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The comparison group of patients was chosen to match the type of operation, and the hospital where they had surgery. Though the prehab patients were only in the program for an average of two and a half weeks before surgery, the program was associated with statistically significant changes in several measures
In addition to the total cost and hospital length of stay differences, the patients in the program were less likely to need home health care after they went home, with 24% of the prehab patients receiving it compared with 29% of non-prehab patients.
However, the prehab patients had about the same rates of nursing home stays, visits to emergency departments and additional hospital stays after they left the hospital. Next steps
Englesbe worked with two Surgery residents who are the lead authors of the new papers – Charles Mouch, M.D., on the statewide study of the MSHOP prehab program, and Mary Shen, M.D. on the framework for incorporating positive psychology into the care processes for surgical teams.
Although prehab programs at many of the participating hospitals ended or scaled back when the study ended, the U-M team has made MSHOP part of the standard of care for Michigan Medicine surgical candidates who have a higher than usual risk of complications. Blue Cross Blue Shield of Michigan supports the effort through a pilot payment project. A full kit of patient materials is available online.
In addition to incorporating more positive psychology aspects, such as having patients express their post-surgical goals and the steps they will take to try to reach them, the MSHOP program has evolved to allow patients to track steps using their smartphones and wearable activity trackers instead of providing pedometers. The program has even been integrated into the electronic portal that patients use, so that they can sync their step counts automatically from their device.
Surgical team members, from pre-op clinic staff to post-surgery rounding teams, are encouraged to work with MSHOP enrollees toward shared ownership of their surgical outcomes, and better wellbeing.
As more hospitals and health systems engage in national programs that incentivize the wringing of more value out of healthcare dollars – such as the Accountable Care Organization programs offered by CMS – Englesbe predicts that the business case for offering prehab will grow.
But in the meantime, he encourages anyone who is getting ready to have surgery to try to increase their physical activity, improve their nutrition, reduce or eliminate tobacco use and focus on their mental state.
For instance, as the team writes in their positive psychology paper, patients should be encouraged to actually write down their own goals for life after surgery – what activities they hope the operation will allow them to do again or more fully, or life events they are looking forward to.
They can also write down the specific steps they will pledge to take to help them attain this – for instance, a physical activity goal or new nutritional habit. Another great step is to write down the names of their family and friends who will support them before and after surgery, and their roles, and to share this with the care team.
If information like patient goals and support people makes it into the patient's medical record, members of the care team can use it too. For instance, they can use the "time out" that precedes the start of every operation to review not only what operation they're doing, but the goals of the patient having it. Or they can use it when doing rounds in the hospital, to prepare them to have a more engaging conversation with the patient.
As they write in the paper, teams should remember that they're not just doing surgery to solve the patient's physical problem, but to help the person who has the problem. Source:
Michigan Medicine - University of Michigan Journal reference:
Mouch, C. A., et al. (2019) Statewide Prehabilitation Program and Episode Payment in Medicare Beneficiaries. Journal of the American College of Surgeons . doi.org/10.1016/j.jamcollsurg.2019.10.014 .
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