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Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 1
Care of the Complex Patient
Ronald A. Paulus, MDEVP, Clinical Operations
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 2
Value-Driven Care for Complex Patients
• Value-based productivity measurement (Value-based RVUs??)– Care Gap Closure value per unit time – Low-value utilization ratio
• Regular care “failures” (e.g., heart failure exacerbations)• Low-value resource consumption (e.g., low-utility imaging)
• Reengineered care processes– Use of EHRs, analytics and decision support (Eliminate
Automate, Delegate, Activate)• Health Care Teams, Accountable Collaboration
– Medical Home, Primary care – specialist collaboration• Cross-spectrum concerns
– End-of-Live and Palliative Care– Medication management
• Fundamentally realigned reimbursement incentives
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
Care of the Complex PatientCare Gap Management
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 4
Care Gaps
• Patients, based upon their age, gender , chronic conditions, etc., have predictable, evidence-based lab, imaging, medication and referral care needs
• Patients who fail to have their evidence-based care needs met have a “Care Gap”
• Complex, chronically ill patients are at high-risk for unclosed Care Gaps
• Traditional health care workflows are inefficient and unreliable at closing Care Gaps
• It is possible to reengineer care to increase both reliability and efficiency with which Care Gaps are closed– Requires IT and analytic infrastructure…
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 5
Feedback ReportsPrompts/RemindersCare Gap Order SetsIntegrated Care plansPatient messagesInformation Rx…
Effectors
…
EBM GuidelinesPatient Preferences
Formulary/Economics
Other Inputs
EHR
Clinical, Schedule
…
Real-time Clinical Status
Decision Support
Clinical Decision
Intelligence System
Normalization, Transformation, Analytic Application
FinanceClaims Ops…
Geisinger Transformation Architecture
…Pop
ulatio
n Tre
nds
Empi
rica
l Nor
ms
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 6
Care Plans
Populations
Care Gaps and Action Arms
Action Arms
Lab and Imaging
“Gap”Management
Referral “Gap”
Management
Care Gaps
Goals –Endpoints
Mammo every yearPrevention
Chronic Diseases
HgA1c less than 8
Unclosed Loops
Abnormal Pap Follow
up
Medication Safety
Methotrexate monitoring
Regular care
“failures”
HF exacerbation
Office-Based Decision Support
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Therapeutic Response monitoring (e.g., labs, symptoms, adherence)
Adverse effects monitoring (e.g., labs, imaging, symptoms)
Medication Management
Therapeutic Goal
Provider and Patient Feedback
Medication Regimen
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 8
Integrated Care Gap Order Sets
• Clinical Care Gaps that require medical decision making– Medication management– Chronic condition not at goal
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
Care of the Complex PatientPrimary Care – Specialty
Collaboration
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 10
Primary Care, Primary Specialist and Collaborative Care
• Certain severely chronically ill patients require ongoing collaborative care by both a primary care and specialist provider
• In order to successfully co-manage care, expectations and roles need to be clarified including identifying the specific involved specialist and who is accountable (Primary Care vs. Specialty Care) for what aspects of care
• Ultimately, the goal of collaborative is to ensure that all care needs are managed and care gaps closed
• Patients needing ongoing co-management feel that the health care team is coordinated and collaborative
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Conditions, Care Gaps and Potential Specialty Engagement
RheumatologyRheumatoid Arthritis
DermatologyMelanoma
CardiologyRecurrent HF exacerbation
NephrologyHTN > 140/90, 3 or more meds
Rheumatology/HiROC50 and over w fx of hip and spine
CardiologyAfib, > 2 CHADS no anticoag
SpecialtyCondition or Care Gap
VascularCarotid stenosis > 60%
Cardiology
Allergy/Pulmonology
Endocrine
Vascular
Nephrology
AAA > 4 cm
LDL > goal, statin allergy
Recurrent Asthma exacerbation
Persistent HgA1c > 9
CKD Stage 4
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Heart Failure “Care Path”
Stage A Stage B Stage C Stage D
Risk Factor Modification
Patient Education
Medication Management
Reversible Causes
Primary Care Provider
Primary CardiologistTOC
Management
Daily monitoring
Transition to transplant
End of Life Care
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
Geisinger Examples
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 14
Creating Real Value: Geisinger’s Core Care Transformation Initiatives
• Population Health Optimization– Geisinger Medical Home
• ProvenHealth NavigatorSM
– Chronic Disease Care Optimization• ProvenCare - Chronic®
• Acute Episodic Care Optimization– ProvenCare - Acute® (aka the “surgical warranty”)
• Transitions of Care Optimization– ProvenTransitionsSM
• Patient engagement and activation throughout all initiatives– ProvenEngagementSM (dealing with “non compliance”
Get consumers into a system of care,
focused on the right things….
