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Service Delivery Innovation Profile

Use of Clinical "Bundles," Fixed Pricing, and Patient Compact Enhances Adherence With Guidelines and Improves Outcomes in Bypass Surgery, Diabetes, and Other Areas


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Snapshot

Summary

Geisinger Health System's ProvenCare® program is a multifaceted initiative that includes the reengineering of care processes to create evidence-based "bundles" of discrete clinical care elements; for inpatient procedures and for pregnancy, the adoption of a fixed per-case rate that covers all aspects of preadmission, inpatient, and followup care; and a "patient compact" that provides education and encouragement for patients to become more engaged in their own care. For chronic care, payment arrangements include a quality-based incentive program for primary care providers. Originally initiated for coronary artery bypass grafting (CABG) surgery, the program has been expanded to cover other surgical and interventional procedures as well as care related to pregnancy, diabetes, coronary artery disease, chronic kidney disease, and adult disease prevention. Published pre- and post-implementation analyses show that the program has significantly increased adherence with guidelines and improved clinical outcomes for both elective CABG surgery and for diabetes care. Internal Geisinger analysis suggests that the program has yielded similar positive results in other clinical areas.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including adherence to CABG and diabetes guidelines; CABG readmission rates; CABG complications; and glucose control, blood pressure control, and vaccination rates among diabetes patients.
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Developing Organizations

Geisinger Health System
Danville, PAend do

Date First Implemented

2006
February

Problem Addressed

Although many guidelines for surgical care exist, they often lack the specificity for application to actual practice and are often incompletely or inconsistently applied. Fixed-fee payment programs can theoretically encourage the adoption and use of guidelines and improve clinical outcomes, but there are few such programs for surgical care.
  • Limited implementation of clinical guidelines: Clinicians often do not follow existing care guidelines consistently in everyday practice because of questions about their validity, opposition to "cookbook" medicine, or difficulties in applying them consistently in clinical settings.1 Attempts to improve guideline adherence, including regulatory and payer mandates, public reporting of outcome measures, and medical society oversight, have had a limited impact on clinician behavior.2
  • Few innovative payment programs to encourage guideline adoption: Most payer-designed programs (including pay-for-performance initiatives) to enhance quality focus on outpatient preventive care and chronic disease management; few innovative payment programs have been developed to encourage use of guidelines for acute, episodic surgical care.3

What They Did

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Description of the Innovative Activity

ProvenCare is a multifaceted program that, for inpatient procedures, includes the reengineering of care using evidence-based "bundles" of discrete clinical elements; adoption of a fixed per-case rate that covers preadmission, inpatient, and followup care; and a "patient compact" that provides education and encouragement to patients to become more engaged in their own care. Originally initiated for CABG surgery, the program has been expanded to cover other surgical procedures, including hip replacement, percutaneous coronary intervention (stent placement and angioplasty), bariatric surgery, and cataract surgery, and to cover care related to pregnancy, diabetes, and coronary artery disease. Key elements of the ProvenCare program include the following:
  • Reengineered care bundles based on guidelines: Within each area, the process of care has been reengineered to incorporate clinically relevant steps drawn from best practices and/or evidence-based care guidelines into the routine workflow. For example, in the CABG program, care teams organize care delivery according to a bundle of 40 care elements2 based on class I and IIA recommendations from the 2004 American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for CABG Surgery. Care elements involve appropriate screenings, interventions, medications, and monitoring and are categorized according to preadmission, operative, postoperative, discharge, and postdischarge care. In the diabetes program, clinicians provide care according to a bundle of nine elements based on the American Diabetes Association's Standards of Care as well as measure sets from the National Committee on Quality Assurance and the National Quality Forum.
  • Electronic support: Electronic health record (EHR) tools (e.g., checklists, default documentation templates, health maintenance gap reminders, and automated order sets) prompt clinicians to either adhere to the care elements or document justification for nonadherence; gaps in care are highlighted so that they can be completed promptly (e.g., before surgery).
  • Bundled pricing: For inpatient services and for pregnancy, ProvenCare bundles all professional and technical fees for the episode of care into one fixed case rate. For example, the CABG case rate includes preoperative evaluation and workup, hospital fees, professional fees, routine discharge care, cardiac rehabilitation services, and management of CABG-related complications that occur up to 90 days after surgery. Rates are negotiated based on retrospective historical cost and reimbursement data; the CABG rate assumed that readmission and complication rates would be cut in half because of the program and provided that benefit, in advance, to the payer.
  • Patient compact: The patient compact, signed by the patient and clinician before surgery, emphasizes the partnership in care between the patient and Geisinger and outlines the patient's responsibility for his or her own health. The compact lays out the patient's commitment to communicate with health care team members; involve his or her family in care; complete important care steps, including medication adherence; and undertake appropriate followup and preventive care. Condition-specific commitments (e.g., an agreement to try to stop smoking) are outlined in each area. Provider commitments, including a commitment to answer patient questions fully and satisfactorily and address patient concerns, are also outlined in the compact.
  • Patient education: Additional educational activities are offered to further engage patients in their health and recovery. For example, a hip replacement class outlines expectations for patient involvement in care, including adherence to physician recommendations regarding exercise, weight management, physical therapy, and other care.

