Patient-Focused Coordination for Improved Surgical Outcomes

Coordination between many different providers, the patient, and home caregivers is essential to a strong recovery after surgery. At TriHealth in Cincinnati, standard tools in Epic and care team communication improved colorectal surgical outcomes across the board, with three fewer hospital days, 62% fewer surgical site infections, and 41% fewer readmissions.

TriHealth’s patient-centered surgical home program standardized each step of surgery, focusing on the patient’s goals for recovery. Before surgery, a nurse navigator collaborates with the patient to address comorbidities and risk factors in the post-op care plan. During and after surgery, a care pathway in Epic helps the surgical and post-op care teams follow best practices and track the patient’s progress while reducing unnecessary costs and variation in care.

On the recovery floor, a discharge care navigator recaps the patient’s at-home care plan with the patient and nurse. The navigator reaches out three days after surgery to check in on the patient’s needs and care experience, and follows up 30 and 90 days afterward. The navigator also summarizes the patient’s progress for the surgeon, PCP, and patient 45 and 90 days post-surgery.

In addition to clinical outcomes, TriHealth saw improved patient satisfaction and reduced costs from the surgical home program.

The program helped garner TriHealth a HIMSS Davies Enterprise Award in 2018.