Based on the ProvenCare Chronic diabetes outcomes, we experienced the following benefits:
• More efficient care processes were created.
• Patients were identified as to when they were likely to need additional care.
• Providers were empowered to carry out their own transformational change as they gained experience and knowledge. Doctors strive to be at the top of a performance list, and when they are in the middle or lower quadrants, there is automatic pressure to improve. At Geisinger, there actually was a best practice competition between community practice sites and among individual providers. We try to understand what is being done better in one group and transmit it to other groups not performing quite as well.
• Patient outcomes were improved with individual measures of care such as influenza vaccination rates, hemoglobin A1C at goal, and LDL at goal. Hemoglobin A1C at goal increased 45 percent over a seven-year period for a study population of 25,000 people, and LDL at goal increased 18 percent over the same period in the same population, even after establishing more strenuous goals. Most important, there also were reduced rates of stroke, myocardial infarction, and retinopathy in the same population.5 Most important, these intermediate and performance metrics subsequently were shown to link to better diabetes-related disease outcomes, less need for acute care hospitalizations, and longer, more functional lives.
• Compliance increased across all measures within the set. For the nine original measures (percentage of influenza vaccination, percentage of pneumococcal vaccination, percentage of microalbumin result, percentage of hemoglobin A1C measured and at goal, percentage of LDL measured and at goal, percentage of blood pressure less than 130/80, and percentage of documented nonsmokers), compliance in the study population of 25,000 increased from 2.4 percent to 14.5 percent over a seven-year period. Within the first year of implementation, compliance went from 2.4 percent to 7.2 percent.6
• IT was used more fully to reinforce the new roles of practice site staff.
For all of the IT enabling that was part of the care reengineering, the key was to change who did what and how the care was actually delivered to patients. The transactional EHR, the functional content added to it, and the analytics that came from the claims and clinical data were useful only in direct linkage to changing the entire care pathway. Both at Geisinger and in the literature, it was obvious that chaos would ensue if the care pathways were not changed at the same point in time for the increased IT usage.
Further, IT both enabled and reinforced the changing roles of the care team and the changed care pathway. The enabling technology and the new pathway had to be easier than what was done previously, because change would not occur if the pathways were more complex than the ones already in use.
For example, when the suggested new pathway for autism didn’t fit this criterion, we accepted it as a failure and did not adopt it. On the other hand, we created and adopted a very successful new care pathway regarding the use of erythropoietin (EPO) in patients with anemia associated with chronic renal disease. The new approach was adopted only when the transactional EHR-enabled best practice algorithm for EPO treatment could be applied to pharmacists and pharmacy techs and withdrawn as a responsibility of the nephrologist. Only through the new approach could significant benefit be shown in tightening indications (for example, using EPO only when iron would not be equally beneficial) and in increasing the efficiency of the actual EPO treatment through algorithm use transacted by techs and supervised by pharmacists and doctors. There are many additional examples of how the best practice bundle was systemized throughout our entire community practice and endocrinology specialists. It could not have been done without strengthening the fundamentally changed care pathway with enabling technology.
PROVIDER PROCESS
To identify a patient with type 1 or type 2 diabetes for inclusion in the diabetes bundle best practice measurement set and to trigger future alerts, the provider must select a diabetes diagnosis and add it to the patient’s list of health problems in the EHR. When the diagnosis is entered on the patient’s problem list, the patient is automatically in the diabetes registry. The registry for diabetes management lists all patients in the practice who meet the measure set criteria.
The diabetes diagnoses offer caregivers the opportunity to select a specific diagnosis that matches the current state of the patient’s condition and allows for patient-specific goal setting. This provides the additional information to ensure accurate measurement.
For example, a typical diabetes diagnosis such as “diabetes mellitus without mention of complication, type 2 or unspecified type, not stated as uncontrolled,” will have specific ProvenCare diagnosis options that map to the same root International Classification of Diseases code. Examples of ProvenCare best practice codes include: diabetes type 2, goal A1C < 7; diabetes type 2, goal A1C < 8; diabetes type 2, goal A1C < 9; diabetes type 2, goal A1C to be determined; and diabetes type 2, goal symptom management.7 The specificity of these ProvenCare codes allows the care team to track the patient’s diabetes measure progress and ensures that all staff are aware of the goals for the patient and are focusing appropriately on the problem. In addition, these specific codes are used in the diabetes set of measures reports.
The presence of a diabetes diagnosis in the patient’s list of health problems will trigger health management reminders, with the EHR system automatically posting the patient-care activities for the evidence-based protocols. Activities can be reflected as due for care, overdue for care, or care completed. Completion of the activity is captured based on information contained in the EHR or other health tracking tools.
