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An EHA Collaboration with Geisinger Health System (GHS)
ValuedCare Programme
Overview
• Strategic Overview
• ValuedCare Hip Fracture
• ValuedCare Heart Failure
- Planning Phase
- Implementation
- Results
RESTRICTED/CONFIDENTIAL/HIGHLY CONFIDENTIAL
ValuedCare Programme Hip Fracture Programme
Heart Failure Programme
Vision
To Transform EHA into a Innovative Organization Focused on Delivery of
Value-Oriented Care and
Population Health Management
Valued Care Programme
Population Health Management
• Life-cycle vs Episodic Care
• Enablers eg IT, Best Practice Elements
etc
Valued-Oriented Care
• From Volume to Value
• Total Cost of Care
• Data Analytics
Systems Level Care Transformation
Valued Care Programme
Save lives through timely acute interventions
Restore functionality by doing the right things first
To keep our patients functional, independent and active in their community
Improve the Quality of Life for our patients
CGH Vision, Mission and Values
ValuedCare Programme: Care Across Continuum
Acute Care
Performance Improvement
EMR Enhancements
Cost of Care
Primary Care
Access Redesign
(Right Sited + Available
Appointments)
Outpatient Performance
Measures
Specialty Care
Access Redesign
(Right Sited + Available
Appointments)
Outpatient Performance
Measures
Transitions of Care
Transitions Performance
Measures
Post-acute Care
Rehab
Community Hospital
(Right Sited, Care
Coordination)
Case Management
Phase 1 Phase 2
ValuedCare - Opportunities
Clinical
Practice
Healthcare
Analytics
Care
Processes
Total
Cost of
Care
Best Practice Elements
Care Gap Analysis
Capability Building Eg. Case Management
Total Quality / Cost of Care
Process Re-Designs
ValuedCare - Opportunities
ValuedCare – Hip Fracture
RESTRICTED/CONFIDENTIAL/HIGHLY CONFIDENTIAL
We aim to improve: The functional status and quality of life
of patients with fragility hip fracture
through reliable delivery of evidence-
based cost-effective care for patients
The process begins with: When hip fracture is diagnosed by the A&E Doctor
The process ends with: 12 months post discharge.
Key Clinical Outcomes
At least 70% fragility hip
fracture patients receive
surgery within 48h
Achieve reduction of the total
stay to 10 days of the acute
hospital (bed) stay.
Mobilisation from 1st POD
Functional Recovery at 3,6 and
12 months It is important to work on this now
because: We want to reduce complications and the length of
stay in acute hospital, in order to reduce cost and
increase bed capacity.
CGH ValuedCare Hip Fracture Program
– Global Aim Statement
Inclusion Criteria Exclusion criteria
65 years and above Non- surgical patients
Single Hip fracture (within 6 months) Multiple trauma
Low energy fall / minor road traffic accidents, i.e. fall from low speed bicycle
Pathological fractures (metastases,
avascular necrosis, severe osteoarthritis)
Neck of Femur, Intertrochanteric, Subtrochanteric fracture with surgical intervention
Operated patients
Only “Urgent” inpatient cases
ValuedCare Hip Fracture Programme
23 Best Practices from A&E to Inpatient Stay to Post Discharge Care
CGH ValuedCare Hip Fracture Programme
A&E Pre-Op Post-Op Discharge Post-Discharge
1. Pain protocol
2. X-rays
3. Stat lab
studies
4. Ortho clerking
5. Pre-fracture
assessment
6. Bowel protocol
7. Delirium screening
8. Antibiotics within
60mins of incision
9. Op within 48hrs
10. Case management
consult
11. X-ray & lab
investigations
12. Discontinue
antibiotics within
24hrs
13. Ortho-geri consult
14. 1st POD WBAT order
15. 1st POD PT commence
mobilisation
16. Finalise discharge
plan with patient
/ caregiver by 2nd
POD
17. Discharge
