LDI Health Policy Seminar 4_6_12: Care Management at Geisinger:Approach, Results, and Plans

Care Management at Geisinger:
Approach, Results, and Plans

Earl Steinberg, MD, MPP
Exec. VP, Innovation & Dissemination

Presentation at Leonard Davis Institute
April 6, 2012

1
Heal • Teach • Discover • Serve Not for reuse or distribution without permission
Geisinger Health System Confidential and Proprietary
Copyright Geisinger Health System 2011

Outline

• Overview of Geisinger
• Key Attributes
• Notable Programs and Results
• Plans
- New Center for Health Care Transformation
- Efforts to Disseminate Geisinger Know-How

2

Geisinger Health System

An Integrated Health Service Organization

Provider
Managed Care
Facilities
Physician Companies

Practice Group
• Geisinger Medical Center
•
• ~298,000 members
Hospital for Advanced Medicine, Janet Weis

Children’s Hospital, Women’s Health Pavilion, • Multispecialty group
(including ~63,000 Medicare

Level I Trauma Center • ~1000 physician FTEs
Advantage members)
• •
Geisinger Shamokin Community Hospital
• ~520 advanced practitioner FTEs
Diversified products
• Geisinger Northeast (3 campuses) •
• Geisinger Wyoming Valley Medical Center
• 65 primary & specialty
~30,000 contracted

providers/facilities
clinic sites (37 community
with Heart Hospital, Henry Cancer Center,
• 43 PA counties
Level II Trauma Center practice sites)
• South Wilkes-Barre Adult & Pediatric Urgent Care, • 3 Ambulatory/outpatient surgery 3
inpatient rehab, pain mgmt, sleep center centers
• Geisinger Community Medical Center •
Geisinger Health System outpatient and Proprietary
million System - Confidential
>2.1Geisinger Health clinicProprietary
Copyright Geisinger System 2012 System 2011
Copyright Geisinger Health
Health Not for reuse or distribution without permission

Geisinger Health System

Geisinger ProvenHealth Navigator Sites Geisinger Inpatient Facilities Careworks Convenient

Contracted ProvenHealth Navigator Sites Ambulatory Care Facility Healthcare

Geisinger Medical Groups Geisinger Health System Hub and Spoke Market Area Non-Geisinger Physicians
LifeFlight Base
4
Geisinger Specialty Clinics Geisinger Health Plan Service Area With EHR

Key Characteristics of Geisinger Health System

• Strong physician leadership • Incentives aligned with aims
paired with admin. partner • Team and system of care
• Organizational culture that orientation
prioritizes quality, efficiency • Infrastructure (IT, IM, EMR,
and innovation Data Analytics)
• Work force that embraces the • Skunk works and
culture transformation units
• A clinical enterprise and a • Focus on work flow and
health plan reliability
• Clear, shared aims • Performance measurement and
feedback

Our Sweet Spot for Innovation

Geisinger Clinical Enterprise

Geisinger Health Plan

6
Aligned objectives for the greatest impact

Evolution of GHS Value Re-Engineering

2011 Transitions Program

2010 Keystone Beacon
2010 NCCCP Cancer Grant

2009 Inpatient EHR Integration

2007 Automated Proactive Outreach
®
2006 ProvenHealth Navigator

2005 Physician Group Practice Demonstration

2005 Physician Directed, Team Delivered Care
®
2004 ProvenCare Chronic (Diabetes Bundle)

2002 Primary Care Redesign, Hub and Spoke model

2001 Networked Personal Health Record

1995 Outpatient EHR
7

Major Geisinger Re-Engineering Initiatives
• Enterprise Data Warehouse
• Primary Care Re-Design
• Make the EMR a Member of the Team
• ProvenCare (Acute and Chronic)
• Advanced Medical Home
• Transitions of Care
• GAPP

8

Clinical Decision Intelligence System (CDIS)
Other Inputs Decision
EBM Guidelines
Support
Patient Preferences
Formulary/Economics
… rm
s
Real-time Clinical Status o
lN
i ca ds Effectors
ir en
p Tr
Em o n
ati Alerts
ul
EHR CDIS P
o p Prompts/Reminders
Order Sets
…
Automated care plans
Clinical, Patient messages
Schedule …
Information Rx
…
Claims Finance Ops
…
9
Normalization, Transformation, Analytic 9
Heal • Teach • Discover • Serve Application reuse or distribution without permission
Not for

Time Required for Primary Care

• Acute Care 4.6 hours/day
• Preventive Care 7.4 hours/day
• Chronic Care 10.6 hours/day
22.6 Hours/day

10
10

Heal • Teach • Discover • Serve 10
Not for reuse or distribution without permission

Key Process Redesign Strategies
• Focus on quality and efficiency of care.

