ProvenCare

by Glenn D Steele

  SCALING AND GENERALIZING WITH PROVENCARE LUNG CANCER

  The success of ProvenCare Lung Cancer is especially compelling, because of huge variation and noncompliance nationally with the most important staging and preoperative requirements for potentially resectable lung cancers of specific histologic types. Patients were not receiving generally agreed-upon evidence-based care, as defined by a number of national discipline-based and cancer-based organizations.

  Since 2010, Geisinger’s ProvenCare template for surgical treatment of lung cancer patients has been piloted by a dozen hospitals of different sizes and models and with more than 2,000 patients through the Commission on Cancer’s ProvenCare Lung Cancer Collaborative.2 The study involves patients with non-small cell lung cancer who are candidates for lung resections.

  Participating hospitals provide treatment according to Geisinger’s ProvenCare Lung Cancer care pathway, containing 38 standardized elements that cover everything from antibiotic administration and pain management to mediastinoscopy and lymph node sampling. Results show compliance with the 38 elements rising to nearly 90 percent from below 40 percent when the study began and similar to what we experienced at Geisinger.

  Researchers now are utilizing the findings, amassed in the Society of Thoracic Surgery National Database, to determine five-year clinical oncological outcomes of these patients, including staging accuracy, interoperate lymph node yield, and pneumonia and other respiratory complication rates before, during, and after the ProvenCare journey. The collaborative expects to see improvement in outcomes as a result of institutions following the ProvenCare pathway.

  A new phase of research is looking at all stages of lung cancer. The program will now involve multiple departments at eight hospitals, including medical and radiation oncology, and encompass 53 elements as opposed to the 38 we started with, everything from diagnosis to staging, treatment, survivorship/palliative care, and end of life care related to lung cancer.

  At the very least, we have demonstrated that the application of the process goes well beyond a single committed institution and is motivated by clinical leadership and pride of accomplishing real improvement in patient care, since none of the non-Geisinger institutions have the advantage of a payer/provider partnership that built in a pricing component as a part of the effort.

  LESSONS LEARNED

  • Continuous improvement is possible in routine clinical practice.

  • Default best practices can improve quality and lower costs.

  • Unjustified variation can be mitigated without resorting to “cookbook” medicine.

  • Scaling to other institutions is promising.

  • Professional pride of purpose and clinical leadership are the key success factors.

  8

  ProvenCare Chronic

  By the time 74-year-old Arthur went to his first appointment with a Geisinger endocrinologist in 2009, he had had angioplasty twice to open blocked coronary arteries. His hemoglobin A1C was 9.6 percent when he began cardiac rehab, met with a registered dietitian and certified diabetes educator, and started to limit his carbohydrates to no more than 45 grams per meal. He followed his prescribed medication regimen and worked hard to manage his blood glucose levels, and in September 2010 underwent coronary artery bypass grafting (CABG) with placement of an implantable cardioverter defibrillator.

  Arthur began growing vegetables, first for himself and his wife, then for family and friends. His garden became so prolific that he brought fresh vegetables to doctor visits during growing season each year. He had 31 appointments with a diabetes educator or endocrinologist from 2009 to 2015, approximately one visit every three months. He lost 18 pounds, maintains his low-density lipoprotein (LDL) or “bad” cholesterol at 72, and has persistent total cholesterol elevations in the 200 to 300 range, despite a combination of atorvastatin, Fenofibrate, and fish oil. Arthur has maintained his hemoglobin A1C at or below 7 percent from 2011 to 2015 and his blood pressure at 124/58 with medication. Now age 80, he enjoys an active retirement and visits from his grandchildren and plans to continue his lifestyle changes for many years to come. Despite the challenges of his disease, our ProvenCare Chronic Diabetes program has enabled him to maintain an active and enjoyable lifestyle.

  The 2006 expansion of our value reengineering portfolio from ProvenCare Acute to ProvenCare Chronic made sense for several reasons. After the success of elective heart surgery and interventional cardiology acute care reengineering and the significant amount of external validation, in both the academic arena and the popular media, our hoped-for flywheel effect occurred dramatically. Additional Geisinger service lines and discipline-based areas of the organization wanted to get in on what they could do for their patients to attack both total cost of care and suboptimal outcome issues. Our success also improved our ability to recruit extraordinarily bright people to join the Geisinger family and further our innovation machine.

  Many hospital-based service lines, including our most innovative first service line, community practice, began to contribute their own ideas about fundamental reengineering of care for the most prevalent diseases in their patients. This was welcome for two reasons.

