Ledina Lushko Revisited: Insight from CDVC

Ledina Lushko Revisited: CDVC

Mrs. Ledina Lushko was diagnosed with adrenocortical carcinoma (ACC) which is an aggressive cancer of adrenal gland. ACC is a very rare cancer that affects approximately 0.5-3 cases per millions. Mrs. Ledina and her family went through a tough period of consulting various doctors, many tests and differing opinions from specialists. In most cases ACC will be diagnosed only after it reaches an advanced stage which gives patients a very limited amount of survival period of three to six months. Due to its rare occurrence, effective treatment for ACC is a challenge to doctors as they had to rely only on the observational studies on small group of patients.

Mrs. Ledina was used to getting healthcare at Albania which did not necessitate her to establish a primary care provider and she had purchased a low-cost high deductible plan for emergency situations. This led to Mrs. Lushko and her family taking time to select their PCP. She had to waste a lot of time and money for her initial evaluation as Johnson Medical center did not have any information about her medical history. Mrs. Lushko’s treatment and diagnosis reveals many shortcomings of US healthcare delivery system. We use this case study as a basis for analyzing Mrs. Lushko’s Care

Delivery Value chain against an ideal CDVC.

Analyzing Care Delivery Value Chain (CDVC)

Care Delivery Value Chain(CDVC) is designed around a medical condition and applies over the full cycle of healthcare delivery. CDVC is a systematic approach where one outlines the discrete activities required for the care, sequence and organization of the care, configure and analyze the delivery process around the medical condition to maximize the overall value for the patients.

In CDVC framework, dedicated and tightly coordinated teams utilize facilities designed for the medical conditions, and patient information is extensively shared. Every entity in the CDVC carry equal responsibility as an team and are equally accountable for performance. Value for the patient care is not measured for individual activities in a cycle of care, instead value is measured as an outcome of the entire cycle. (Rhatigan, J. & Jain, S. & Mukherjee, J. S. & Porter, M. E., 2009) .

In current healthcare delivery system and for most of the providers has care delivery value chains for medical condition but they are not explicitly delineated. This framework is difficult to be analyzed and measured for outcomes/value of the health outcomes. To implement CDVC model, providers need to go through a transformation where one has to define and measure the outcome of the process on the medical condition level. Once the process is defined, configuring and organizing the structure are the next steps to deliver the increased value based services for patients.

According to Porter and Tiesberg, Care Delivery Value chain begins with monitoring and prevention that includes tracking patients medical conditions, risk evaluation, steps to prevent illness/injury. Then the value chain progresses to diagnosing, preparing, intervening, rehabilitation and monitoring and managing. Last step in the value chain is as important as other steps as not only constantly managing patients condition to sustain the recovery but also taking preventative steps to avoid reoccurrences are a part of monitoring and managing.

Let us now track back to Mrs. Ledina Lushko’s treatment and diagnosis to analyze the kind of care she received. Mrs. Ledina Lushko did not have any form of medical history in US as she was receiving most of her care in Albania. Mrs. Lushko and her family took some time to identify her PCP and her choice of hospital to receive her treatment.

She had to undergo series of detailed evaluation as doctors at Johnson couldn’t establish access to her medical records and assess the risk involved. They also did not have any idea about her preventative steps if she had taken any which made the situation even more demanding for the doctors to conduct all possible tests to diagnose her condition as accurately as possible. Let us look at the ideal CDVC in parallel to the care delivery which Mrs. Lushko received at Johnson Medical center.

In Mrs. Lushko’s case, even though she underwent expedited inpatient evaluation, she had to consult different specialists and they asked almost the same questions which indicates that there is no seamless sharing of information/records about a patient’s medical condition. Also, these specialist teams were not working as single integrated team of specialists to determine her treatment plan which is why her initial evaluation took so much time and she received conflicting opinions about removing her tumor.

