New Multidisciplinary Clinic Aims to Improve Surgical Outcomes in Older Adults

A multidisciplinary team of specialists has launched a special clinic to improve surgical outcomes for older adults treated at Massachusetts General Hospital. The Perioperative Optimization of Senior Health (POSH) Clinic conducts an extensive personalized assessment, then implements multidisciplinary strategies before, during, and after surgery. The goal is to prevent or minimize complications and optimize outcomes in frail patients in a highly individualized and integrated way.

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"So much of what we do in healthcare is a conveyor belt, not individualized. When you have a medically complex, potentially frail older adult entering into the health system, they may be exposed to the homogeneity of the standard of care, including interventions and procedures that may not be appropriate for them based on where they are in their trajectory," says Matthew Russell, MD, a Mass General geriatrician and POSH's clinical director of Geriatrics. "The POSH Clinic gives us all an opportunity to identify their unique needs and considerations, offer interventions to reduce the risk of patient harm, and have a more satisfactory outcome based on the patient's personal goals."

Improving Surgical Outcomes in Older Adults

There are different criteria for defining frailty, but one of the criteria indicates that a person is considered frail when they meet at least three of the following:

• Low levels of physical activity
• Low energy (exhaustion)
• Unintentional weight loss
• Slowness
• Weakness

The literature has established that frail patients are at significant risk of adverse events. Studies have shown increased risks of postoperative mortality, longer length of stay, unplanned readmissions, and discharge to somewhere other than home among frail patients compared to non-frail patients.

"Frailty does not necessarily correspond with age. Instead we have to identify the vulnerabilities unique to each patient and address them as best we can in order to optimize the outcomes for these surgical patients," says Hiroko Kunitake, MD, MPH, a gastrointestinal and colorectal surgeon who serves as POSH's surgical director. "For many frail patients, the recovery period also extends far beyond their hospitalization, and we know they are at particular risk during transitions of care. We work hard to try make this critical period a success."

The POSH Clinic is based on a model established at Duke University School of Medicine. That program has been operating for about 10 years and has documented successful interventions. For example, Duke reduced hospital length of stay by two days and drastically reduced the rate of seven-day readmissions in the target population. Mass General clinicians and surgeons visited Duke's clinic and learned from its experiences, launching the Mass General program in 2021.

The model allows patients to express what matters most to them.

"The goal at Mass General has always been to provide the right care for the right patient at the right time. In that spirit, this clinic focuses on what's most important to the patient, recognizing that each older person will be unique in their phenotype, whether that's cognitive or functional, and age alone doesn't tell the whole story," says Dr. Russell. "We do a threat assessment, looking at the person for their vulnerabilities, then optimize or eliminate the threats—or at least put traffic cones and police tape around them—to alert the team and avoid predictable hospital complications."

Masaya Higuchi, MD, MPH, medical director for POSH, adds, "We have observed that a lot of potential complications and in-hospital adverse events associated with surgery could have been prevented or could have been minimized by proactive intervention and perioperative optimization."

The POSH Team: Multidisciplinary Care for Frail Patients

Patients experience better outcomes and are more satisfied when they have multidisciplinary care—a fact that is well established in specialties such as oncology and other medical disciplines. "What's interesting about the POSH Clinic is that it's multidisciplinary care for frail patients. That's not necessarily a diagnosis like cancer, where we automatically think about multidisciplinary care," Dr. Russell says.

The POSH team encourages primary care physicians, specialists, and surgeons in the Mass General network to partner with the clinic months, weeks, or days before a patient has surgery. All stakeholders have a voice:

• Patient
• Family caregivers
• Primary care physician
• Surgeon
• Case manager
• Physical therapist to design plans for prehabilitation and postoperative mobility
• Nutritionist to optimize nutrition
• Pharmacist to review medications
• Anesthesiologists and pain-management specialists

Patients and their caregivers have a 90-minute comprehensive assessment in the POSH Clinic. Each patient is then discussed in a multidisciplinary conference where a perioperative plan is made based on the patient's needs. POSH Clinic assessments consider the whole patient, including:

• Delirium, which can be helped by having family present during the immediate recovery period
• Hearing or vision impairment, which may benefit from amplification devices
• Mobility issues that can be addressed with a prehabilitation plan or assistive devices
• Special pain-management needs or anesthesia adjuncts
• Lack of patient awareness of surgical risks, which affects informed decision-making
• Likelihood for a prolonged hospital stay or the need to plan for a postoperative skilled nursing facility or nursing home

POSH patients are followed in the hospital after surgery and may also follow up post-discharge to help bridge the patient to the next transition of care.

Refer Your Older Patients for a Geriatric Assessment

Any patient being considered for surgery can be referred to the POSH Clinic by a primary care physician, surgeon, or any specialist providing long-term care. General eligibility criteria are:

• 85 and older
• 65 to 84 years of age with any significant comorbidities, functional or cognitive impairment or would benefit from an in-depth evaluation by Mass General geriatricians and the POSH multidisciplinary team

Dr. Kunitake says, "Feedback thus far has been very positive from the full range of stakeholders—patients, family caregivers, nurses at the bedside, advanced practice providers and physicians on inpatient recovery units, and surgeons."

"We're working to collect data that capture the effects of the POSH Clinic, including patient-reported outcomes and qualitative outcomes in terms of the patient and family experience, as well as the experiences of clinicians, surgeons, and other health care professionals," says Dr. Higuchi.

To refer a patient to the POSH Clinic, place an order through Epic or call 617-726-4600 and ask for the POSH Clinic.

Learn more about the POSH Clinic

Refer a patient to the Division of Palliative Care & Geriatric Medicine