The Evolution of Care Coordination at Ambulatory Surgery Centers

Feb. 4, 2022
Andrew H. Lovewell, administrator of a Columbia, Missouri ASC, sees ASC leaders increasingly moving towards comprehensive care management as a key component of a high-quality care experience

By Andrew H. Lovewell, MHA, MSHI

Over the past decade, many procedures once performed in hospital outpatient surgery departments have moved to ambulatory surgery centers (ASCs). As of 2017, more than half of outpatient surgeries were performed in an ASC, up from 32 percent in 2005.

Despite a temporary, pandemic-related drop in surgical cases, ASCs will likely see a steep rise in volume in the next few years, caused in part by regulatory changes. CMS has continued to modify the Outpatient Prospective Payment System and ASC Payment System to allow for more complex musculoskeletal cases to be performed in both hospital-based outpatient departments (HOPDs) and ASCs when clinically appropriate.

As ASCs take on ever more complex surgical procedures, the need for postoperative care coordination is growing. Given a health plan’s typical fee schedules, however, there is rarely additional reimbursement to be gained from providing care coordination services. As a result, many ASCs have continued to operate as usual, despite a clear demand for a more holistic, long-term approach to care management.

In the next few years, more and more ASCs will begin to realize that comprehensive care management is now an essential component of a high-quality, affordable care experience. The time of purely transactional surgeries has long since passed. To build a sustainable business, ASCs must embrace patient-friendly practices and scalable digital technologies that will allow them to thrive in a crowded market.

Quantitative data on patient progression

At The Surgical Center at Columbia Orthopaedic Group, we’ve found that providing effective aftercare can become a staple of one’s brand. Almost two years ago, we launched a digital care management platform that connects patients to our care team throughout their episodes of care. Before surgery, patients log on to learn how they can prepare themselves and their homes in advance. After surgery, they log on throughout their recoveries to watch exercise videos, ask our team questions about their concerns, and stay engaged in achieving their recuperation goals.

The platform creates a direct conduit for our providers to get instant, quantitative feedback on how patients are progressing. Previously, we assessed patient outcomes in a much more qualitative manner, relying on our clinical expertise as well as what was essentially anecdotal evidence from the patient’s postoperative visit: “My knee feels so much better.” 

Now, our joint surgeons can see actual data points on their patients’ progress both individually and as a collective, which drives protocol improvements. Surgeons can log into their dashboards and view their patients’ outcomes as compared to their colleagues’ patients, which leads them to ask more questions about best practices. Perhaps they decide to send patients directly to outpatient physical therapy instead of outpatient home health services, or perhaps they notice a correlation between a certain preoperative medication and reduced postoperative swelling. Having actionable recovery data at our fingertips has helped us identify and implement a variety of care path improvements.

Our care management platform also lets us track additional KPIs that can directly impact care quality. For example, we send our surgeons monthly reports with data points, such as how often their patients log into the care management program and the number of exercise videos they’re watching, which gives our staff new insights into overall patient engagement levels. By identifying three top priorities for each surgeon every month, we’ve built a culture of continual improvement in which we’re all working in tandem to improve care delivery at our facility.   

Patient education is key to improving outcomes

Comprehensive patient education is essential for outpatient surgeries, but the process is often quite time-consuming. Five years ago, our standard of care included a preoperative patient appointment in the clinic, during which the doctor would explain the surgical process and share next steps. The doctor’s staff gathered patient lab work and clinical data and served as a conduit for questions. Despite this investment of time and resources, we found that patients often didn’t remember all of their instructions, due in part to the timing of delivery. Contrary to popular belief, research suggests that patients only remember 49% of the information their doctors deliver in person.

Our care management platform corrects this retention gap by using short, relevant videos that minimize the patient’s cognitive load—content is parceled out on a need-to-know basis at the best time in the process. Transitioning so much of our resource-intensive manual interventions onto a technology platform has helped us create a more sustainable, scalable system. Instead of delivering the same information to countless patients over the phone, our staff now allocates their time to those patients who need extra help, while our doctors have more time for patient care.

Surgeons also monitor how quickly their care teams respond to patient messages on the platform, critical for reducing readmissions. A huge percentage of readmissions are avoidable and are driven primarily by a lack of knowledge and connectivity. In the past decade, we’ve had many patients visit the ER to address superficial concerns, such as blisters beneath their wound dressing, or drainage from the incision site.

Now, patients are more adept at determining what is normal and what isn’t. Patients who need help can send us pictures and messages via the platform, and our nurse navigators follow up with them to alleviate their concerns. By teaching patients how to get the answers they need, we help them avoid unnecessary trips to urgent care or potential complications down the line. Our infection rate was already quite low, but it’s dropped to zero after we implemented digital care management.

By using patient feedback to develop and tweak our own custom protocols, we’ve arrived at a system that delivers excellent results for our patients while reducing care variation. Our protocols get patients up and moving as quickly and as safely as possible, because ambulation is the key to recovery. The digital care management platform supports patients through the process of beginning to walk and move around, with step limits to ensure their safety and an interactive approach to pain monitoring and management. 

The value of an exceptional patient experience

For years, ASCs have enjoyed a reputation as being much more cost-effective for patients than inpatient surgeries, as we deliver on a value equation that hospitals cannot touch. The research bears this out: Orthopedic day surgeries at an ASC enable 17% to 43% direct cost savings when compared to inpatient treatment.

Due to consumer trends and the steady rise in volume, some ASCs have become complacent about enhancing the patient experience. This inertia is compounded by the fact that ASCs typically lack visibility into the patient’s complete care journey, as they see only one step: the surgery. With our digital care management solution, we are now able to maintain a connection with patients past the episode of care. If a patient falls, dislocates a joint, or suspects a potential infection, we’re likely to receive a question via the direct messaging component of our care platform.

In my opinion, ASCs that fail to provide quality care coordination do a disservice not only to their patients, but also to their businesses. While quality aftercare does not necessarily bring direct reimbursement, patients who benefit from an exceptional care journey become deeply loyal customers, who are then likely to share their experiences with friends.

Our patients love the sense of teamwork and connection that our digital care management system brings them, as we can all see their steady progress toward their recovery goals. They also appreciate the cost and time savings of virtual rather than outpatient physical therapy. Their enthusiasm is reflected in our patient-reported outcomes response rate:  an impressive 96% of our patients take the time to complete a one-year postoperative outcome assessment via the platform.

As a result of our productivity improvements, patients now flow through our clinics much more efficiently, which has in turn increased overall capacity. Since implementing our digital care management platform three years ago, our total joint and spine case volume has more than doubled.

In the next decade, outpatient surgery volumes will continue to climb, and the market will respond with additional competitors. ASCs that provide their patients with more value than their peers—by establishing evidence-based care management systems and implementing patient-friendly policies like transparent pricing—will be well-positioned for growth.

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Andrew H. Lovewell, MHA, MSHI, is the administrator of The Surgical Center at Columbia Orthopaedic Group in Columbia, Missouri.

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