we need the right surgery for the right reasons, the right indications, and also the right time, so when they're actually ready for it. So again, for bariatric surgery, often we'll work with our patients to optimize their diet and their nutrition, make sure they have all the resources they need at home lined up to have the optimal recovery to prevent complications in post-operative period. But there's also, importantly in the pre-op period, shared expectations. I think it's unrealistic from a health policy side or the clinician's side to say, we will reduce nursing home use by X percent or reduce readmissions by a Y percent.

The patients don't know that. So I think it's important to set the right expectations up front of, this is what optimal recovery could look like, and this is how we're gonna work together to make sure that you can have the optimal recovery. That was actually an important conversation we had with patients as we moved towards an opioid or narcotic-free pathway of recovery for our patients is that we can actually use lots of different ways to manage your pain, that we don't have to default to a narcotic pain medication, and giving that buy-in from patients ahead of time is really, really important. Post-operatively though, I think one of the most important, again, counterintuitive, I think a lot of the health policy I think is that less is more, that with funnel payments or other programs, we can use less and less care.

Less care, less post-acute care, less readmissions, and less nursing home use doesn't mean less effort. I think that is a big difference. Utilizing less care for the patients may actually require more effort on the part of both the patient and the clinical providers. I think that is a important thing to appreciate is that more effort may mean more investment on the part of the hospital.

Team actually allows for gang sharing, sort of like shared incentives between the hospital and the surgeons, because in order to prevent a patient from going to the emergency room for dehydration, you need that close follow-up with the patient, whether it's phone calls, having them come to the office for labs and evaluation, setting up an outpatient infusion center for your patients. So it may actually require more effort, even though the goal is less utilization. So I think it's really important to kind of focus on what we're trying to solve for and how best to do it. Yeah, that's great.

I love the fact that it's not less effort, in fact, it's probably going to take more resources, more thinking, more collaboration, it's overall more effort. That's a great point. I probably need to be talking about that more often. So you led an enhanced recovery initiative for bariatric surgery, that same day surgery discharges above 90%.

So that consistency is pretty remarkable. And so what did it take to make that protocol reliable and where did technology fit in kind of sustaining that at the execution, making that at scale, right? Succeeding in scale? So I think there are a couple of elements.

First, we wanted to pull together the best evidence-based guidelines around the recovery around the country. So I met with colleagues from hospitals around the country to learn which of the protocols they were using and where they were seeing successes and where they were seeing sort of areas for improvement. So one is just bring together the best evidence-based guidelines. And as much as we tried to standardize our enhanced recovery protocols at our hospital, Brigham and Women's Hospital, which is an academic teaching hospital and the sister hospital, Brigham and Women's Faulkner Hospital, which is a community hospital just a couple miles down the road, we also wanted to preserve flexibility.

I think that's also an underappreciated element of any kind of quality improvement effort is while there's an important role for standardizing unnecessary variation, there's also necessary variation. The big teaching hospital has a very different mix of patients, very different staffing and resources than a community hospital does. So how do you actually apply the best in-class evidence, but implement it in a way that is actually feasible and optimal for a local situation? So that required, in our case, the buy-in with our anesthesiologists, our post-operative nurses, our surgical ward nurses, our surgeons, our physician assistants, our residents at all the different sites, and most importantly, our patients to make sure that everybody was on board.

So it was a year-long effort and to really create that culture and the buy-in. So I think it was as much of it was the what to do, like do we need to give this medication ahead of time and to prevent post-operative vomiting, like what the actual pieces of the protocol were, but that's not the secret sauce. The secret sauce was making sure that people view this as a priority and it was not just our priority for the surgeons, but it was like their priority as part of this broader initiative focused on providing more efficient care for the patients. And in this case, the incentives were very much aligned.

It was better for patients. It was better for the hospitals, especially this happened in a time where we had a hospital capacity challenge. This was during the time of COVID actually when we launched our enhanced recovery protocol. So it allowed opportunities for other patients who needed to be in the hospital to be taken care of.

So that really, that shared approach was critical. As a follow-up to that, I think it goes really nicely and you've started to answer it a little bit. So what does it really take then for a digital health tool or technology to move beyond a pilot and then actually become part of how a surgical team delivers care every day, right? How do you move that?

And it sounds like you have great experience in that just based on what you did on the enhanced recovery initiative. Yeah, so I think it's two ways. I have to think about what this means for the clinician's workflow because that's how the digital care journey gets adopted and implemented from the surgeon or the healthcare provider side. So as I mentioned with the home hospital program and our enhanced recovery program, the goal isn't to just add technology to your existing workflow.

The idea is how to use technology to change and optimize the workflow for the benefit of the patients. The second piece of that is the focus on what this means for the patients. So whether it's home hospital programs with remote patient monitoring or enhanced recovery protocols with a patient engagement and digital care journey platform. As mentioned, part of it is optimizing the patients ahead of time.