instructions
(WBAT, mobility,
functional,
wound care)
18. Compliance
to follow-up
visits
19. Wound check
20. Parker
Mobility
21. Modified
Barthel Index
22. Quality of life
(EQ-5D)
23. DVT Prophylaxis and Skin Assessment
21 Best Practices from A&E to Inpatient Stay to Post Discharge Care
CGH ValuedCare Hip Fracture Programme
A&E Pre-Op Post-Op Discharge Post-Discharge
1. Pain protocol
2. X-rays
3. Stat lab
studies
4. Ortho clerking
5. Pre-fracture
assessment
6. Bowel protocol
7. Delirium screening
8. Antibiotics within
60mins of incision
9. Op within 48hrs
10. Case management
consult
11. X-ray & lab
investigations
12. Discontinue
antibiotics within
24hrs
13. Ortho-geri consult
14. 1st POD WBAT order
15. 1st POD PT commence
mobilisation
16. Finalise discharge
plan with patient
/ caregiver by 2nd
POD
17. Discharge
instructions
(WBAT, mobility,
functional,
wound care)
18. Compliance
to follow-up
visits
19. Wound check
20. Parker
Mobility
21. Modified
Barthel Index
22. Quality of life
(EQ-5D)
23. DVT Prophylaxis and Skin Assessment
ValuedCare Hip Fracture (n= 329)
68.4% 81 years old
75.1% Chinese
47.4 %
Live independently without a carer
94.8% Live at home pre-fracture
61% Did not require walking aids pre-fracture
69.3% HPT 44.1 % Hyperlipdemia
33.7% DM 15.5 % IHD
71% of VC cohort had higher anaesthetic risk (ASA 3-4)
25% reduction
in ALOS
ValuedCare Hip Fracture Outcomes
60%* of patients had
surgery within 48 hrs *when medically unfit patients
excluded
Significant reduction in
inpatient complication
rate of Delirium, Pneumonia,
UTI and Pressure Ulcer
48% reduction in
median time to surgery
(50.5 hrs)
51%# regained
prefracture dependency
status (#MBI at 6 months-
54/107 patients)
SACH Accelerated Discharge SACH Standard Care
Admission to SACH CGH hip fracture patients admitted under ‘SACH rehabilitation’
CGH hip fracture patients admitted under ‘SACH rehabilitation’
Age ≥65 years old ≥65 years old
Type of fracture Low impact, single hip fracture Low impact, single hip fracture
Weight bearing status on admission to SACH
Full weight bear Full weight bear/Partial weight bear/ Non-weight bear
Premorbid parker index 9 <9
Post Acute Rehab @ SACH: Inclusion Criteria
Care Processes Indicators @ SACH
PCC done within 7 working days
Caregiver education
Home exercise advised Caregiver return demo
Home assessment
done
Community service referral
Falls education advised
Osteoporosis management: Calcium/Vit D
Bisphosphonate
Do not copy or distribute without permission
Variable Accelerated rehab pilot [Aug – Dec ‘15] (n=31)
Accelerated rehab [Jan – Mar ’16] (n = 21)
Length of inpatient stay (days) Mean
Median
30.5 25
33 35
Transfer back, n (%) 8.8% 8.7%
Osteoporosis management, n (%) Calcium/Vit D
Bisphosphonate
96.8% 51.6%
100% 47.6%
Admission barthel (median) 59 47
Discharge barthel (median) 86 86
VC Hip Fracture Programme – Phase 2 (Post acute rehab @ SACH)
Variable Standard rehab pilot
[Aug – Dec ‘15] (n=59) Standard rehab
[Jan – Mar ‘16] (n = 46)
Length of inpatient stay (days) Mean
Median
35.6 32
36.8 31.5
Transfer back, n (%) 14.1% 14.8%
Osteoporosis management, n (%) Calcium/Vit D
Bisphosphonate
98.3% 30.5%
100% 32.6%
Admission barthel (median) 41 40
Discharge barthel (median) 64 63.5
ValuedCare – Heart Failure
How can we recruit
more patients with
existing resources?
RESTRICTED/CONFIDENTIAL/HIGHLY CONFIDENTIAL
We aim to improve: The functional status and quality of life
of patients with heart failure through
reliable delivery of evidence-based cost
effective care
The process begins with: Upon diagnosis of heart failure during index admission*
The process ends with: 12 months post discharge.
