Post Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator

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1 Post Acute Continuum Lessons Learned from Geisinger s ProvenHealth Navigator Janet Tomcavage, RN, MSN VP Health Services, Geisinger Health Plan Danville, PA February 3, 2012

2 Patient-centered primary care Integrated population management Medical Neighborhood Geisinger s PHN model has five core components Patient and family engagement & education Enhanced access and scope of services PCP led team-delivered care Chronic disease and preventive care optimized with HIT Population segmentation and risk stratification Preventive care GHP employed in-office case management Disease management Micro-delivery referral systems 360 care systems SNF, ED, hospitals, HH, etc Quality outcomes Value-based reimbursement Patient satisfaction HEDIS and bundled chronic disease metrics Preventive services metrics Fee-for-service with P4P payments for quality outcomes Physician and practice transformation stipends Value-based incentive payments Payments distributed on Quality Performance

3 Transitions of Care Pt contact within hrs post discharge Telephonic outreach Medication reconciliation Ensure safe transition post discharge with appropriate services in place Coordinated post hospital PCP appt within 3-5 days Weekly follow up for 30 days

4 Medical Neighborhood Micro-delivery referral systems High volume specialties Ancillary services Radiology, Lab 360 degree care systems Hospital care Home Health Pharmacies SNF s ER coverage Community resources

5 Home Health Identify those agencies preferred by practice What services are provided? Therapies such as PT, OT, Speech Respiratory, IV s, Hospice Disease management How do those agencies communicate with the practice? Access & service practices Friday afternoon? 5

6 Creating a New Delivery Model in the Nursing Home has been Critical Daily presence of an advanced practitioner Focus on care redesign Eliminate acute care stay need Medication reconciliation Earlier identification of acute exacerbations Prevention focus good skin care, I s & O s, fall prevention Enhanced connectivity to case manager & primary care team for discharge planning

7 What has the focus on care redesign delivered? OUTCOMES TO DATE

8 Improving Diabetes Care for 24,791 Patients 3/06 3/07 6/10 6/11 Diabetes Bundle Percentage 2.4% 7.2% 12.8% 12.6% % Influenza Vaccination 57% 73% 75% 77% % Pneumococcal Vaccination 59% 83% 84% 83% % Microalbumin Result 58% 87% 79% 78% % HgbA1c at Goal 33% 37% 51% 50% % LDL at Goal 50% 52% 53% 55% % BP < 130/80 39% 44% 54% 56% % Documented Non-Smokers 74% 84% 85% 85%

9 Value Driven Care Patient Centered Outcome Improvements Microvascular Retinopathy 10 fewer cases per over six years Macrovascular Heart Attack 30 fewer cases per less over six years Amputations One less case per over six years Stroke 20 fewer cases per less over six years

10 Acute admissions show improvement in the Medicare population Risk Adjusted Acute Admissions / sites sites sites sites sites PHN Non-PHN 44 Current PHN Sites

11 Readmissions are also lower Medicare - Risk Adjusted Readmissions/ sites sites sites sites sites PHN Non-PHN 44 Current PHN Sites 11

12 Early Results for Nursing Homes Look Promising Nursing Home Baseline Readmissions PY 1 Readmissions Reduction Nursing Home A 34% 18.5% % Nursing Home B 18.5% 14.5% % Nursing Home C 27% 9% % Nursing Home D 44% 33% - 25% Nursing Home E 42.5% 31% - 27% Nursing Home F 27.5% 24% %

13 Cumulative percent difference in spending attributable to PHN 0% -2% -4% 95% Confidence Interval -6% Median Estimate 95% Confidence Interval -8% -10% -12% Q Q Q Q Q Q Q Q Q Q Cumulative percent difference in spending (Pre-Rx Allowed PMPM $) attributable to PHN in the first 21 PHN clinics for calendar years Dotted lines represent 95% confidence interval. P = < 0.003

14 Discussion & Questions