Care Transitions and Readmissions · Care Transitions and Readmissions Janet Tomcavage RN, MSN...

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Heal • Teach • Discover • ServeCopyright Geisinger Health System 2011

Not for reuse or distribution without permissionGeisinger Health System Confidential and Proprietary

Care Transitions and Readmissions

Janet Tomcavage RN, MSNChief Administrative Officer

Geisinger Health Plan



Geisinger Health System Components

Provider Facilities1

2

Geisinger Medical Center Danville Campus: Hospital for Advanced Medicine, Janet Weis Children’s Hospital, Women’s Health Pavilion, Level I Trauma Center, Ambulatory Surgery Center

Geisinger Shamokin Community Hospital Geisinger-Bloomsburg Hospital Geisinger Wyoming Valley Medical

CenterGeisinger South Wilkes-Barre campus with Urgent Care, Ambulatory Surgery Center and Inpatient Rehabilitation

Geisinger Community Medical Center Geisinger Lewistown Hospital Marworth Alcohol & Chemical Trtmt

Center Mountain View Care Center Bloomsburg Health Care Center 1,619 licensed inpatient beds 77K admissions/OBS & SORUs

Physician Practice Group

2Multispecialty group ~1,100 physicians ~560 advanced practitioners ~380 residents & fellows 71 primary & specialty clinic

sites 42 Community Practice Sites

all using ProvenHealth Navigator® model of advanced medical home

Freestanding outpatientsurgery center 2.3 million outpatient visits/yr

Managed Care Companies

3 ~450K members (including

~70K Medicare Advantage members, ~115K Medicaid members)

All lines of business & full spectrum of products

~34,000 contracted providers/facilities

Operate in 44 PA counties with 2.6M population

Out of state TPA contracts and MA plan

2



Revised 6-28-12. Geisinger PR & Marketing Department

Geisinger Health System Footprint

3



The Geisinger Journey

4

1995–1999• Condition

Management• EHR Installation

2000–2004• Data Warehouse• Clinical Decision Support• Patient Portal

2005–2006• ProvenCare®

• PGP Demo• Wellness

• All-or-none Bundles2007–2010

• ProvenHealth Navigator®

• Practice-based CareManagement

• Post Acute development

• Remote Monitoring

2011–2012

• Proof of concept engagements

beyond Central Pennsylvania

2013• Applying what

we’ve learnedto help others…

3



Sweet Spot for Partnership and Innovation

Aligned objectives between the health plan and clinical enterprise, with each organization contributing what it does best.

Health Plan

Joint:• Population

Health• Population

Served• EHR/

Infrastructure

Clinical Enterprise

• Population analysis • Align reimbursement • Finance care• Engage member and employer• Report population outcomes• Take to market

• Care delivery• Identify best practice• Design systems of care• Interpret clinical reports• Continually improve• Activate patient and family

5|



Geisinger’s PHN Model has Five Core Components

Patient-centered primary care

• Patient and family engagement and education• Enhanced access and scope of services• PCP led team-delivered care• Chronic disease and preventive care optimized with HIT

Integrated population

management

• Population segmentation and risk stratification• Preventive care• GHP employed in-office case management• Disease management

Medical neighborhood

• Micro-delivery referral systems• 360°care systems – SNF, ED, hospitals, HH, etc.

Performance management

• Patient satisfaction• HEDIS and bundled chronic disease metrics• Preventive services metrics

Value-based reimbursement

• Fee-for-service with P4P payments for quality outcomes• Physician and practice transformation stipends• Value-based incentive payments• Payments distributed on quality performance 6|

4



PHN Expansion

Sites

Medicare Advantage

MembersCommercial

membersFFS

Medicare

Geisinger CPSL -PA

42 23,328 61,206 42,715 26,708

Non- Geisinger -PA

40 5,939 18,762 0 8,595

West Virginia 3 0 4,835 0 0

Maine 6 0 1,717 2000 0

Total 91 29,267 86,520 44,715 35,303

PHN began in 2006 with 3 Pilot sites. The three pilot sites started with: 5,000 Medicare Advantage , 4,100 Commercial, and 2,100 Medicare lives.

# of Sites

GHP Family (Medical

Assistance)Members

Aug 2013



PATIENT CENTERED PRIMARY CARE

Building the foundation for transformation

| 8

5



9|

PHN Key Success Factors

• Manage the change, manage the change• Establish leadership and teams to:

– Re-design the process; customize available tools; and allow teams to innovate

• Embedded disease and case managers• Proactive patient identification and stratification• Monthly primary care team meetings• Actionable data to drive interventions



Building Systems of Care

• All or none “bundle” measure for diabetes• Clinical process redesign – Eliminate,

Automate, Delegate, Incorporate, Activate• Clinical decision support – Health

Maintenance and Best Practice Alerts• Patient specific strategies using registry

report data• Care gaps• Patient centered strategies – patient report

cards• Compensation

10|

6



Monthly Care Team Meetings

• Foundational to success• Shared leadership•Case review◦Missed opportunities◦Pattern recognition