Context of the Innovation

Geisinger Health System is a large, physician-led integrated health care delivery system operating in central and northeastern Pennsylvania. The system includes the following components: three hospitals on two campuses (a closed-staff hospital in Danville and a two-hospital campus in the Scranton-Wilkes Barre area) that are organized by service line; the Geisinger Clinic, with more than 750 physicians; and the Geisinger Health Plan, which provides coverage to approximately 220,000 enrollees. Geisinger implemented ProvenCare to drive improvements in quality and efficiency associated with better guideline adherence and more reliable, streamlined care. Geisinger chose CABG as an initial target for the ProvenCare program because the procedure was performed at all Geisinger hospitals, seven of eight cardiac surgeons were employed by the system, CABG guidelines had recently been updated by the American Heart Association/American College of Cardiology (AHA/ACC and the financial impact of CABG on the system is significant.

Did It Work?

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Results

Published pre- and post-implementation analyses show that the ProvenCare program significantly increased adherence to guidelines and improved clinical outcomes for both elective CABG surgery and for diabetes care. Internal Geisinger analysis suggests that the program has yielded similar positive results in other clinical areas. These results have been achieved in spite of the fact that Geisinger's quality performance in these areas was generally strong before program implementation.

CABG Surgery2 A pre-and post-implementation analysis compared all 117 elective CABG patients treated between February 2, 2006, and February 2, 2007 (the ProvenCare group), with 137 elective CABG patients treated in 2005 (the conventional care group). It found:
  • Better adherence to guidelines: All ProvenCare patients received all 40 care elements included in the bundle, compared with just 59 percent of those in the conventional care group.
  • Fewer readmissions, complications, and operative deaths: Six percent of the ProvenCare group was readmitted within 30 days, compared with 6.6 percent in the conventional care group. Another Geisinger analysis indicated that over an 18-month period (before and after program implementation), the 30-day readmission rate fell by 45 percent among ProvenCare patients.
  • Lower length of stay (LOS) and costs: Average total LOS was 5.3 days in the ProvenCare group, compared with 6.3 days in the conventional care group. These shorter stays contributed to a 5-percent reduction in hospital charges.
  • More likely to be discharged home: Ninety-one percent of the ProvenCare group was discharged home, compared with 81 percent of the conventional care group.
All ProvenCare patients received all 40 care elements included in the bundle, compared with just 59 percent of those in the conventional care group.

Diabetes Care4
A pre-and post-implementation analysis comparing the care of almost 20,000 Geisinger diabetes patients (now more than 22,000) found significant improvements in guideline adherence, care processes, and clinical outcomes.
  • Improved adherence to guidelines: The percentage of patients who received all nine bundle elements increased from 2.4 percent (447 patients) at baseline to 6.5 percent in February 2007 (1,266 patients), and then reached 11.6 percent by May 2008.
  • Increased vaccination rates: The percentage of patients receiving a pneumococcal vaccination increased from 56.5 percent at baseline to 80.8 percent in February 2007; comparable figures for influenza vaccinations are 55.1 percent and 71 percent.
  • Better glucose and blood pressure control: The percentage of patients with ideal glucose control (defined as hemoglobin A1c levels below 7 percent) increased from 32.2 percent at baseline to 34.8 percent by February 2007 and reached 45 percent by May 2008. The percentage of patients with ideal blood pressure control (defined as below 130/80 mg/dL) improved from 39.7 percent at baseline to 43.9 percent in February 2007 and reached 49 percent by May 2008.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including adherence to CABG and diabetes guidelines; CABG readmission rates; CABG complications; and glucose control, blood pressure control, and vaccination rates among diabetes patients.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Creating a steering committee: A steering committee consisting of clinical and executive leaders from the cardiac surgery department, the health system, and Geisinger Health Plan met periodically to design program goals, negotiate contract terms, and create and support workgroups.
  • Making guidelines actionable: A workgroup that included all Geisinger cardiac surgeons met to review the AHA/ACC CABG guidelines and their primary sources. The workgroup converted the guidelines into 40 actionable, measurable care process steps integrated with Geisinger's EHR.
  • Documenting existing care processes: A second workgroup documented existing CABG care processes and associated clinician workflows. Finding considerable variation in care, the workgroup recommended that only elective CABG surgeries be included in the ProvenCare program, because elective cases would allow sufficient time to adhere to all 40 elements of care.
  • Designing a new workflow: A third multidisciplinary workgroup designed a new workflow process that incorporated the 40 care elements. This process served as the framework for a structured template that information technology (IT) staff incorporated into the EHR; accompanying electronic tools (e.g., automated order sets) were designed by the IT staff with input from clinicians.
  • Designing flat-fee pricing: A fourth workgroup interviewed self-funded employer purchasers of GHP's insurance products to determine their interest in a program that would transfer financial risk to the providers. The workgroup found that purchasers were interested in financial predictability and thus liked the idea of an all-inclusive package price for elective CABG surgery.
  • Designing a patient compact: A fifth workgroup consisting of physicians, nurse educators, and marketing staff designed a patient compact that outlined the patient's responsibilities in care.
  • Expansion to other clinical areas: The development process outlined above—reviewing pertinent guidelines, developing actionable care elements, redesigning workflow, creating a packaged price, and adapting the patient compact—was subsequently used to roll out the program to other types of surgery and other areas of patient care, as noted earlier.
  • Update of coronary artery bypass care protocols: The program is incorporating the 44 Class I guidelines for Coronary Artery Bypass Surgery in the 2011 American College of Cardiology Foundation (CCF)/American Heart Association (AHA) Guidelines along with 22 additional guidelines reviewed and adopted by Geisinger's cardiac surgeons into a second iteration of ProvenCare for coronary artery bypass; this new iteration will be deployed at Geisinger's three cardiac surgery sites in the Spring of 2013 (updated February 2013).

