Heal Teach Discover Serve Geisinger Value 1 Transitions of Care/Personal Health Navigator January 31, 2009.

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Presentation transcript:

Heal Teach Discover Serve Geisinger Value 1 Transitions of Care/Personal Health Navigator January 31, 2009

Heal Teach Discover Serve Geisinger Value 2 Agenda Geisinger Overview Transitions of Care Personal Health Navigator aka Medical Home

Heal Teach Discover Serve Geisinger Value 3 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 –ProvenCare tm –Chronic Disease Optimization –Personal Health Navigator –Transitions of Care –EPIC enabled

Heal Teach Discover Serve Geisinger Value 4 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

Heal Teach Discover Serve Geisinger Value 5 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

Heal Teach Discover Serve Geisinger Value 6 Transition Patient Flow Design Pre- admission/ ED Ad- mission Inpatient Stay DischargePost 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 BackDischarge Synopsis Enhanced Nsg. Home Clinical Capabilities Discharge Plan Palliative Care

Heal Teach Discover Serve Geisinger Value 7 Admission Checklist Screening Care Management Assessment Expected Length of Stay Planned Disposition Medication History PT/OT Needs Wound Care Diabetes

Heal Teach Discover Serve Geisinger Value 8 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?

Heal Teach Discover Serve Geisinger Value 9 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

Heal Teach Discover Serve Geisinger Value 10 Personal Health Navigator Team Provides Patient Care and Navigation aka Medical Home

Heal Teach Discover Serve Geisinger Value 11 Five Functional Components Patient Centered Primary Care Integrated Population Management Value Care Systems Quality Outcomes Program Value Reimbursement Program

Heal Teach Discover Serve Geisinger Value 12 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

Heal Teach Discover Serve Geisinger Value 13 Embedded PCP Case Managers are Key to Success Embedded Case Manager (per Medicare pts) –High risk patient case load % ( 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

Heal Teach Discover Serve Geisinger Value 14 Case managers engage within 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