• Workflow gaps and redesign• Performance monitoring• Review of patient ID reports and

performance outcomes• Care Team training



INTEGRATED POPULATION MANAGEMENT

Understanding and managing a population

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7



Care Approach by Patient Risk Status

Well

At-Risk

Chronic-Complex

• Advanced Primary Care • Practice redesign • Automated prevention care gaps and interventions• Health IT reinforces guidelines and best practices• Patient education and activation• Care team performance management meetings

•Chronic Disease Care•All of the above•ID and stratify•Self management and education•Close gaps in care•Driving to goal

• Concentrated Care• All of the above plus• Embedded Case Manager • Predictive analytics• Transitions• Advanced clinical management• Care coordination



Embedded Case Management has been Core to our Success

Embedded Case ManagerPersonal Care Link Recognized Team Member

Patient, family support contact

-High risk patient case load - 15 - 20% Medicare- 5% commercial- 125 - 150 pts per CM

Care Coordination –home care, hospice,

AAA

TOC follow-up – acute care, SNF, ED

Comprehensive Care Review – medical, social

support

Direct phone access –questions, exacerbation

protocols

Facilitates access – PCP, specialist, ancillary

Links health care team to payer

Regular follow-up of high risk patients

- 1 CM per 800 Medicare lives- 1 CM per 5000 commercial lives- 1 CM per 3500 Medicaid lives

- Not disease management focused

- Focus on those at most risk- Focus on driving issue within the

case

14|

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Going beyond the walls of primary care

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DEVELOPING A HIGH VALUE MEDICAL NEIGHBORHOOD



Coordinating Care Along the Continuum

Inpatient• IDTs

• Pharm D med reconciliation

• 24 hr D/C summary

• ED alerts thru HIE

• Scheduled f/up appts

SNF

• APRNs

• 24 hr initial assessment

• SNF on-call group

• First week “intensity”

• SNF Log

Outpatient• CM 24 – 48

hr call

• Med reconciliation

• Action Plan

• < 7 day f/up

• IVR

• Home visits

2023

16

9



MDS 3.0 or OASIS Medical Summary

HealthInformationExchange

17

The “Gobbler”

Long-Term Care & Home Health Get in the Game



Utilizing Tele-Health

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Remote Patient Tele-monitoring

•Extends care manager reach

•Helps prioritize the patients to focus on

•Provides that daily “touch” with the nurse for the patient

•Provides early warning signs

10



Evolving Healthcare Landscape

19

Integrated Health System Focus

Integrated Health System Focus

Solepractitioners

Virtualcommunity networks

Independentpractice

associations

Physician hospital

organizations

Multi-specialtygroup practices

Fully-integrated delivery systems

Care

pro

vid

er

paym

en

t m

od

els

Fee-for-service

Bundled services payment

Episode of illness payment

Professional servicesrisk model

Global risk model

Care provider practice models

Taking greater financial risk and responsibility for population outcomes requires providers to change the way they deliver care under payment reform



Moving the Payment Model

• Pay-for-Performance– Often quality-based– Gets attention, but

doesn’t maintain behavior

• Results Share– Drive to

outcomes-based reward

– Challenge to get there from FFS

• Bundled Payment– Challenge for

distribution of funds

• Full Capitation– Are organizations

ready for this risk?

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11



Pay-for-Value Programs

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Home Health (HH)

• Reporting• Readmissions• Emergency department (ED)• Admitting diagnosis• Denial monitoring

• 5 Metrics weighted at 20%

• Fee increase at risk

• Next phase – setting increases based on readmissions, niche services, medications, etc.

Skilled Nursing Facility (SNF)

• Pressure ulcer evaluation, treatment and healing better than national average

• Readmissions less than GHP book of business

• ED visits during SNF stay

• Fee increase at risk



PROVENHEALTH NAVIGATOR®

Evaluating the Impact

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12

ProvenHealth Navigator® Quality Outcomes -2012

Phase 1 and 2 trends represent 2007 through 2011 trends – Blue Bar = 2007 & Red Bar= 2012Phase 3 trends represent 2008 through 2011 trends – Blue Bar = 2008 & Red Bar = 2012Phase 4 trends represent 2009 through 2011 trends – Blue Bar = 2009 & Red Bar = 2012 Phase 5 trends represent 2010 through 2011 trends – Blue Bar = 2010 & Red Bar = 2012

