1. Transitions of Care/Personal Health Navigator

2. Agenda Geisinger Overview Transitions of Care
Personal Health Navigator aka Medical Home

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
ProvenCaretm
Chronic Disease Optimization
Personal Health Navigator
Transitions of Care
EPIC enabled 3

4. Geisinger Health System
Gray’s Woods
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

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

6. 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
We have designed a series of interventions that start when the decision is made to admit the patient and conclude after the patient has been discharged and is in the ambulatory setting. This program interfaces with our Medical Home/Personal Health Navigator initiative for patients with a Geisinger PCP.

7. Admission Checklist Screening Care Management Assessment
Expected Length of Stay
Planned Disposition
Medication History
PT/OT Needs
Wound Care
Diabetes

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?

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