• Agree on standardized production functions.

• Eliminate steps that are found to be unnecessary.

• Automate any work that can be automated.

• Delegate work to appropriately trained non-physician staff when
possible. (All personnel to “operate at the top of their license”.)

• Support agreed upon workflows with various types of EMR
reminders, decision support tools and work flow facilitators to
increase the reliability of the care provided.

• Activate and engage the patient and their family. 11

Reengineering Clinical Care

Population Identification
Populations

Patients and Conditions
Bundle Development 100% Care Processes and Protocols (Digital)

Low Efficiency and Reliability High

Workflow Modification Delegation and
Regular Care Algorithms
Automation Patient Activation

12

Closing Care Gaps: Content, People and Health
Information Technology (HIT)
Content People HIT
Prevention Outpatient Reengineering and Innovation Oversight Diagnosis Naming Conventions
Diabetes
Problem List Manager
CAD
Care Gaps Team
Clinical Data Capture
CKD
Clinical Workgroups
Heart Failure Patient Reported Data Capture

Vascular Disease Innovation

Osteoporosis Office-Based Decision Support
Medical Informatics
Obesity
EPIC Design Team Automating orders
HTN and Lipids
Automating outreach
Analytics and IT
Asthma/COPD

Scheduling Services Real-time opportunity reports
*End of Life

*Medication Safety
Data Visualization
*Atrial Fibrillation
Care Gaps Manager

Patient Communication 13

Nurse Rooming Tool

14
14


Improvements from Nurse Rooming Tool

MyG Enrollments Urine Microalbumin

8000 88
86
7000
84
6000 82
5000 80
78
4000 76
Delegate To
3000 74
72
2000 Nurses 70
1000 68
66
0
Jul-07 Aug-07 Sep-07 Oct-07 Nov-07
Dec-05 Jan-06 Feb-06 Mar-06

15
15


Improving Preventive Care for 220,946 Patients
11/07 8/11
Adult Preventive Bundle 9.2% 31%
Breast Cancer Screening (q 2 40-49, q 1 50-74) 46% 61%
Cervical Cancer Screening (q 3 yr Age 21-64) 64% 71%
Colon Cancer Screening (Age 50-84) 44% 66%
Prostate Cancer Discussion (Age 50-74) 72% 77%
Lipid Screening (Every 5 yr M > 35, F > 45) 75% 87%
Diabetes Screening (Every 3 yr > 45) 85% 90%
Obesity Screening (BMI in Epic) 77% 97%
Documented Non-Smokers 75% 78%
Tetanus Diphtheria Immunization (every 10 yr) 35% 72%
Pneumococcal Immunization (Once Age >65) 84% 86%
Influenza Immunization (Yearly Age >50) 47% 59%
Chlamydia Screening (Yearly Age 18-25) 22% 37%
16
Osteoporosis Screening (every 3 yr Age > 65) without permission
Heal • Teach • Discover • Serve Not for reuse or distribution
52% 73%
Alcohol Geisinger HealthAssessment
Copyright Intake System 2011 84% 92%

Practice Redesign: Diabetes
• 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
• Financial incentives

17
17


Improving Diabetes Care for 25,071 Patients

3/06 3/07 8/10 8/11
Diabetes Bundle Percentage 2.4% 7.2% 13.0% 12.5%
% Influenza Vaccination 57% 73% 75% 76%
% Pneumococcal Vaccination 59% 83% 83% 82%
% Microalbumin Result 58% 87% 78% 78%
% HgbA1c at Goal 33% 37% 52% 50%
% LDL at Goal 50% 52% 54% 55%
% BP < 130/80 39% 44% 55% 57%
% Documented Non-Smokers 74% 84% 85% 85%

18

®
ProvenCare

– Establish evidence or consensus-based best practices.
– Reliably deliver these by redesign of work flow supported by
EMR when possible.
– Activate patients and families, engaging them in the care
processes.

19

®
ProvenCare CABG: Process flow

Return
Clinic Pre-op OR Post-op
Clinic

20

ProvenCare® CABG: Process flow

Return
Clinic Pre-op OR Post-op
Clinic

•Carotid Eval •Antibiotics •Antibiotics
•Beta Blockade •Beta Blockade
•Vascular Consult •Glycemic Control •Glycemic Control •ASA Therapy
•Clopidogrel
•Inf.MI/RV •IABP use •Beta Blockade •Lipid management
•Warfarin •ASA Therapy
•Clopidogrel •Atherosclerotic •Cardiac Rehab
•Warfarin Aortas •Afib prevention •Smoking Cessation
•Beta Blockade •Cardioplegia •Lipid management
•Smoking Cessation •Arterial Conduits •Ant.MI/WMA
•Smoking Cessation

