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Heal • Teach • Discover • Serve
The Geisinger ProvenCare Experience
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A strong business case for quality
• Not all appropriate care is rendered
• Unnecessary care is being provided
• Compliance with evidence-based guidelines known to improve outcomes is poor
• Outcomes of care vary widely
Division of Clinical Effectiveness
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ProvenCare®
• Concept: Link evidence-based practices to a continuum of care in a subclass of patients and reliably give that care to each and every patient
• Purpose: Fully optimize patient outcomesReduce unnecessary variability in careCreate an idealized flow for providers and patients
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Evidence
• Evidence-based practices are Class I and Class IIa recommendations published by the sub-specialty’s national governing body
• Physician consensus-based practices are guided by the sub-specialty’s national governing body
• Applicable regulatory requirements are incorporated into best practices
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ProvenCare®
Elective CABG
Elective Cataract Surgery
Elective Total Hip Replacement
Elective PCI (Percutaneous Coronary Intervention)
Bariatric Surgery
Low Back
Perinatal
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Why? Because typical care has…
• Clinical– Uncertain appropriateness– Variable compliance with known-to-be beneficial
evidence-based best practice– Limited patient engagement– Variable outcomes
• Business – Lack of accountability for outcomes and quality – A la carte payment for services – Perverse incentives: more payment for complications
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Snapshot:- 6 Interventionalists- 2 Hospitals
ProvenCare patients through July 2009945
ProvenCare PCI
Snapshot:-5 Surgeons -2 hospitalsProvenCare patients through Aug 2009393
ProvenCare CABG
ProvenCare CAB and PCI
ProvenCare CABG
0%10%20%30%40%50%60%70%80%90%
100%
Feb-0
6Apr
-06Ju
n-06
Aug-06
Oct-06
Dec-06
Feb-0
7Apr
-07Ju
n-07
Aug-07
Oct-07
Dec-07
Feb-0
8Apr
-08Ju
n-08
Aug-08
Oct-08
Dec-08
Feb-0
9Apr
-09Ju
n-09
Aug-09
% patients receiving all ProvenCare components
ProvenCare Elective PCI
0%10%20%30%40%50%60%70%80%90%
100%
Oct-07
Nov-0
7Dec
-07
Jan-0
8Feb
-08Mar
-08Apr-
08May
-08Ju
n-08
Jul-0
8Aug
-08
Sep-0
8Oct-
08Nov
-08
Dec-0
8Ja
n-09
Feb-09
Mar-09
Apr-09
May-09
Jun-0
9Ju
l-09
% of patients receiving all
components of ProvenCare
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Snapshot:- 9 Surgeons - 4 Hospitals (2 non-Geisinger)- 2 Surgical CentersProvenCare patients through July 20094022
ProvenCare Cataract
Snapshot:- 6 Surgeons- 2 HospitalsProvenCare patients through July 2009871
ProvenCare THR
ProvenCare Cataract and Total Hip Replacement
ProvenCare Total Hip Replacement: GMC and GWV
0%10%20%30%40%50%60%70%80%90%
100%
Mar-07
May-07
Jul-0
7Sep
-07Nov
-07Ja
n-08
Mar-08
May-08
Jul-0
8Sep
-08Nov
-08Ja
n-09
Mar-09
May-09
Jul-0
9
% patients receiving all ProvenCare components
ProvenCare Cataract
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Mar-07
May-07
Jul-0
7Sep
-07
Nov-0
7Ja
n-08
Mar-08
May-08
Jul-0
8Sep
-08
Nov-0
8Ja
n-09
Mar-09
May-09
Jul-0
9
% of patients receiving ALL ProvenCare components
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Snap Shot:
Patient population: ~800 in the program, 400 proceed to surgery each year
Duration: Pre-surgery- 7 months
Post-surgery- 12 months
Surgical approaches: 2
Professionals: Surgeons-5 Internal Medicine- 2
Psychology-2 Nutritional Spec.-6
ProvenCare BariatricBariatric Surgery ProvenCare®
0%
20%
40%
60%
80%
100%
May-08
Jun-08
Jul-08Aug-0
8Sep-0
8Oct-0
8Nov-
08Dec-
08Jan-0
9Feb-09
Mar-09Apr-09
May-09
Jun-09Jul-09
Months
% of patients receiving all components
of care
ProvenCare patients through July 2009599
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Perinatal ProvenCare® Goals• 103 Discrete evidence-based elements of care are
incorporated, measured and tracked for compliance• Redesign, from the ground up, all aspects of provider
workflow– Drive fundamental efficiency improvements– Increase patient safety and process reliability– Reduce/eliminate documentation redundancy– Streamline patient education and cut costs
• Seek observable reductions in C-section rates and premature births
• Enhance management of comorbid conditions• Improve fetal/child health and wellness
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Does it work?
