Managed Care - January 2008 - (Page 18) attractive for insurers to provide incentives to their enrollees to have these procedures done at the Geisinger Clinic. Perhaps Geisinger can also use the warranty as a way to negotiate higher payment rates from insurers.” (To see what other experts are saying, read “Experts weigh in on Geisinger’s experiment” on page 22.) Physicians must document 40 steps that Geisinger identified as necessary for CABG patients. They are divided into five categories: preadmission, operative, post-operative, discharge, and post-discharge. “We have taken guidelines from the American College of Cardiology and the American Heart Association and translated those guidelines into best practices that we believe are reasonable,” says Casale. “You can opt out of any one of them as an attending surgeon simply by writing a note in the chart saying I know that I’m supposed to do X, but here’s the reason why I’ve actively chosen to not do it for Mrs. Jones. This isn’t slavish robot medicine, but it is a slavishly robotic need to think about each of 40 points. There is a big difference.” (To see all 40 points, turn to “Physician performance crucial in ProvenCare’s success” on page 23.) Patients who volunteer to participate must sign a “patient compact” that spells out exactly what they need to do to help themselves post-operation. “It says, I understand that you’re going to be doing a lot of things and you’re committed to doing things right,” says Casale. “So I’ll commit myself to watching my diet, keeping my appointments, telling you if I have a problem. There are about 25 things on the patient compact.” The steps under “post-discharge” include questions that the patient needs to answer, such as “Did you stop smoking?’ and “Are you correctly taking Pharmacy plays an important role in ProvenCare effort ean Parry, RPh, director of clinical pharmacy programs at Geisinger, says that ProvenCare helps to ensure that appropriate considerations are made, and appropriate guidelines are followed, in prescribing. “Rather than the physicians having to remember everything they need to order for the patients, we work with them to create order sets and we do them both on paper and in the computer system, depending on the situation,” says Parry. “The doctor signs off on them, but the details of what may need to be prescribed and the appropriate laboratory tests are all laid out for him.” The ordering process has traditionally been more openended, he says. “The key with ProvenCare is taking the current best-practice guidelines plus sitting the entire team that is involved in the care down together and making decisions that we apply on a universal basis,” says Parry. D Geisinger officials have yet to determine whether that process has cut pharmacy costs. “It could take a year or two to notice savings,” says a spokesman. On the clinical end, though, pharmacists at Geisinger feel a sense of ownership. “Pharmacists tend to be fairly datadriven,” says Parry. “So utilizing the data that’s out there in terms of outcomes is definitely a strong point for us. That’s one of the things that ProvenCare does.” For example, ProvenCare does a better job of controlling blood glucose after surgery. “High blood glucose can contribute to post-operative infections and also to increased length of time to recover from the surgery,” Parry notes. Increased recovery time and/or increased risk of infection can result in significant increases in cost of care. “We worked through a process of looking at all the data, figured out what’s the best method for controlling blood glucose, and then came up with a plan on how to manage the patient to prevent hyperglycemia from occurring,” says Parry. Timeliness is crucial in medication management. Discharge checklist ProvenCare also makes sure that patients are taking all of the correct medications at discharge. Many of the medications are necessary to prevent late complications from the surgery. Each patient has a checklist that reminds the discharging physicians of the medications that need to be considered. Patients who then need ongoing anticoagulation therapy, with medications such as warfarin or low-molecular-weight heparin, are referred to a systemwide pharmacist-run anticoagulation management service, where pharmacists take responsibility for monitoring and overseeing dosage adjustments. 18 MANAGED CARE / JANUARY 2008
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