How to Use the CMS H&P Exception to Improve Surgical Pre-Assessment Caseload by +60%

By Dr. Gajan Srikanthan, Medical Director, Lumeon

Even before the COVID pandemic took hold, CMS revised the hospital requirements for comprehensive medical history and physical (H&P) examinations. Recently, the rules were relaxed so that organizations no longer had to implement an H&P 30 days before a procedure if not necessary, but why change the processes, and what is the benefit? 

The CMS and The Joint Commission updated their requirements for ASCs and hospitals to ensure all patients have a comprehensive medical history and physical examination with the objective of removing those that were identified as “unnecessary, obsolete, or excessively burdensome on health care providers and suppliers.” The agencies also wanted to increase the “ability of healthcare professionals to devote resources to improving patient care by eliminating or reducing requirements that impede quality patient care or that divert resources away from furnishing high quality patient care.” 

My conclusion has long been that the elimination of non-indicated tests in low-risk patients promotes patient safety, improves quality of care, and results in substantial cost savings – here is more support for that view. Getting buy-in to change the process is often hard, but given the increasing need to drive efficiencies and deal with having insufficient nurses and burnt-out staff, the justification for doing just that is becoming much stronger. 

Here’s an example: 

Before the pandemic, one of our IDN clients developed a new model of PAT assessment that had proven to reduce delays and cancellations and provide a high level of quality and safety to their patients. This nurse-led approach centralized the H&P (History & Physical Assessment) and used face-to-face visits within the 30-day window to ensure that every patient was properly prepared and ready for surgery. 

Their challenge was that they didn’t have enough nurses to handle the caseload. “The approach worked, but we couldn’t resource it to the scale we needed to handle the volume of patients we had to deal with,” they told us. As a result, a steady 30% of patients were optimized by their PCP or surgeon, resulting in inconsistent quality and avoidable issues on the day of surgery. 

When the pandemic hit and providers faced a tsunami of COVID patients at the same time as sudden and rapid attrition of the nursing team, the CMS rule change has given providers the opportunity to be more selective about who they bring in for an H&P based on a combination of the patient presentation and the procedure. 

This change allowed the team at the IDN to partner with Lumeon to deliver a triage algorithm that proactively identified high-risk patients who required a formal H&P, while lower-risk patients were “fast-tracked” through surgical pre-assessment and received a much more focused day of surgery H&P. The Lumeon system determined risk by scanning the patient’s medical record for problems, allergies, medication, and recent lab results on file, combining these with a digital assessment sent to the patient. All this was done in compliance with the history and physical requirements from The Joint Commission and CMS hospital conditions of participation. 

Within three months, the pre-assessment nurses went from performing a full H&P on all surgery patients to only doing so for about 30%, with the rest being managed by digital chart review and phone calls. 

The reduction in average time spent with each patient meant the team was able to free up capacity by over 60% and see more patients through their PAT process, reducing inconsistent care and also being able to traverse some of the operational issues brought on by the pandemic. They told us: “The solution transformed how we deliver care up to the day of surgery, within a week of it being activated. The patients love it, it completely eliminates unnecessary tests and visits to the clinic, and the anesthesia team has been freed-up to focus their attention only on those patients that need it.” 

Some may question the approach of fast-tracking low-risk patients. What happens if the risk determination is incorrect?  

Well, there was always a safety net in place. ALL patients received a digital chart review at the very least by a clinician, who could override the system-derived risk profile and assign a patient to the most appropriate level of review. Interestingly, when we looked at that override rate, it varied between 2-5%. When we looked at this for a cohort of 30 low-risk procedures, the override rate was just above 1%! It did make us wonder whether the review step could be removed for a defined list of low-risk procedures, as long as there was some element of a ‘day of surgery’ review? 

We understand that selectively changing how patients are optimized on a case-by-case basis could be burdensome from an administrative and operational point of view. But, if done well with the right level of automation and the support of Lumeon, this can represent a substantial improvement in clinical efficiency and patient experience. 

Contact us today if you would like to discuss how Lumeon can help your organization maximize the benefits of preoperative optimization.