21

ProvenCare® & the Electronic Medical Record (EMR)

22

Patient Activation

• Clinical, executive, and legal team developed a “Patient
Compact” to engage patients and families
– Reflects bilateral commitment to optimize outcomes
• Engage as a “partner” in care process
• Promptly notify team of all issues
• Comply with recommended medications
• Complete cardiac rehabilitation
• Engage with GHS care management services
• Stop smoking
• Manage weight

• Education workgroup revised all patient education
materials to comply with ProvenCare® concepts
23

ProvenCare® CABG

Component Process Measure = “Compliance” All-or-None Measure = “Reliability”
24

Reporting Period: FY2011 Q4 Apr-Jun
Update Date: July 5, 2011

25

Clinical Outcomes

Comparison of before (n=132) and after (n=321) ProvenCare®

• 80% improvement in In-hospital mortality

• 61% reduction in re-intubations

• 63% reduction in deep sternal wound infection rate

• 40% reduction in neurologic complications
26

26
•
29% reduction in pulmonary complications

Financial Results: CAB

Base Line Look Back Variance
(FY2006) (FY2010)
Cases 116 131 15

LOS 7.60 6.28 (1.32)

CM Per Case 17,810 21,949 4,139

Net Revenue per Case 35,482 43,429 7,947

27
27 Geisinger Health System Confidential and Proprietary

ProvenHealth® Navigator: (Advanced Medical Home)

• Partnership between primary care physicians and GHP that provides
360-degree, 24/7 continuum of care

• “Embedded” nurses

• Assured easy phone access

• Follow-up calls post-discharge and post-ED visit

• Telephonic monitoring/case management

• Group visits/educational services
28
• Personalized tools (e.g., chronicdistribution without permission cards)
Heal • Teach • Discover • Serve
Not for reuse or
disease report

5 Core Components of Geisinger’s Medical Home
• Patient and family engagement & education
Patient-centered • Enhanced access and scope of services
primary care • PCP led team-based care
• Population segmentation and risk stratification
• Chronic disease and preventive care optimized with HIT
Integrated
• GHP employed in-office case management
population • Disease management
management • Micro-delivery referral systems
Medical
• 360°care systems – SNF, ED, hospitals, Home Health, etc
Neighborhood • Patient satisfaction
Quality Measurement
• HEDIS and bundled chronic disease metrics
••Fee-for-service with P4P payments based on quality of care
Preventive services metrics
Value-based
• Physician and practice transformation stipends
reimbursement • Value-based incentive payments 29

Embedded Case Management

Personal Care Link Embedded Case Manager Recognized Team Member

-High risk patient case load Regular follow-up of high risk
Comprehensive Care Review –
- 15 - 20% Medicare
patients
medical, social support - 5% commercial
Facilitates access – PCP, specialist,
- 125 - 150 pts per CM
TOC follow-up – acute care, SNF, ED
- 1 CM per 800 Medicare lives ancillary

- 1 CM per 5000 commercial lives
Direct phone access – questions, Facilitate special arrangements –

exacerbation protocols home care, hospice, AAA
- Not disease management focused

- Focus on those at most risk
Patient, family support contact Links health care team to payer
- Focus on driving issue within the case

30

Acute admissions show improvement in the
Medicare population

31

Readmissions are also lower

32
| 32

Cumulative Percent Difference in Spending

Attributable to PHN
0%

-2%

-4%
95% Confidence Interval
-6% Median Es tim ate
95% Confidence Interval
-8%

-10%
Q1 2005

Q3 2005

Q3 2006

Q1 2007

Q1 2008

Q1 2009
Q1 2006

Q3 2007

Q3 2008

Q3 2009
-12%

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
33

Geisinger PGP Year over Year Per Capita Trend
Geisinger PGP Results
•Quality Rating •Shared Savings
•PY 1 73% •PY 1 $0

•PY 2 100% •PY 2 $0

•PY 3 100% •PY 3 $1.95M

•PY 4 100% •PY 4 $1.79M

•PY 5 100%* •PY 5 $0*

•Geisinger is the only group to achieve •Year 5 had the lowest cost trend
100% years 2-5

34

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

35

Early Results for Nursing Homes Look Promising

Nursing Home Baseline PY 1 Readmissions Reduction
Readmissions 2009
2008
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%

36
Nursing Home F
27.5% 24% - 12.7%

Geisinger’s Transitions Approach
• Screening of all admissions

• Daily interdisciplinary communication

• Transition planning

• Timely transition communication

• Post-discharge engagement
37
| 37

Transition Bundle
• Electronic Discharge Instructions
– Signed copy to patient prior to discharge

• Electronic Discharge Summary
– Delivered within 48 hours of discharge over 90% of time

• Automatic Document Delivery
– At time of document authentication

• Discharge Appointment within 7 days
38
– Leave hospital with appointment 88% of time
| 38

Aspiration of New Geisinger Center for Health
Care Transformation (CHCT)

• Become known as the premier place in the country
for development and evaluation of innovations that are designed
to reduce cost of care and improve quality of care.

