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
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
Transitions of Care Pt contact within 24-48 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
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
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
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
What has the focus on care redesign delivered? OUTCOMES TO DATE
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%
Value Driven Care Patient Centered Outcome Improvements Microvascular Retinopathy 10 fewer cases per 1000 750 over six years Macrovascular Heart Attack 30 fewer cases per 1000 2250 less over six years Amputations One less case per 1000 75 over six years Stroke 20 fewer cases per 1000 1500 less over six years
Acute admissions show improvement in the Medicare population Risk Adjusted Acute Admissions / 1000 350 300 250 200 150 100 50 0 294 2006 0 sites 309 301 303 292 286 257 2007 3 sites 240 232 241 2008 13 sites 2009 25 sites 2010 37 sites PHN Non-PHN 44 Current PHN Sites
Readmissions are also lower Medicare - Risk Adjusted Readmissions/1000 50 45 40 35 30 25 20 15 10 5 0 43 2006 0 sites 47 46 47 41 2007 3 sites 31 2008 13 sites 44 34 34 2009 25 sites 42 2010 37 sites PHN Non-PHN 44 Current PHN Sites 11
Early Results for Nursing Homes Look Promising Nursing Home Baseline Readmissions PY 1 Readmissions Reduction Nursing Home A 34% 18.5% - 45.5% Nursing Home B 18.5% 14.5% - 21.6% Nursing Home C 27% 9% - 66.6% Nursing Home D 44% 33% - 25% Nursing Home E 42.5% 31% - 27% Nursing Home F 27.5% 24% - 12.7%
Cumulative percent difference in spending attributable to PHN 0% -2% -4% 95% Confidence Interval -6% Median Estimate 95% Confidence Interval -8% -10% -12% Q1 2005 Q3 2005 Q1 2006 Q3 2006 Q1 2007 Q3 2007 Q1 2008 Q3 2008 Q1 2009 Q3 2009 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 = < 0.003
Discussion & Questions