The provider can view a summary report for a particular patient before entering the examination room. This report provides an update of the relevant information for treating diabetes based on care protocols and assists the provider in preparing for the actions that should occur during the particular office visit. The diabetes summary report provides the following information on the patient:
• Allergies
• Current medication list
• Body mass index
• Social history
• Blood pressure, pulse, height, and weight from the past two office visits (if available)
• Diabetes labs for the past three results over two years
• Most recent immunizations/injections
• Summary of patient care activities, indicating via a symbol what is late, due, due soon, or on hold
The provider will address any alerts displayed for the patient. Patients and their family members share information to assist the provider in making complex diabetes care decisions based on combining information from the EHR and/or other clinical systems such as lab values, patient care activities, and the diabetes diagnosis. The provider reviews each alert, selects the appropriate care action, then accepts the alert to satisfy the action. How these specific activities are satisfied is outlined in Figure 8.3.8
FIGURE 8.3 EHR Alerts
CLINICAL ORDERS
At the end of the office visit, the provider reviews and signs the orders the nurse has noted as pending during the patient rooming process. The provider has the option to sign all the orders at one time, edit an order, or remove orders that are unnecessary based upon information captured during the office visit. If not already completed, the provider determines what care is due based on the diabetes protocols. The provider reviews the patient’s health problems to decide if the diabetes diagnosis is still applicable and adjusts the treatment as necessary. New problems are added to the patient’s problems list in the EHR. For subsequent visits, administrative staff can inform patients that they are overdue for certain care and at the visit prepare orders for the provider. Any appropriate clinical staff members, who also view alerts for best practices, can perform procedures such as diabetic foot screenings.
Performance data for the diabetes management set of measures is displayed in multiple management reports to aid operational and clini
cal staff in monitoring and addressing performance on a monthly basis. Practice site directors, operations managers, clinic staff, and providers access appropriate reports for the site they are responsible for at the level of detail needed. We obtain individual patient and individual site feedback in near real time and use the variation in performance to determine why one site or one individual is doing better than another. This must be part of the socialization process for provider behavior change to occur.
PATIENT OUTREACH
It’s important for diabetes patients to become active partners in their care with the caregivers they see regularly for ongoing diabetes care and other health issues as well, since most diabetes patients have multiple issues. In addition to our clinicians developing such partnerships with their patients during their office visits, Geisinger uses patient self-management and regular chronic disease “communications” (both letters and e-mails) to encourage patient involvement. The self-management messages explain the patient’s current diabetes condition and offer suggestions for clinical care. They encourage the patient to become a member of the care team. Much of this outbound communication has been enabled by our Epic patient portal and the recent systemwide rollout of progress notes being available to patients.9
The chronic disease communications are designed as targeted outreach to encourage patients to seek care by scheduling an appointment. The communications are automatically generated monthly to patients who meet the following criteria: older than age 65; PCP within the Geisinger system; diabetes diagnosis present on the patient list of health problems or a diabetes diagnosis used more than four times at an office visit; no appointment scheduled with a PCP in the next four months; no chronic disease management visit scheduled in the next four months; did not receive a chronic disease management phone call; and did not receive a chronic disease letter in the past six months.
ACHIEVEMENT
As reported in the American Journal of Managed Care, a study of claims data for Geisinger Health Plan (GHP) members meeting the criteria for a diagnosis of diabetes found a “significantly lower risk of macrovascular and microvascular disease end points in the first three years of a diabetes system of care that included an all-or-none bundled measure compared with primary care without this intervention.… Perhaps the most notable finding is the apparent early impact of the care model. The findings suggest an impact in the first three years with the possibility that a reduction in risk began to emerge after the first year.”10
Another study published in this journal utilized GHP claims data for patients exposed to our diabetes system of care who met the Healthcare Effectiveness Data and Information Set criteria for diabetes and had two or more diabetes-related encounters prior to 2006. This group was compared to a second group of patients from 2006 to 2013 who were not exposed to ProvenCare Chronic. The study found that, “Over the study period, the total medical cost saving associated with bundled best practice exposure was approximately 6.9 percent. The main source of the savings was reduction in inpatient facility cost, which showed approximately 28.7 percent savings over the study period. During the first year of the bundled best practice exposure, however, there were significant increases in outpatient (13 percent) and professional (9.7 percent) costs.”11
There were two reasons why costs were higher at the beginning. First, before any steady state was achieved in many cases, patients generally were seen more frequently either at the community practice offices, in their homes, or in skilled nursing facilities to ensure that everything was done to achieve the bundled best practice. Second, a significant amount of the benefit in achieving the best practice goals for these bundles came through improved medication adherence, which was viewed to be a worthwhile trade-off. If pharmacology costs went up but the consequence was significantly decreased need for emergency room visits, office visits, and ultimately hospitalizations, the net gain both in terms of quality of outcome for patients and decreased total cost of care was extraordinarily worthwhile. But there was a lag in the decreased hospitalization benefit until after some period of increased pharmacologic adherence was achieved. The overall benefit in quality outcome and decreased total cost of care was a twofold value increase in our diabetes population.
