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Care Transitions and Readmissions
Janet Tomcavage RN, MSNChief Administrative Officer
Geisinger Health Plan
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Geisinger Health System Components
Provider Facilities1
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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
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Revised 6-28-12. Geisinger PR & Marketing Department
Geisinger Health System Footprint
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The Geisinger Journey
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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…
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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
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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|
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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
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PATIENT CENTERED PRIMARY CARE
Building the foundation for transformation
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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
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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
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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
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INTEGRATED POPULATION MANAGEMENT
Understanding and managing a population
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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
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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
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Going beyond the walls of primary care
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DEVELOPING A HIGH VALUE MEDICAL NEIGHBORHOOD
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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
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MDS 3.0 or OASIS Medical Summary
HealthInformationExchange
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The “Gobbler”
Long-Term Care & Home Health Get in the Game
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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
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Evolving Healthcare Landscape
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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
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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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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
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PROVENHEALTH NAVIGATOR®
Evaluating the Impact
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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%
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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
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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
PHN Non-PHN 67 Current PHN Sites
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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
PHN Non-PHN 67 Current PHN Sites
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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
PHN Non-PHN 67 Current PHN Sites
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PHN Results for Medicare
(Am J Manag Care. 2010;16(8):607-614)| 29
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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
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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.
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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
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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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Discussion & Questions
Top Related