Resources Used and Skills Needed

  • Staffing: Geisinger's Department of Clinical Effectiveness assigned one of its staff members to the CABG initiative. Other staff members at Geisinger, including clinicians and IT, also devoted significant time to the development effort.
  • Costs: Data on program costs are unavailable; the primary costs consist of the salary and benefits of staff members working on the initiative.
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Funding Sources

Geisinger Health System
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Tools and Other Resources

A list of the 40 CABG care elements and a copy of the ProvenCare patient compact is available at: Casale AS, Paulus RA, Selna MJ, et al. "ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care. Ann Surg. 2007;246(4):613-21. [PubMed]

The 2004 American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for CABG Surgery are available at http://circ.ahajournals.org/cgi/content/full/110/9/1168.

The Diabetes Association's Standards of Care are available at http://www.guideline.gov/browse/by-organization.aspx?orgid=159.

Adoption Considerations

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Getting Started with This Innovation

  • Ensure surgeon/physician support of guidelines: Surgeons must believe in the value of guidelines if they are going to adhere to them. To encourage support, the guidelines team assigned the review of a particular guideline to the surgeon who was most skeptical of its clinical value.
  • Create a multidisciplinary team: To ensure ease of adoption, physicians, other clinicians, IT personnel, and administrators should all be involved in designing the program.
  • Seek the buyer's perspective: Include health plans and self-ensured employers in discussions about bundled pricing to solicit input, align incentives, and ensure interest in this financing mechanism.
  • Design workflows carefully: An ideal workflow should be designed in a precise yet logical way so as to facilitate its implementation while eliminating variations in care.
  • Hardwire the process into electronic systems: The redesigned workflow should be enabled, supported, and documented in electronic systems to the greatest extent possible (including postintervention reporting).
  • Give physicians the ability to opt out: Geisinger physicians were more accepting of the guidelines because they knew they could opt out of a particular element of a bundle by providing justification in the EHR.

Sustaining This Innovation

  • Leverage templates and modules in other areas: The upfront investment of time and energy required to create the first program will pay off when it is time for expansion to other types of surgery and care because templates and modules can be relatively easily adapted for use in other areas.

Additional Considerations

  • As an integrated health system with employed physicians and its own health insurance plan, Geisinger has control over clinical processes and can assume the financial risk of fixed pricing. By contrast, a nonintegrated health plan or insurer would likely lack the direct control over clinical processes needed to implement the program, whereas a standalone hospital might not be in a position to take on the financial risk.

More Information

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Contact the Innovator

Alfred Casale, M.D.
Director, Geisinger Heart Institute
Geisinger Health System
MC 36-10
1000 East Mountain Blvd
Wilkes-Barre, PA 18711
(570) 808-6027
E-mail: ascasale@geisinger.edu

Innovator Disclosures

Dr. Casale has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Weber V, Bloom F, Pierdon S, et al. Employing the electronic health record to improve diabetes care: a multifaceted intervention in an integrated delivery system. J Gen Intern Med. 2008;23(4):379-82. [PubMed]

Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008;27(5):1235-45. [PubMed]

Casale AS, Paulus RA, Selna MJ, et al. "ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care. Ann Surg. 2007;246(4):613-21. [PubMed]

Footnotes

1 Steinbrook R. Guidance for guidelines. N Engl J Med. 2007;356:331-3. [PubMed]
2 Casale AS, Paulus RA, Selna MJ, et al. "ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care. Ann Surg. 2007;246(4):613-21. [PubMed]
3 Rosenthal MB, Frank RG, Li Z, et al. Early experience with pay for performance: from concept to practice. JAMA 2005;294:1788-93. [PubMed]
4 Weber V, Bloom F, Pierdon S, et al. Employing the electronic health record to improve diabetes care: a multifaceted intervention in an integrated delivery system. J Gen Intern Med. 2008;23(4):379-82. [PubMed]
Comment on this Innovation

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Original publication: May 25, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 27, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.