  First, it demonstrated that our major strategic goal of fundamental innovation could in fact be disseminated into the various discipline-based and multidisciplinary service lines. Not only was there top-down demand to achieve a common high-level strategic aim, there was bottom-up demand regarding goals for individual caregiving entities. The entire effort could not have been done without combined top-down strategic discussion and agreement and a bottom-up ability to define specific goals that were compelling to our people who were actually taking care of the patients. In addition, affirmation in both professional pride of purpose and total compensation was uniform and aligned throughout the entire organization. The top-down strategic insistence plus the bottom-up buy-in to individual provider-led patient care reengineering was the winning combination for getting everyone throughout the organization incentivized and energized to the Geisinger concept of a healthcare innovation engine.

  The second reason we welcomed the enthusiasm for reengineering the management of prevalent chronic diseases was that almost every acute care episode was a window into a much larger, ongoing chronic disease management problem. Quite simply, doing an effective coronary artery bypass or placing a stent for a clogged coronary artery relieved the immediate problem, but did not change the overall challenge of long-term outcome in patients with systemic vascular disease. The interventional surgery was not a reset button, and it did not change the ultimate biology that caused the blockage. Only the combination of the effective intervention plus a fundamental reengineering of the patient’s and the doctor’s approach to the chronic disease would ultimately expand life and functionality.

  Because ProvenCare Chronic would require close cooperation between primary care physicians (PCPs) and specialists, we sought assistance from our community practice service line (primary care) leaders to help identify the specific chronic disease we would tackle first.

  COLLABORATING ON CHANGE

  As with ProvenCare CABG, we wanted to start our chronic disease reengineering effort with a high-impact, high-probability winning result. There is strong incidence of diabetes in the Geisinger service area, nearly one million adults age 18 and older, according to the Pennsylvania Department of Health.1 Our community practice doctors were caring for approximately 30,000 type 2 diabetes patients, and we had just recruited a full complement of excellent endocrinologists at our two hospital hubs.

  Type 2 diabetes was challenging because it involved a number of departments and caregivers not typically collaborating to benefit patients, including endocrinologists, PCPs, pharmacists, nutritionists, general internists, and nurses, among others.

  Our starting point was to entice the hospital-based specialists to open their hospital-based clinic schedules to diabetic patients in crisis. But our aspiration for ProvenCare chronic disease management went well beyond simply openin
g up schedules and being responsive, because it’s unacceptable that patients must travel from wherever they are and from whomever is taking care of them to see hospital-based specialists.

  The endpoint for ProvenCare Chronic reengineering for care of all chronic conditions was to identify ahead of time the patients at most risk for medical crisis and fundamentally change our care for them before they go into crisis. We wanted to get as much collaborative best practice care to patients near where they live, with the entire provider group (and at Geisinger, the payer as well) committing to achieve a common metric of all-or-none best practice bundle-of-care measures delivered to the patient in the community setting. Some of these best practices are taken from the discipline-based evidence and consensus process led by the specialty societies, and some are decided upon internally as part of the default best practice socialization process.

  The reengineering approach to chronic disease care requires a fundamentally different interaction between specialists and PCPs. From the beginning of the reengineering effort, we insisted on bringing care to patients with extraordinarily difficult type 2 diabetes management, rather than demanding that they come to us. Instead of opening up schedules for these patients to be seen when necessary at the endocrinology-based clinics typically near our hub hospitals, we systematically took our endocrinology expertise out to the community practice offices. This fostered interaction between endocrinologists and our PCPs when patients with type 2 diabetes were in or approaching a crisis.

  The only way bundled best practice works, and to some extent it’s used as a forcing function, is if data from payers is used to stratify which chronic disease patients need the most intense care. Initial redesign for all type 2 diabetes patients would have been useless and incredibly costly. For the most fragile diabetes patients, for example, our initial goal was to hone in on those patients requiring the most intense care and to meld the rapidly changing specialty knowledge of the endocrinologist with the access, general management, and credibility in the community-based practitioner. This was a superb way of creating more patient-centric care delivery without sacrificing the expertise that prior to our bundled best practice and care reengineering demanded that patients physically move from their community practice-based interaction to the specialists in or near the hospital hubs.

  We took a similar approach to congestive heart failure, involving hospital-based cardiology specialists and community practitioners in a way that enabled a significant amount of caregiving for the most difficult patients to be provided in the community practices near where patients lived, as opposed to simply opening up schedules and demanding that patients and their families travel to hospital-based hubs. Almost 80 percent of the patients normally referred for specialist visits could be cared for much more efficiently by having specialists available to the PCPs in our 55 community practice sites. Our outcome metrics are decreased acute care needs, decreased frequency of secondary disease consequence, and decreased cost of care over time, the ultimate increased value outcome.

  There’s another compelling reason for specialist and PCP collaboration in reengineered prevalent chronic disease care. Without making the most expert opinion available to frontline caregivers and caring for both healthy and sick patients, we could not feel confident that the best care was delivered in the most convenient way to our sickest patients. Working together toward this goal was directly correlated with the 20 percent innovation-related compensation targets for the specialists as well as the PCPs.