So how do you deliver the information, the expectations for the patients ahead of time, what to expect during surgery, after surgery. Also following a patient through that journey with technology, being able to deliver information to the patients when they're home, using the tools to assess how the patients are doing when they're home. So I think these are all the important opportunities. But again, the goal has to be tailored to both the clinician's ability to use them.

And then secondly, tailored to the benefit for the patient. Are you surprised or maybe some physicians themselves or clinicians surprised generally isolate physicians, but generally speaking, people in hospitals that when they use a digital health technology, right? And it works. Do you find that they're surprised?

It's almost like the light bulb goes off and they're like, wait a minute, wow. Maybe there wasn't resistance or maybe I didn't know about it. Do you find some of the light bulbs that go off? Oh yeah, absolutely.

I think that's the, there are all these, I think opportunities for very kind of pleasant surprises is like how you, I should say, I wish there was a tool that did this, where like, well, there actually is a tool that I had that does this. So even the challenge facing surgeons and clinicians or generally in America is not a lack of tools, is how do we actually pull together the tools, or to use a sports analogy, there's no shortage of plays, but the challenge is what's the right kind of game plan or playbook that you pull together. So I think that's the key thing is how do we actually leverage all these different tools to help patients recover faster and help surgeons deliver more efficient care. A lot of this will require integration into the EHR, into their, again, adding in a good way, I don't mean adding in the sense of more work, adding meaning complementing their existing workflows, I think that is the critical piece of it.

So the last question I have for you, so maybe just spend a few minutes on this one, you've spent your career at the intersection of surgery policy and delivery innovation, right? So if you could redesign the surgical patient journey, which you've spoken about all through this conversation, from the first consultation through recovery, what would that look like? And where are those gaps today? Yeah, I think we actually have a lot of the elements of it, but in some ways by circumstance and not by design, but the opportunity is being able to do it by design and pull it together in a streamlined way.

Right now our patients come see a surgeon to see from a referral from a primary care doctor or other specialists to see if they qualify for surgery, or that there's a consultation with a surgeon that's shared decision-making, which I think is critical, but increasingly there's an additional visit for preoperative testing that is being done, and there's opportunities actually to coordinate that, to make sure that that is streamlined for the patient, so they're not seeing multiple providers just to try to get to the care that they need. The operations themselves, I think, have made incredible progress in being more streamlined through minimally invasive procedures, that's why our life-to-stays have decreased so much over time. That's why we're also shifting from surgeries being conducted on the inpatient setting to the outpatient setting, because we've optimized a lot of our outcomes. But I think the biggest opportunity is in that post-operative phase, is once a patient is home, is making sure the patient doesn't feel that they're on their own, and I think that's gonna be increasingly important as care shifts out of the hospital setting to the outpatient setting, where what was happening in the hospital with nursing or a physical therapist, or the surgeon team rounding on the patients, that burden of recovery is now on the patient or their family and their caregivers.

So how do we actually alleviate the burden on the patients themselves, and also on their caregivers? Some of that is preparation we can do ahead of time, and the idea of using digital care journeys to help patients navigate, that is incredibly important, but especially in post-operative phase, having a link back to their surgical teams. As we said earlier, sometimes the more efficient care is actually more effort. So how do we actually link the patients back to the care teams in a way that they're not just playing phone tag, trying to get to somebody who can answer the questions, and they didn't end up in the emergency room anyway?

That is, how do we actually redesign the care so we're meeting the patients where they are, and not waiting for the patients come to us when there's a problem? Right, and so in that example of like phone tag back and forth, or even the portal, right, where something like, you know, of course, we're in NovoNav, we're able to kind of have that communication in our technology. I have found, or I've seen, like you said, you want the patients to be comfortable. I think that's a way to get them to feel comfortable because they know they're connected, and they know that that information in the technology is real time, or they can put their information in an alert.

And then for you or your team, really you can manage by seeing what are the most important aspects, right? What do we address? So I think just to, you know, bring that full circle, I would imagine the patients feel good. I mean, you have a better experience on that, but do you feel that they've adopted, they're adopting that as well on the patient side?

Yeah, no, absolutely. I think that the key point you made there is connection. Patients want to feel connected, and they should feel connected to the system. So once they leave the operating room, doesn't mean that the connection to the surgical team ends.

And the challenge and opportunity is how do we use digital patient engagement platforms, digital care journey platforms to maintain that connection with our patients once they leave the hospital. And on that same point, that's why it's increasingly more important to think about how we measure the patient experience with patient-reported outcomes. That will be increasingly important as care shifts out of the hospital into the outpatient and home settings. Yeah, I think that's a great way to wrap everything.

It's true, I think maybe in a whole nother conversations about patient-reported outcomes, I probably could take up another podcast, but Dr. Tsai, thank you for your time. I appreciate it, and we'll talk soon. Great, thank you so much, Elisa.

Thanks for listening to The Surgical Journey. Join us next time as we continue examining smarter, more connected approaches to perioperative care.