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ProvenCare®
brings national attention
May 24th, 2007 at the George Washington University Medical Center
HEALTH CARE: Hillary Remarks on Reducing the Cost of Health Care
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Lessons Learned
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• Decreased LOS– 3.6% reduction
• Decreased 30 day readmission rate– 58% reduction
• Decreased DVT rate– 49% reduction
• Decreased PE rate– 67% reduction
Total Hip Quality Manager Data Improvements with >90% compliance
Quality Manager Data
Not statistically significant
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Quality Manager Data/ Not statistically significant
CY prior to ProvenCare Expected CY 2009 % change
Mortality 0.90% 0.10% 0.00%
Morbidity¹ 3.50% 1.90% 1.00% 71%
Complications 27.90% 27.10% 16.30% 42%
LOS 3.8 2.8 2.8 26%
Geometric Cost $10,057 $14,292 $12,715 26%
¹Morbidity Rate, as defined by Quality Manager, is the percentage of patients who develop at least one morbid complication during hospitalization. Patients are said to have a morbid complication if the clinical impact of the complication was determined to be in the category of D or E as outlined below:Morbidity Clinical ImpactA None or trivialB One or two day increase in LOSC Unscheduled ICU admission and one or two day increase in LOSD 50%+ risk of temporary impairment, unscheduled ICU admission and / or 3+ day increase in LOSE 50%+ risk of temporary impairment, unscheduled ICU admission and / or doubling LOS
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ProvenCare Total Hip Average LOS
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
4.00
2007 2008 2009
GMCGWVcombined
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Transfusion Rate
0%
5%
10%
15%
20%
25%
2007 2008 2009
GMCGWV
Quality Manager Data
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ProvenCare Perinatal Quality Measures
GWV Primary C-Sections Jan 2008-Dec 2009
Avg=21.4
Avg=29.0UCL=31.4
UCL=45.5
LCL=11.4LCL=12.5
2
7
12
17
22
27
32
37
42
47
Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09
Perc
ent
Implementation of electronic process
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Balancing the Message- AHRQ Patient Safety Indicator 17• The numerator includes any of the following
diagnosis codes: 767.0, 767.11, 767.3, 767.4, 767.5, 767.7, 767.8
• Subdural and cerebral hemorrhage (due to trauma or to intrapartum anoxia or hypoxia)
• Epicranial subaponeurotic hemorrhage (massive)• Injuries to skeleton (excludes clavicle)• Injury to spine and spinal cord• Facial nerve injury• Other cranial and peripheral nerve injuries• Other specified birth trauma
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Quality Performance- AHRQ Patient Safety Indicator 17
Population of Mothers
Population of Babies
# of All Diaganoses birth trauma cases
Number of Excluded cases
Numerator based on PSI 17 definition
Birth Trauma Rate based on PSI 17 definition (per 1000 babies)
FY2008 2635 2888 20 5 15 5.19FY2009 2786 3054 10 5 5 1.64
-At GWV, there is no change in PSI 17 Birth Trauma Rates although vaginal deliveries have increased (GWV remains below the national average)-As a system, there is a significant decline in PSI 17 for FY09 (p=0,047). The national average is 2.31
http://www.ahrq.gov/qual/nhqr07/measurespec/patient_safety.htm#rtraumt1
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Length of stay• 488 Proven Care patients from May 2008 through June 2009• Length of stay was categorized into two group (<=2 days, 3+ days). This was
correlated with a 4-level categorical version of compliance (<90%, 90-94%, 95- 99%, 100%) using a Cochran-Armitage trend test.
• Results: Those with a lower rate of compliance were more likely to have an extended length of stay (>2 days)
55%
27%23% 21%
0%
10%
20%
30%
40%
50%
60%
<90% 90-94% 95-99% 100%
Rate of compliance
% w
ith >
2 da
y le
ngth
of s
tay
N=40 N=126N=93
Cochran-Armitage Trend test p-value = 0.0002
N=229
This categorical length of stay was correlated with 100% compliance using a Cochran-Armitage Trend test.
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90 day Readmissions
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
FY 2008 FY 2009
Rate
FY 2008: 413 cases, 51 readmissionsFY 2009: 427 cases, 29 readmissions
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Why Were Our Outcome Not Even Better?
• Only 60-70% of patients received all 42 measures
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Why Were Our Outcome Not Even Better?
• Only 60-70% of patients received all 42 measures
--- But most patients missed only 1 measure
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Why Were Our Outcome Not Even Better?
• Only 60-70% of patients received all 42 measures
--- But most patients missed only 1 measure
Heal • Teach • Discover • Serve
Why Were Our Outcome Not Even Better?
• Only 60-70% of patients received all 42 measures
--- But most patients missed only 1 measure
• Some measures increased detection of complications
Heal • Teach • Discover • Serve
Why Were Our Outcome Not Even Better?
• Only 60-70% of patients received all 42 measures
--- But most patients missed only 1 measure
• Some measures increased detection of complications
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Why Were Our Outcome Not Even Better?• Only 60-70% of patients received all 42 measures--- But most patients missed only 1 measure• Some measures increased detection of complications
– Proven PCI measures that prevent complications: 14– Proven PCI measures detect more complications: 10– ProvenPCI measures no affect on complications: 18
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ProvenCare should deliver more value • Approach is patient centric • Evidence-based care delivers better
outcomes • Provider documents appropriateness• Enables an activated participative member
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Every system is perfectly designed to get the result it gets- Paul Batalden, MD