Define the population: Patients >18 years old with a primary discharge
diagnosis of heart failure from cardiology
CGH ValuedCare Heart Failure Program
– Global Aim Statement
Key Clinical Outcomes
Non- elective
readmission rate (within 30
days & 12 month)
Mortality rate (within 30 days
& 12 months)
22 Best Practices from A&E to Inpatient Stay to Post Discharge Care
CGH ValuedCare Heart Failure Programme
A&E In patient Post-Discharge
1. Appropriate
Diagnosis of HF
2. Identify Etiology
3. Identify precipitant
4. CXR
5. ECG
6. HF Order set
7. IV Diuretics
8. Weight measured
9. Urine output
measured 1 hr post
diuretics
10. Medication reviewed
11. Transthorcic echo within 12
months
12. Appropriate B Blocker/
Ivabradine prescribed
13. Appropriate ACE/ ARB
prescribed
14. Etology identified
15. Precipitant identified
16. Daily Weights
17. Referral to HF nurse upon
diagnosis
18. Patient Education
19. NYHA class
20. Device need assessment
21. Discharge instructions
22. HMU follow up calls)
19 Best Practices from A&E to Inpatient Stay to Post Discharge Care
CGH ValuedCare Heart Failure Programme
A&E In patient Post-Discharge
1. Appropriate
Diagnosis of HF
2. Identify Etiology
3. Identify precipitant
4. CXR
5. ECG
6. HF Order set
7. IV Diuretics
8. Weight measured
9. Urine output
measured 1 hr post
diuretics
10. Medication reviewed
11. Transthorcic echo within 12
months
12. Appropriate B Blocker/
Ivabradine prescribed
13. Appropriate ACE/ ARB
prescribed
14. Etology identified
15. Precipitant identified
16. Daily Weights
17. Referral to HF nurse upon
diagnosis
18. Patient Education
19. NYHA class
20. Device need assessment
21. Discharge instructions
22. HMU follow up calls)
ValuedCare Heart Failure (n= 530, no of admission =1129)
39.4%
70 years old*
55% Chinese
56% Diabetes
66.3% HPT
67.5 % IHD
37% CKD Stage 1 & 2
62% CKD Stage 3 & 4
34.8% Mean EF
Normal (≥ 50%): 26% Mild (40% - 49%): 14% Moderate (30% - 39%): 17% Severe (<30%): 43%
Conclusions 1. VCHF population is older with a higher prevalence of DM, HPT as compared to baseline
cohort. 2. No significant difference in readmission & mortality rate between VCHF & baseline cohort.
Frees up clinicians
and case managers
to focus on patient
care and function at
top of license
*Simulated data for illustration purposes
Allows the process
of data extraction/
analysis be less
onerous
Improves decision
support and allows
team to be more
responsive
Comparing the care of HF patients at CGH after ValuedCare
28
Heart Failure Primary Diagnosis
2012
CCP –71%
Nov 2014 – Apr 2015
Heart Failure Primary Diagnosis
Implementation of ValuedCare has seen a greater proportion of
heart failure patients being managed under a care pathway.
Frequency of HMU calls matched to patients’ needs
• Patients are risk-stratified
upon inpatient discharge
• Shared Co management
model at Bedok Family
Medicine Centre (FMC)
• Services at Bedok FMC:
o Medication titration
o Symptoms monitoring
o Mgmt of other chronic
conditions
o Holistic case
management by FMC
Care Managers
• Implemented at Bedok FMC
on 1st Mar 2016
• Collaboration at Singhealth
Polyclinics targeted for Q1
2017
VC Heart Failure Program – Phase 2 (since Mar 16)
VC Heart Failure Program – Phase 2 (since Mar 16) Co-management with Bedok FMC – Uptake & 30D Readmission rate (Mar – Jun 16)
Mar – Jun 16 = 199 patients
Collaborating with SHP to
finalise the co-management
clinical care pathway.
To implement co-management
model at selected SHPs
polyclinic. Estimated start date
of CGH / SHP co-management
by Q1 CY17. Number of Patient
30D All-cause Readmission
Rate
Enrolled 64 10 16%
- Actualized 43 5 12%
- Drop Out 21 5 24%
Not Enrolled 135 34 25%
TOTAL 199 44 22%
Engage our champions/ leads
Define our problem
Establish our standards/
measurements
Gap Analysis/ Process redesign
IT hardwiring / Data Analystics
Improve
Celebrate Early Successes
Conclusion
ValuedCare Programme
Hip Fracture Programme
Heart Failure Programme
Acknowledgements
• Meg Hogan, xGHealth Solutions
• Geisinger Health System consulting team
• Dr Poon Kein Boon, CGH team lead
• Dr Goh Kiat Sern, CGH team lead
• Dr Gerard Leong, CGH team lead
• Dr Janet Choo, CGH case management
• Dr Edward Goh, SACH team lead
• Dr Chow Wai Leng, HSR, EHA
• Yap Mei Foon, EHA
• ValuedCare Hip Fracture & Heart Failure Teams, CGH
• ValuedCare Programme Office, CGH
• Case Management, CGH
• Health Services Research, EHA
• Health Management Unit, EHA
Thank You!