It is predicted that by 2030 in the United States, almost 20% of the population will be over the age of 65, and this age group will consume approximately 50% of the US healthcare budget. Surgical complications are one of the most expensive, preventable aspects of this cost. The most common complications in the surgical geriatric patient are pulmonary (7%), cardiac (12%), and neurologic (15%) [10]. Given this data, it is apparent why the geriatric population has been the most appropriate target for most of the PSH initiatives to date. Orthopedic surgery in particular has lent itself to surgical home techniques given the vulnerable patient population and long-term impact on quality of life.

While increasing physiologic age confers added risk [11], it remains apparent that comorbidities and type of surgery confer a greater risk [12]. As we transition philosophically from concentrating on mortality to considering morbidity-associated quality of life, risk stratification becomes increasingly important in preoperative decision-making in regard to choosing the right surgery or surgery at all. Frailty is increasingly becoming recognized as an independent risk factor and a target for many surgical home initiatives. According to the National Surgical Quality Improvement Project (NSQIP) database , 7.4% of patients from home undergoing elective vascular procedures did not return home, with frailty conferring a twofold increase in nonhome discharge [13]. The majority of patients undergoing joint replacements are elderly, and in this population, frailty confers increased risk of 1-year mortality, admission to an intensive care unit, length of stay, readmissions, and discharge to institutional care, thereby increasing costs and decreasing quality of life [14]. Preoperative assessment in a PSH could initiate components of prehabilitation to mitigate risk as well as coordinate planning for discharge with the patient and potential caregivers.

A large number of older patients who suffer a hip fracture have a significant loss of mobility and decrease in ADLs as well as change in where they live and other social impacts [15–17]. In the current environment, there are economic and quality pressures to decrease length of stay. Given the risk of loss of mobility and functionality, rehabilitation is a crucial part of long-term recovery. However, inpatient geriatric rehabilitation , while effective, can be costly and require a longer LOS. Utilization of aggressive home, multidisciplinary, rehabilitation services has had variable results with some studies showing a decrease in length of stay and improved ability to perform ADLs and decreased burden on caregivers, while others have shown no difference [18–21]. Additionally, models of early transfer to an intermediate care facility after acute hospitalization of geriatric patients have not been shown to decrease the number of days living at home during a year, but in orthopedic patients it may increase mortality [22, 23]. The variability in outcomes may be related to differences in baseline patient characteristics such as presence of dementia and differences in resources for a particular healthcare system in terms of inpatient versus home rehabilitation. This variability is the perfect opportunity and example of how a Perioperative Surgical Home could tailor the care for an individual patient in a particular system by assessing underlying risk and advising appropriate rehabilitation and discharge planning.

In developing a model of best teams, there is variability in the perioperative team members. Geriatric patients have a history of being particularly vulnerable and may be the “orphan” on a ward or in a preoperative clinic. The PSH allows for an opportunity to gather expertise in the care of specialized patients. The VA (Veterans Administration ) has instituted a robust medical home that uses patient-aligned care teams in which the registered nurse (RN) care managers provide continuity and coordination of care. The aging veteran population, much like the general population, faces increasing disability from chronic illness, cognitive decline, and increasing functional dependence in the last few years of their lives. Healthcare in these scenarios is often accessed during a crisis, at an emergency room or at fragmented multiple specialists’ visits. Implanting an onsite geriatrician and geriatric RN manager increased detection of dementia, decreased subspecialty clinic visits while maintaining primary care clinic visits, increased phone call contacts, and increased facilitated planned transitions [24]. Integration of a specialist in geriatrics may similarly augment thoughtful care coordination for a vulnerable patient population. This concept has been implemented in a number of different models including inpatient comanagement by a geriatrician with positive results including a decrease in LOS and delirium rates [25–27].

Patient-centered care and shared decision-making are other venues that are considered “low hanging fruit” for a geriatric surgical home. Elderly patients are at increased risk for postoperative complications not related to surgical sites, and when they do have complications, there is elevated risk of long-term and short-term mortality. For example, patients older than 66 years old who are on mechanical ventilation for greater than 96-h post-surgery have a fourfold increase in 30-day mortality. If they survive the traditional 30-day mark, they still have a fourfold increase in 1-year mortality with almost half dying at 1 year and significantly more living in a skilled nursing facility [28]. This in conjunction with the general feel that older patients, particularly those with chronic illnesses, have a tendency to emphasize quality of life over quantity provides an opportunity for informed discussion [29, 30]. Perioperative care coordination should include a detailed discussion prior to surgery with the patient and surrogate decision-makers in terms of likelihood of quality of life return. Discussion around specific scenarios such as prolonged ventilatory support needs to be conducted preoperatively which could mitigate some of the conflict and stress around decision-making after the operation.

To quote H. James Harrington: “Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” The PSH uses a multitude of techniques to achieve its quality improvement goals. Most institutions do not have the resources to try to acquire data and perform full overhauls of their perioperative systems. Their cost-effective pragmatic approach has been to choose a few service lines from which to learn how to capture the right data, analyze it, and make improvements. Based on the successes of these pilot projects, extrapolations can be made to the general perioperative processes when appropriate.

Data analysis is the key to providing the measurements, understanding, and decision-able options in order to improve the perioperative care. Acquiring data either from electronic health records or paper documentation and compiling it into usable information are a challenge for every institution. Data marts housed on separate computer servers have been advocated as the number crunching analysis of millions of points of data tend to slow down electronic medical record systems.

Six Sigma and Lean Management are two quality improvement concepts which share similar methodologies and tools. Six Sigma’s focus is on reducing variability and eliminating defects, while Lean Management’s focus is on eliminating waste and improving efficiency. Both use dozens of statistical tools as well as defined methodology to achieve their goals. Having access to talent and experience in both methods can facilitate change and improve value.