Optimize the delivery of high-cost, high
capital care
Minimize hand-off errors, reduce wasteful
end-of-life spending and degradation
Get consumers and families involved, with
personal responsibility
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ProvenHealth Navigator®
Geisinger’s Value-based Patient-Centered Medical Home
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 16
Functional Components
1. Team-based, patient-centered primary care (including embedded care management nurse)
2. Joint payor-provider population management3. High quality, efficient specialist identification
and referral4. Quality Outcomes Program5. Value-based Reimbursement Program
1. Baseline FFS2. Practice transformation stipends3. Quality-gated gain sharing
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 17
Inpatient Admission Reduction
Risk Adjusted Acute Admits/1000
250
270
290
310
330
350
Jan-Nov 2006 Jan-Nov 2007 Jan-Nov 2008
Empl Phase 1 Sites Empl Phase 2 Sites M edicare Comparison Group
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Impact: COPD Admissions
COPD acute admits/1000
600
700
800
900
2005
2006
2007
2008
PHN Non-PHN
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Impact: Diabetes Admissions
DM acute admits/1000
300
400
500
600
2005
2006
2007
2008
PHN Non-PHN
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Impact: CHF Admissions
HF acute admits/1000
800
900
1000
1100
1200
2005
2006
2007
2008
PHN Non-PHN
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
ProvenCare - Chronic®
Chronic Disease Optimization
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 22
Diabetes Intermediate Outcomes
Diabetes Trending
R2 = 0.8865
R2 = 0.8206
R2 = 0.8012
30%
35%
40%
45%
50%
55%
60%
65%
Feb-0
6
Apr-06
Jun-0
6
Aug-0
6
Oct-06
Dec-06
Feb-0
7
Apr-07
Jun-0
7
Aug-0
7
Oct-07
Dec-07
Feb-0
8
Apr-08
Jun-0
8
Aug-0
8
Oct-08
Dec-08
Feb-0
9
Apr-09
Jun-0
9
% W/A1C < 7.0
% W/LDL < 100
% BP < 130/80
Linear (% W/LDL < 100)
Linear (% BP < 130/80)
Linear (% W/A1C < 7.0)
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 23
Diabetes: Resistant Control Group
• Despite the success of the Diabetes Bundle, 8% of the 21,667 known diabetic patients continue to have HgbA1C levels over 9%
• Intervention target: Knapper Clinic– 1,074 diabetic patients– 10% had HgbA1C levels over 9% – This group of patients at highest risk for
diabetic complication was targeted for our program
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High Risk Diabetes Outreach Program Invitation Process
Invitation Process:
PCP invitation letter
Up to 3 phone calls from Scheduling Office
Phone call from Knapper Clinic staff
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Results: Change in HgbA1C% (Cases vs. Baseline)
<0.001-1.8315 weeks (n=23)
<0.001-1.578 weeks (n=39)
P-valueChange in HgbA1C%Time to F/u HgbA1C%
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 26
High Risk Diabetes Outreach Program Provider Survey
Provider Surveys: Pre & Post
0
1
2
3
4
5
Res
pons
es:
Scal
e 1-
5
Pre Intervention (n=8) 2.5 4.4 2.4 2 1.8 2.9 3.3 3.9 4.1
Post Intervention (n=8) 4 4.5 2.3 2 2.3 3 4.8 4 4.8
Sat. of manage of DM
patients?
Dif ficulty w ith DM Bundle
Pt. medication compliance
Pt. dietary compliance
Pt. record keeping
Pt.know ledge of DM
Sat.w ith Endo depart
Sat. other depart
Would DM outreach
clinic helpful?
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 27
High Risk Diabetes Outreach Program: Patient Survey
Patient Surveys: Pre & Post
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Res
pons
es: R
ange
1-6
Pre Intervention (n=30) 4.3 3.3 3.6 4.2 4.1 4.0 4.6 3.9
Post Intervention (n=26) 5.4 3.8 4.1 5.4 5.1 5.3 5.5 5.4
Satisfaction w ith current treatment
Glucoses not too high
Glucoses not too low
Treatment Convience
Treatment Flexiblity
Understanding of Diabetes
Recommend this treatment
Going to continue current treatment
Qustions from Diabetes Treatment Satisfaction Questionnaire (DTSQ) © 1993 Dr. Clare Bradley , Diabetes Research Group, England
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
End of Life Planning and Care
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary 29
Chronic Disease Spectrum and End of Life Activities
Fu
nct
ion
al
Sta
tus
Advanced Directives Discussion and Planning
Palliative Care Discussions
Healthy
Supportive Care Referral
Advanced Directive Reviews
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
Thank You.
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