PATIENT CASE STUDIES
Creating better outcomes for patients was the key to energizing our doctors and team to develop and implement the reengineering innovations. The following patients presented to our PCPs with extremely poor diabetes control and consequent high risk of developing diabetes complications. By working with diabetes management clinic pharmacists and other members of the care team, the necessary medication and lifestyle adjustments were made to improve care over a relatively short period of time. As a result, none of these patients had their disease progress to nephropathy, retinopathy, neuropathy, or vascular disease.
Candice is a 34-year-old patient referred to one of our clinics for diabetes management and education. She presented with a baseline hemoglobin A1C of 11.9 and no previous education about diabetes care. She was not tolerating her only diabetes medication, experiencing stomach upset. Our physicians and pharmacists worked with Candice to switch to an extended-release version of the medication and slowly increased the dose to a tolerable and effective level. Working with our team, Candice was able to develop a meal plan and exercise routine to fit her lifestyle. After six months, her hemoglobin A1C improved to 6.5 and was at goal. Despite being at high risk for diabetes complications at a young age, Candice changed the trajectory of her health by partnering with our team.
Marie is a 44-year-old patient referred to a diabetes management clinic for disease management and education. She presented with a baseline hemoglobin A1C of 11.1 and no previous education about diabetes care. She was on Lantus insulin and glimepiride, but admitted that she was not compliant with the medications because she felt defeated by her diabetes and had gained weight since starting them. She had been on metformin in the past, but the medication was discontinued because she could not tolerate the nausea and intestinal distress. Our physicians and pharmacy team worked closely with Marie to adjust her medications. The pharmacists replaced glimepiride with Victoza and added the extended-release version of metformin, slowly titrating the dose based on Marie’s tolerance. Over the next 10 months, we worked with Marie to make dietary improvements and continued to adjust her medications. Her diabetes control improved significantly, with her hemoglobin A1C decreasing to 6.6. Not only was her diabetes better controlled, she required less insulin than at baseline and was working toward continued weight loss in an effort to become less dependent on medications to maintain her health.
Matthew is a 35-year-old patient who came to one of our diabetes clinics for disease management and education. He was recently diagnosed with type 1 diabetes and had a hemoglobin A1C of 14.1. He was overwhelmed by his diagnosis, as he had just started a family of his own and suddenly life as he knew it was changing. Our physicians and pharmacists started him on intensive insulin therapy and followed him weekly to make necessary adjustments to his dosing. Our nutritionists and pharmacists provided Matthew with a thorough education of his disease state, including carbohydrate counting, exercise, sick-day rules, and self-care principles. Working with all members of the interdisciplinary primary care team, Matthew was empowered to control his diabetes by making adjustments specifically tailored to his lifestyle. After just three months, his diabetes was significantly improved with his hemoglobin A1C down to 5.5. More important, Matthew had gained an understanding of the active role he plays in his diabetes care and felt confident knowing he could now maintain his health and avoid the many complications of this disease.
LESSONS LEARNED
• It’s possible to apply default best practice to how chronic disease is managed.
• Provider-led, technology-enabled commitment to a bundle of best practices for diabetes begins to change medical outcomes in one year.
• As medical outcomes improve, total cost of care decreases.
• Pa
yers, PCPs, and hospital-based endocrinologists must work together to improve where and how care is provided.
• Patients and their families are key partners in redesigning and receiving care.
• Innovation at the highest level of institutional strategy must be transacted by providers energized to help patients to better long-term outcomes.
• Success in care reengineering creates a flywheel effect.
• Socialization of fundamental care redesign must be consistent and consistently affirmed throughout the organization.
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ProvenHealth Navigator: Geisinger’s Advanced Medical Home
Like many elderly patients, Robert had multiple chronic conditions including diabetes, lung disease, and heart failure. His heart, functioning only between 12 and 14 percent, was his main problem, but he was a Geisinger Gold Medicare HMO member and participant in our ProvenHealth Navigator® (PHN) advanced medical home program, which allowed him to stay as healthy as he could and out of the hospital for as long as possible. And for that, he was grateful.1
To help patients like Robert, we embed nurse care managers, who are employed by our insurance company, in the primary care office, where they become part of the patient-care team. The care manager’s job is to focus on the sickest patients in the practice, such as those with congestive heart failure or diabetes, and ensure they are taking prescribed medications appropriately, keeping appointments, and following up with preventive measures. The goal is to help these patients maintain health and avoid repeated hospitalizations.
Our pioneering concept of the embedded care manager as concierge caregiver for the sickest patients is the foundation of Geisinger’s version of advanced medical home. We designed this concierge care based on payer data that showed us which patients needed the most hands-on care. The embedded care manager concept came from our conviction about providing such care physically, as opposed to what has been shown in many studies, both anecdotal and formal clinical trials, that telephonic or distant care management does not work. We decided that this physical interaction with our embedded nurses as care managers was an absolute necessity for our sickest 150 or so patients per community practice, and it enables our physicians to do a different task than they were doing prior to stratification and segmentation of care. They are freed from a focus on increasing patient volume across all severity stratifications into something much more manageable.
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