The Indian Health Service (IHS) provides health care to 2.2 million American Indian/Alaska Native (AI/AN) people from 567 federally recognized tribes. Care is provided in many different settings including large urban referral hospitals, smaller hospitals and clinics on reservations, and at home in remote areas.1 Providing high quality surgical care can be challenging due to a variety of factors facing the IHS. Compared with other Americans, AI/AN people have lower health status with shorter life expectancy and disproportionate burden of disease. For example, mortality rates for AI/AN people are higher than other Americans for cirrhosis, diabetes, and trauma (including suicide, homicide, and unintentional injuries).2 Per capita expenditures per beneficiary for the IHS are markedly lower than other programs; IHS users receive about ~$3000 per user which is half that for Medicaid and Veteran users.3
Phoenix Indian Medical Center is a 127-bed hospital that serves 140,000 AI/AN patients from Arizona, Utah and Nevada, who represent over 67% of all federally recognized tribes. In 2013, the General Surgery department at PIMC recognized a need for improved high quality, coordinated, patient-centered care. We were also concerned about a lack of peri-operative resources needed to care safely for surgical patients. In response, we founded our Peri-Operative Surgical Home program, to which we refer as POSH.
The core POSH function is the Assessment and Planning (A&P) process. After initial communication between the surgeon and primary care provider, the patient is referred for the A&P process. Patients are selected for the program based on complexity of co-morbidities and/or operation. Departments contributing regularly to POSH include surgery, primary care medicine, hospitalist medicine, anesthesia, operating room staff, central supply, inpatient nursing, pharmacy, physical therapy, respiratory therapy, case management and behavioral health. Patients are first discussed to determine if we have the resources to safely care for the patient at PIMC. If we do, then plans are made for pre-operative optimization and testing, intra-operative plans, and post-operative course.
Through the A&P process, we have identified many opportunities for building capacity at PIMC. We have developed clinical pathways based on enhanced recovery protocols and implemented a formal early mobilization program for all admitted patients. POSH developed an educational program, “POSH U,” that is designed for all members of the team with continuing education credit. POSH leverages technology to support our goals; the Electronic Health Record is used for documentation and order sets, and a public website gives staff access to all POSH resources from any computer.
In 2015, POSH was recognized as a finalist in the annual HHS Innovates contest, designed to encourage innovation within the government, and was honored as the Employees’ Choice of the finalists. We are currently at work on a formal outcomes project in order to rigorously examine the impact of POSH on patient care.
POSH receives no institutional funding or additional staffing; this has required us to be creative and to maximize use of our existing resources. We began with a meeting in a basement conference room with fifteen staff members and have grown organically to encompass the entire institution as team members have become increasingly engaged and excited. POSH has reorganized, reinvented, and repurposed disparate processes, equipment, staff, and time into a unified, innovative program with a single mission of excellent patient care. We believe POSH can be one solution to the challenge of providing high quality surgical care in the U.S. and especially within resource constrained environments.
- IHS 2015 Fact Sheet. Available at https://www.ihs.gov/newsroom/factsheets/disparities. Accessed 3/13/16.
- Mortality Disparity Rates Fact Sheet. Available at https://www.ihs.gov/newsroom/factsheets/disparities. Accessed 3/13/16.
- Skinner D. The Politics of Native American Health Care and the Affordable Care Act. J Health Polit Policy Law. 2016;41(1):41-71.