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Transitions of Care/Personal Health Navigator
January 31, 2009
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Agenda
• Geisinger Overview• Transitions of Care• Personal Health Navigator aka Medical Home
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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
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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
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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
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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
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Admission Checklist
• Screening• Care Management Assessment• Expected Length of Stay• Planned Disposition• Medication History• PT/OT Needs• Wound Care• Diabetes
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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?
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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
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Personal Health Navigator Team Provides Patient Care and Navigation
aka Medical Home
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Five Functional Components
• Patient Centered Primary Care• Integrated Population Management• Value Care Systems• Quality Outcomes Program• Value Reimbursement Program
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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
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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
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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