  PERFORMANCE MEASURE SET

  The ProvenCare approach to diabetes management is a team-based model of care that uses the ProvenCare methodology to help practitioners manage type 1 and type 2 diabetes patients in the primary care setting. The three-pronged approach combines work flow improvement, information technology (IT) optimization, and performance measurement. The system helps caregivers proactively manage their patient population’s compliance with a set of nationally recognized performance measures. Based on these measures, providers can pursue appropriate chronic condition management for their patients. Specifically, the diabetes management system of care includes:

  • An all-or-none set of 14 measures for diabetes that tracks patient compliance to evidence-based guidelines. (See Figure 8.1.) The measures provide a consistent way to manage the diabetes patient’s health based on best practice care, and all measures are required in the all-or-none measure set.2

  FIGURE 8.1 Diabetes Patient Compliance Measures

  • Clinical process redesign to eliminate, automate, delegate, incorporate, and activate.

  • Clinical decision support through the electronic health record (EHR) at clinic nurse and provider levels (evidence-based alerts and health management reminders).

  • Patient-specific strategies using registry report data.

  • Activation strategies such as patient letters and e-mail communication via secure patient portals.

  An all-or-nothing measures set raises the performance bar by more closely reflecting the interests and desires of patients, fostering a systems approach to achieving all goals, and providing a more sensitive scale for assessing improvements. Both patients and physicians want to either slow disease progression or prevent the consequences of additional diseases that might be avoided by more optimal treatment. We presupposed this could happen only if all the known best practices for a given condition were achieved every time for every patient. So we committed to a best practice bundle even though there could be either medical or practical issues mitigating optimal achievement for individual components of the bundle.

  Not all patients will achieve each measure; for example, not all will quit smoking. The set of measures offers real-time feedback regarding progress by the patient and in the population. The measures also attempt to stratify the type 2 diabetes patients most at risk and to enable much more proactive input from the endocrinologist in addition to the PCP. Finally, the measures also seek to include patients and their families in a self-care partnering arrangement to achieve the best possible outcomes.

  We included patients and families in each of the care delivery reengineering processes, redesigning the care pathways, delineating new responsibilities for providers, patients, and their families in jointly defined accountability to achieve optimal outcome, and fundamentally reframing the relationship between the caregiver and patient. Even giving patients and their families access to our progress notes was a fundamental realignment. Finding out how often the patients and their families did not understand or agree with what was documented in their progress notes was eye-opening. Setting a new baseline of mutual understanding and agreement was an important starting point in optimizing chronic disease management.

  Our initial approach was to use our EHR, Epic, employed across the entire Geisinger system, to embed the provider prompts and feedback enabling behavior. We now are working on bolt-on and content embedding applications that would enable connections to Epic, Cerner, and Athena Health.

  In the beginning, our PCPs and endocrinologists committed to achieve nine best practice goals for the type 2 diabetes patient population. The first few years focused essentially on the usual surrogate markers, such as hemoglobin A1C, microalbumin, pneumococcal vaccination, LDL, blood pressure, and so on. We eventually included 14 best practice measures.

  To the aggravation of most community practice leaders, whenever there was a year-over-year improvement in the process or surrogate panel, particularly since it would always meet or beat the innovation requirements for the performance part of compensation, Dr. Steele would ask, “So what?” He was interested in the actual long-term benefit to diabetes patients included in the improved best practice bundle.

  Remarkably, it took only three years of this fundamentally changed set of practice incentives and practice enablers to show that the answer to “So what?” meant that there were 306 prevented heart attacks compared to what would have been expected; likewise 141 prevented strokes and 166 prevented cases of retinopathy, simply by having
the patients cared for within this bundled best practice value reengineering change.3 In addition to the patient benefit, bundled best practices significantly decreased the total cost of care. Value was increased by both improving quality and lowering costs.4 (See Figure 8.2.)

  FIGURE 8.2 Diabetes Bundle Exposure Impact on Total Medical Cost of Care ($ per Member per Month)

  The bundled best practice sets then were expanded from the initial 30,000 diabetes patients to almost 20,000 patients with coronary artery disease and to more than 260,000 patients who were placed under a series of care best practices for prevention purposes. The specific preventive care metrics depended upon whether the patients were young, middle-aged, or old. Most important was the commitment of PCPs to consider everything known in the literature about prevention as a “must-do” for their patients, with rational compartmentalization regarding what was appropriate for various age groups, lifestyles, and behaviors.

  For the type 2 diabetes patients, the most important ramification of our care change was diminishing long-term disease consequences. The economic benefit of decreasing the need for hospital care and treatment for diabetes-related diseases went straight to our insurance company’s bottom line. As usual, a financial deal was made between Geisinger as provider and Geisinger as an insurance company, but similar to ProvenCare Acute, the care reengineering was expanded to include all of our type 2 diabetes patients, no matter who insured them.