39
| 39

Three Part Mission
• Improve Quality and Efficiency of Health Care
• Identify opportunities to improve the quality and clinical outcomes of
care, as well as patient satisfaction with care delivered by Geisinger
Health System
• Identify opportunities to improve the quality and clinical outcomes of
care, as well as patient satisfaction with care delivered by a
spectrum of health care providers other than Geisinger
• Identify opportunities to reduce the cost of care delivered by
Geisinger Health System through improved efficiency and
elimination of unwarranted variation in practice
• Identify opportunities to reduce the cost of care delivered by a
spectrum of health care providers other than Geisinger through
improved efficiency and elimination of unwarranted variation in
practice
40
| 40

Three Part Mission
• Improve Quality and Efficiency of Health Care (cont.)

• Develop 1) incremental improvements in and 2) new models for
care delivery that can increase health care value at Geisinger
Health System (in all instances) and at a broad spectrum of
other health care delivery systems (in some instances)
• Determine how to integrate those incremental improvements
and innovations into clinical work flow at Geisinger, and
elsewhere, so they are delivered consistently
• Enhance Geisinger’s national and international reputation as a
leader in health care innovation and quality and efficiency of
health care delivery

41
| 41

Three Part Mission (continued)

• Product Development
• Develop a platform and system for development of
products that enhance quality and/or efficiency of
health care at a broad spectrum of health care
delivery systems
• Develop prototypes of products that could be used
by a broad spectrum of health care delivery systems
to improve the quality and efficiency of health care.

42
| 42

Three Part Mission
• Evaluation
• Quantify the effects of particular incremental improvements and
major innovations on:
• care-process reliability
• quality of care
• patient outcomes (including satisfaction)
• cost of care
• at GHS and in different types of health care delivery
• organizations and market environments
• Identify the factors associated with successful (and unsuccessful)
adoption, use and performance of particular changes in health care
delivery
• Center personnel will strive to develop credible, but practical
methods for evaluation of the products of rapid cycle innovation 43
| 43

What Will Differentiate the Center?
• Although much of the focus of the Center will be on development of
incremental improvements and major innovations that are useful at GHS, the
Center also will focus on development of value-improving innovations that
can be employed by a spectrum of health care delivery systems that lack
Geisinger’s resources.
• In an effort to help the Center’s work have a broad impact, the Center will put
substantial effort into development of prototypes of products that can be used
by a broad spectrum of providers.
• There will be a focus on producing evidence regarding the impacts of
innovations at Geisinger and elsewhere – and on development of credible,
but pragmatic methods for evaluation of rapid cycle innovation
• There will be a focus on helping to ensure that best practice is delivered
consistently – not on determining what constitutes best practice
• We will employ Geisinger as a laboratory for testing and adapting innovations
developed by others
44
| 44

The Market Need
• Anticipation of changes in the way health care is
paid for is prompting many health care providers to
begin to change how they are organized and deliver
care.
• Most providers lack the capabilities that will be
required to be successful under risk- and/or
performance-based payment.
• Geisinger is ideally positioned to assist health care
providers who want to prepare themselves for a
value-, rather than volume-oriented payment
system.
45
| 45

Planned Products and Services
• Services to Support Value-Driven Care
- Population Health Data Analytics
- Care Management

• Consulting Services

• Licensing Geisinger IP to product manufacturers
and health care delivery systems

• Software apps based on Geisinger IP 46
| 46

Questions We Seek to Answer Re: Dissemination
1. Can particular approaches Geisinger has used to
provide high value care be replicated in other health
care environments?
2. If so, which approaches can be replicated and under
what circumstances?
3. Do those approaches produce the same improvements
in quality of care and patient outcomes, the same
reductions in cost of care, and the same improvements
in patient and provider satisfaction in other settings as
they have at Geisinger?
4. If so, under what circumstances?
|
47
47

| 47

LDI Health Policy Seminar 4_6_12: Care Management at Geisinger:Approach, Results, and Plans

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to LDI Health Policy Seminar 4_6_12: Care Management at Geisinger:Approach, Results, and Plans

Similar to LDI Health Policy Seminar 4_6_12: Care Management at Geisinger:Approach, Results, and Plans (20)

More from Leonard Davis Institute of Health Economics

More from Leonard Davis Institute of Health Economics (20)

Recently uploaded

Recently uploaded (20)