Geisinger Clinic achieved a more than 90% sustained cure rate for insured hepatitis C virus patients after implementing a program focused on providing "comprehensive, cost-efficient, and streamlined care," Sandeep Khurana, medical director of liver transplantation at Geisinger Medical Center, and colleagues write in NEJM Catalyst.
About the program
Khurana, Sara Gaines, a clinical pharmacist at Geisinger Medical Center, Thomas Lee, chief medical officer for Press Ganey Associates, and others note that "the Geisinger Clinic provides services in counties with some of the highest rates of Hepatitis C virus infection in Pennsylvania." And while "new direct-acting antivirals have transformed hepatitis C from a chronic disease to a curable infection, these treatments are expensive and require strict adherence," which the authors write can pose a challenge, particularly for patients in rural Pennsylvania, "where access to health care is limited."
"To meet this challenge, we developed a comprehensive approach by marshaling resources across the health care system," Khurana and colleagues write. That approach, called the ProvenCare hepatitis C program, aims to get the patient needed care in just one in-person visit. To do so, the program relies on a multidisciplinary team of gastroenterologists, pharmacists, nurse coordinators, nurse practitioners, data analysts, leadership, research, and representatives from Geisinger Health Plan, Khurana and colleagues write.
Under the program, a patient must be referred. From there, a nurse coordinator or a pharmacist contacts the patient "explain[n] the flow and structure of the program," Khurana and his colleague write.
The first step is a blood test, which takes place before the clinic visit to "ensur[e] the availability of the information needed to make treatment decisions and avoids additional clinic visits," the authors write.
During the clinic visit, the clinician and staff will give an overview of the treatment regimen and "explain the treatment regimen in detail and emphasize the importance of adherence to treatment and subsequent monitoring (i.e., blood work)." Follow-up evaluations are completed over the phone and are scheduled at the patient's convenience, the authors write.
"This approach allows improved access, efficient treatment decision planning, and enhanced patient engagement; the latter is paramount to a successful program as direct observation therapy is neither available nor feasible," Khurana and colleagues write.
"For patients who are not able to afford treatment, [Geisinger] utilize[s] manufacturer-based copay assistance programs and grant money from public foundations," the authors write. "At Geisinger Clinic, no patient has ever been denied treatment because of financial difficulties."
According to the authors, the 12-week sustained virologic response rate for HCV infection was 94% for Geisinger Health Plan-insured patients treated through Geisinger's ProvenCare model. According to Khurana and his colleagues, 3.6% of patients were "lost to follow-up (as determined on the basis of insurance claims data and manual chart review)."
In comparison, the HCV cure rate was 56% among Geisinger Health Plan-insured patients treated at non-Geisinger facilities, with 44% of patients being lost to follow-up.
5 key steps for implementing program
Khurana and colleagues summarize five key steps that Geisinger followed to implement the program and increase HCV cure rates.
- Self-evaluation: Before developing a comparable Hepatitis C program, Khurana and colleagues note that it's essential for hospitals to examine and understand their current processes, including barriers to care and any existing care gaps.
- Teamwork: To develop the program, Khurana and colleagues write Geisinger used a multidisciplinary team. In particular, Geisinger engaged in early collaboration with a team involving Geisinger's health plan and informatics partners, which allowed Geisinger to leverage the skills and abilities of their team, such as having providers practice to the full extent of their licenses.
- Balanced solutions: Khurana and colleagues write that hospitals should ensure their clinical care vision and related action steps are both grounded in science and "sensitive to patient needs."
- Data infrastructure investments: Khurana and colleagues write Geisinger designed a data infrastructure to maximize efficiency and help track patients. However, Khurana and colleagues note this step may not be essential for other health systems seeking to implement a similar program as they could instead develop and implement a standardized spreadsheets to effectively track patients.
- Get staff involved: To get staff on board, Khurana and colleagues write that hospitals should "[i]ncentivize the clinical staff involvement and designate a clinical champion who drives implementation." For example, they note that Geisinger's "Gastroenterology and Pharmacy departments were incentivized to hire additional nurse coordinators and clinical pharmacists" (Khurana et al., NEJM Catalyst, 7/11).
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