Mrs. Lushko was not admitted through oncology department instead of primary team. It could have eased her oncology/endocrinology evaluation tests and diagnosis during her initial evaluation. In addition, each doctor had his/her own interpretation of data instead of collaboratively working as a team to decide upon definitive treatment plan. Excellent providers will not only integrate across the value chain within their own organizations, but also with independent entities involved in the care cycle. An ideal CDVC should have an enhanced communication set up that seamlessly share information between different teams.

Mrs. Lushko got her tumor removed at Johnson medical center and her recovery was closely monitored. Before discharging she was given a list of ten medications without clear instructions of dosage. Johnson failed to provide her a counseling therapy on her recovery, dosage and post-discharge plan.

This led to the Mrs. Lushko taking high doses due to which she experienced adverse reactions and was admitted back to the hospital. In an ideal CDVC, patients are counseled with information about their procedures, getting education about their recovery and post-discharge plans. Hospitals/Providers should make sure that the patient receive clear instructions about their medications, possible side effects so that they can reach out to doctors if necessary. It will avoid any errors/ complications that will delay the patients recovery.

Mrs. Lushko’s condition was not monitored post-discharge. Side-effects of her chemotherapy treatment were not kept in check constantly and most importantly oncologists and endocrinologists were not communicating with each other about Mrs. Lushko’s treatment and dosages. That could have avoided complications faced during her therapy (Sachin H. Jain, Michael E. Porter, Fatima Akrouh, Carolyn A Daly). Most of the providers do not emphasize the importance of monitoring patients medical conditions which goes beyond the discharge. CDVC model indicates that the discharge from the hospital is not the end of the cycle nor is the admission to the hospital in the beginning. Monitoring the patient’s lifestyle, constant follow up with patients will prevent the reoccurrence of the disease in cases like cancer and other chronic diseases. This is one of the reason why some providers have started to emphasize more on disease management.

Providers and hospitals should harness Information Technology to aid in their efforts to monitor patients health and communicating with them constantly. Information technology can be used to measure the performance of each and every activity in the care cycle. CDVC is an iterative model where errors is one activity could lead that to next steps and may result in complications/risk patients conditions. Multiple iterations is not a good sign that may have caused by mistakes, poor processes and inattention to the overall care cycle( Michael E. Porter, Elizabeth Tiesberg, page 207)

Conclusions and Recommendations

Care Delivery Value Chain looks at the overall care cycle where in each individual activity is interlinked. Value for the care in CDVC is measured for the entire cycle as performance of one activity affects the results of another. Defining activities in CDVC is very important to close the gaps in performance, remove redundant activities, improved accountability and eventually adding value to the health outcomes. Delineating individual activities will yield important insights in configuring, organizational and performance improvement and also help in coordinating care delivery, between the particular activities and across the care cycle(Porter and Teisberg, 2006, page 212).

One of the strong points of CDVC’s design is its structure around particular and co-occurring medical conditions. Facilities, specialist physicians, staff and equipments are designed to the specific medical conditions which leads to better efficiency, improved coordination and better value from a patient standpoint.

Designing integrated teams in the care delivery chain will encourage innovation among employees and knowledge development among staff in their field of expertise. Providers must examine their scope of services and simultaneously made jointly accountable for the overall results. CDVC model empowers provider to design the process that integrates activities and effectively evaluate their performance, and the development of this process around the medical condition will result in a greater performance improvement over the entire cycle of care.

References:

Jain, S. H. & Porter, M. E. & Akrouh, F. & Daly, C. A. Case Study-Ledina Lushko: Navigating Health Care Delivery. Harvard Business School. 9-710-459. January 25, 2010.

Porter, M. E. & Teisberg, E. O. (2006). Redefining Health Care: Creating value-based competition on results. Boston: Harvard Business School Press.

Rhatigan, J. & Jain, S. & Mukherjee, J. S. & Porter, M. E. ( 2009). Applying the Care Delivery Value Chain: HIV/AIDS care in resource poor settings. Boston: Harvard Business School Press.