Transitions of Care/Personal Health Navigator

Heal • Teach • Discover • Serve Geisinger Value1

Transitions of Care/Personal Health Navigator

January 31, 2009


Agenda

• Geisinger Overview• Transitions of Care• Personal Health Navigator aka Medical Home


Overview of Geisinger System

• Geisinger Clinic:– 750 Physicians – 42+ Community Practice Sites

• Three Acute Care Hospitals:– Geisinger Medical Center– Geisinger Wyoming Valley– Geisinger South Wilkes-Barre

• Geisinger Health Plan:– 80 Hospitals, 17,000 Providers

• Clinical Innovation Strategy– ProvenCaretm

– Chronic Disease Optimization– Personal Health Navigator– Transitions of Care– EPIC enabled


Geisinger Health System

Geisinger Inpatient Facilities

Geisinger Medical Groups

Geisinger Health System Hub and Spoke Market Area

Geisinger Health Plan Service Area

Careworks Convenient Healthcare

Non-Geisinger Physicians With EHR

Gray’s Woods


Geisinger Transitions of Care (“TOC”) Project

• Started in January, 2008 as a joint quality-efficiency initiative complementing the medical home– Eliminate unnecessary readmissions– Free up capacity for more acutely ill medical and surgical

patients

• Seeks to build on the disease-specific readmissions work performed at numerous institutions over the last decade, with several key differences:– System-wide vs. narrow population– Multiple pilots to test impact of different interventions– Focused primarily on quality enhancement and future

economic positioning, with limited/no current negative impact


Transition Patient Flow Design

Pre-admission/

ED

Ad-mission

Inpatient Stay

Discharge Post Acute

Screening for High Risk

Detailed Assess-ment

Interdisci-plinary Rounds

PCP Appt. Proactive Outreach

Pre-Hospital Care Mgmt for Elective Pts

Early Nurse Care Activation

Teach Back Discharge Synopsis

Enhanced Nsg. Home Clinical Capabilities

Discharge Plan

Palliative Care


Admission Checklist

• Screening• Care Management Assessment• Expected Length of Stay• Planned Disposition• Medication History• PT/OT Needs• Wound Care• Diabetes


Interdisciplinary Team Rounds

Today’s discharges:• Confirm that all plans are being executed for a timely discharge• Outstanding issues Patients being readied for transition:• What is the planned discharge date?

– What is keeping the patient from going home or to a lower level of care?– Can anything be implemented today to expedite the discharge date?

• Is there a risk for readmission? What can be implemented to reduce that risk?

– Are activities of daily living (walking, eating, elimination) at an appropriate level to prepare for transition?

– Need Nutrition/PT/OT/Diabetes/Wound intervention? PICC line for post acute infusion?

– Is the patient and family teaching completed in preparation for transition?– Referrals/insurance authorizations needed? Placement arranged?– Is the family and home ready for transition? Are there any patient safety

considerations?


Discharge/Proactive Outreach

• PCP Appointment Scheduled Before Discharge

• Discharge Synopsis to PCP• Inpatient Screening leading to Post Acute

Care Management– Medication Reconciliation and Teaching– Physician Appointment Follow Up– Home Care and DME in Place– Trigger Management


10

Personal Health Navigator Team Provides Patient Care and Navigation

aka Medical Home


Five Functional Components

• Patient Centered Primary Care• Integrated Population Management• Value Care Systems• Quality Outcomes Program• Value Reimbursement Program


Integrated Population Management

• Population profiling and segmentation– Predictive Modeling

• Health promotion• Case Management on site

– Patient specific intervention plans

• Disease Management• Remote monitoring

– HF and transitions of care

• Pharmaceutical management– Donut-hole


Embedded PCP Case Managers are Key to Success

• Embedded Case Manager (per 700-800 Medicare pts)– High risk patient case load 15 - 20% (125 - 150 pts)– Beyond disease education

• Personal patient link– Comprehensive care review – medical, social support– Transitions follow up (acute/SNF discharges, ER visits)– Direct line access – questions, exacerbation protocols– Family support contact

• Recognized site team member– Regular follow ups high risk patients– Facilitate access – PCP, specialist, ancillary – Facilitate special arrangements (emergency home care, hospice care)

• Linked to Remote & Tele-monitoring for specific populations


Case managers engage within 24 - 48 hours to manage transitions

• Frequent medication issues at care transitions– Confused, do not fill prescriptions

• Discharge plan often unclear and not scheduled– Follow up communication absent, incomplete, illegible– PCP & Specialty appts not available per plan– Community resources not realized

• Most patients not hospitalized at Geisinger

Transitions of Care/Personal Health Navigator

Documents

Transcript of Transitions of Care/Personal Health Navigator