0

5

10

15

20

Diabetes Bundle

Phase 1 Trend 7.6%

Phase 3 Trend 6.7%

Phase 2 Trend 11.1%

Phase 4 Trend 4.0%

Phase 5 Trend 33.7%

0102030405060

A1C Less than 7%

Phase 1 Trend 4.7%

Phase 3 Trend 3.4%

Phase 2 Trend 4.9%

Phase 4 Trend 4.3%

Phase 5 Trend -1.0%

05

1015202530

CAD

Phase 1 Trend 4.9%

Phase 3 Trend 12.4%

Phase 2 Trend 2.4%

Phase 4 Trend -0.6%

Phase 5 Trend 12.5%

0102030405060

LDL Less than 100 or Less than 70 if High Risk

Phase 1 Trend 3.9%

Phase 3 Trend 6.7%

Phase 2 Trend 2.6%

Phase 4 Trend 2.0%

Phase 5 Trend 6.1%

Phase 1 Trend 3.9%

Phase 3 Trend 6.7%

Phase 2 Trend 2.6%

Phase 4 Trend 2.0%

Phase 5 Trend 6.1%

05

101520253035

Preventive Care

Phase 1 Trend 32.3%

Phase 3 Trend 22.5%

Phase 2 Trend 29.8%

Phase 4 Trend 10.8%

Phase 5 Trend 15.7%

010203040506070

Mammogram

Phase 1 Trend 13.8%

Phase 3 Trend 3.7%

Phase 2 Trend 7.0%

Phase 4 Trend 0.4%

Phase 5 Trend 1.5%



Patient Satisfaction Survey Responses: Overall Experience with the Medical HomeHas your care improved? How satisfied are you with

your Primary Care site?

98%

2%

Very satisfied and satisfied

Very dissatisfied and dissatisfied

93%

7%

Agree and Strongly Agree

Disagree and Strongly Disagree

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Medicare Risk-Adjusted Acute Admissions/1000

257240 231 234

222 214

309 301 303 292 288276

264296

0

50

100

150

200

250

300

350

2006 2007 2008 2009 2010 2011 2012

PHN Non-PHN 67 Current PHN Sites



Medicare Risk-Adjusted Readmissions/1000

41

3033 34

29 29

47 46 4744

42 42 4244

0

5

10

15

20

25

30

35

40

45

50

2006 2007 2008 2009 2010 2011 2012


14



MedicareRisk-Adjusted ED Visits/1000

293

262 256 260 263 272264 249

264285 292

323 328

268

0

50

100

150

200

250

300

350

2006 2007 2008 2009 2010 2011 2012




Commercial Risk-Adjusted ED Visits/1000

176192

173 180195

227 230 238 233248

267

204

0

50

100

150

200

250

300

2007 2008 2009 2010 2011 2012


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PHN Results for Medicare

(Am J Manag Care. 2010;16(8):607-614)| 29



Cumulative Percent Difference in Spending Attributable to PHN

-12%

-10%

-8%

-6%

-4%

-2%

0%

Q1 2

005

Q3 2

005

Q1 2

006

Q3 2

006

Q1 2

007

Q3 2

007

Q1 2

008

Q3 2

008

Q1 2

009

Q3 2

009

95% Confidence Interval

Median Estimate

95% Confidence Interval

Cumulative percent difference in spending (Pre-Rx Allowed PMPM $) attributable to PHN in the first 21 PHN clinics for calendar years 2005-2009. Dotted lines represent 95% confidence interval. P = < 0.00330|

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Population Health More Broadly

• Accountable Care– Keystone ACO– MSSP “ACO”

• CMMI Bundled Payment– 16 hospital systems in Geisinger cohort

• Expanding Health Plan opportunities– MA in New Jersey with Meridian HS– TPA with WVU & EMHS– Pioneer with EMHS

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West Virginia United Health System

• Administrative services agreement for enhanced TPA services for employee health plan

• Administrative services agreement for enhanced TPA services for employee health plan

Relationship

• Enhanced TPA services• Development and operation of

medical homes• Population health data analytics• Care management• Wellness

• Enhanced TPA services• Development and operation of

medical homes• Population health data analytics• Care management• Wellness

Services

32

17



Medical Surgical Admissions & Readmissions

60.5/1000

50.6/1000

6.9/1000 5.7/1000

-

10.0

20.0

30.0

40.0

50.0

60.0

70.0

2011 2012

Ad

mis

sio

ns

per

10

00

Mem

bers

Admits Readmits 33Conf

Medical Surgical Admissions decreased 16.4% And Readmissions decreased 17%

WVUHS Medical & Surgical Admissions Only.



Eastern Maine Health System

• Administrative services agreement for expanded population health capabilities for employees and dependents

• Administrative services agreement for expanded population health capabilities for employees and dependents

Relationship

• System and primary care practice accountable care assessments

• TPA services• Development of medical homes• Data Analytics• Care management• Wellness

• System and primary care practice accountable care assessments

• TPA services• Development of medical homes• Data Analytics• Care management• Wellness

Services

34

18



35

49 / 1000

31.3/ 1000

12.1 / 1000 6.9 / 1000

0

10

20

30

40

50

60

2012 2013

Admits Readmits

•Incurred January through July and Paid through October 2013 EMHS .•Not Risk Adjusted..

Medical Surgical Admissions have decreased 36%Readmissions have decreased 43%

Medical Surgical Admissions & Readmissions



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