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Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary1
Innovations in Reducing Cost and Improving Quality
of Health Care:
Geisinger Health System Example
Ronald A. Paulus, MDEVP, Clinical Operations and Chief Innovation Officer
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary2
Geisinger Health System
Careworks Convenient Healthcare
Non-Geisinger Physicians With EHR
Last updated 07/09/09
Geisinger ProvenHealth Navigator SitesContracted ProvenHealth Navigator SitesGeisinger Medical GroupsGeisinger Specialty Clinics
Geisinger Inpatient FacilitiesAmbulatory Care Facility Geisinger Health System Hub and Spoke Market AreaGeisinger Health Plan Service Area
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
Geisinger Transformation Infrastructure
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary4
Alerts Prompts/Reminders Order Sets Automated care plans Patient messages Information Rx …
Effectors
…
EBM GuidelinesPatient Preferences
Formulary/Economics
Other Inputs
EHR
Clinical, Schedule
…
Real-time Clinical Status
Decision Support
CDIS
Normalization, Transformation, Analytic Application
FinanceClaims Ops …
Clinical Decision Intelligence System (CDIS)
…Pop
ulat
ion
Tren
ds
Empi
rica
l Nor
ms
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary5
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”
Delivering a “System of Care” focused on the
right things…
Optimizing high, cost, capital intensive care
(bundling with a “warranty”…)
Incentivizing Quality – eliminating rework
Incentivize engagement and self-care
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
ProvenHealth Navigator®
Geisinger’s Value-based Patient-Centered Medical Home
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary7
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 Proprietary8
Acute Admissions Show Improvement
Risk-adjusted acute admits/1000 (Medicare)
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary9
50 51 535541 3943 48
31
0
75
2006 2007 2008Medicare Comparison Phase 1 Sites Phase 2 Sites
Readmissions Show Improvement
Medicare Readmissions/1000
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary10
Spending Decreased Compared to Expected Trend
Spending (-8%)
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
ProvenCare - Chronic®
Chronic Disease Optimization
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary12
DM Best Practice Alert/Order Set
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary13
MyGeisingerPatient Reminder View
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Patient Education
Letter
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary15
Patient Trend Report
Most recent values displayed
Therapeutic goals are stated
Clinical consequences are stated
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary16
Diabetes Bundle Primary Care Average (n=23,404)
Diabetes Bundle Improvement (12/06-12/09)
R2 = 0.8142
0%
3%
7%
10%
13%
16%
Dec
-06
Mar
-07
Jun-
07
Sep-
07
Dec
-07
Mar
-08
Jun-
08
Sep-
08
Dec
-08
Mar
-09
Jun-
09
Sep-
09
Dec
-09
DM
Bun
dle
Perc
enta
ge
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary17
CAD Bundle Primary Care Average (n=14,714)
Primary Care Average CAD Bundle 12/06-12/09
R2 = 0.785
0%
5%
10%
15%
20%
25%
Dec
-06
Mar
-07
Jun-
07
Sep-
07
Dec
-07
Mar
-08
Jun-
08
Sep-
08
Dec
-08
Mar
-09
Jun-
09
Sep-
09
Dec
-09CA
D B
undl
e Pe
rcen
tage
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary18
Adult Preventive Care (n=209,090)
11/07 12/09
Adult Preventive Bundle 9.2% 25%
Breast Cancer Screening (q 2 40-49, q 1 50-74) 46% 61%
Cervical Cancer Screening (q 3 yr Age 21-64) 64% 73%
Colon Cancer Screening (Age 50-84) 44% 62%
Prostate Cancer Discussion (Age 50-74) 72% 75%
Lipid Screening (Every 5 yr M > 35, F > 45) 75% 83%
Diabetes Screening (Every 3 yr > 45) 85% 87%
Obesity Screening (BMI in Epic) 77% 94%
Documented Non-Smokers 75% 78%
Tetanus Diphtheria Immunization (every 10 yr) 35% 65%
Pneumococcal Immunization (Once Age >65) 84% 87%
Influenza Immunization (Yearly Age >50) 47% 53%
Chlamydia Screening (Yearly Age 18-25) 22% 33%
Osteoporosis Screening (every 3 yr Age > 65) 52% 66%
Alcohol Intake Assessment 84% 88%
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
ProvenCare Acute®
Geisinger’s Bundled Episodic Care
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary20
GHS Receives “All In” Global Fee
• One fee for the ENTIRE 90-day period including all surgery-related care:– ALL surgery-related pre-admission care – ALL inpatient physician and hospital
services, including cardiologists, cardiac surgeons, anesthesia, consultants, etc
– ALL surgery-related post-operative care– ALL care for any related complications or
readmissions
• Aligns incentives across provider, patient and payor
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary21
Process Redesign: Work Flow
PCP referred-Outpatient with suspected CAD
Inpatient-Hospital admission or ER patient
with suspected CAD
Referred for Diagnostic
Cath
Clinical assessment
warrants cath?
Referred to Cardiology for work up
ECG & Labs ordered (CBC,
BMP, +/- PT/INR, +/- lipid panel, +/-
ALT, +/- Hgb A1C)
Cath performed
Pt clearly meets criteria
for PCI?
Day of Cath
Require GMC cardiology f/u?
Current inpatient?
Pt returns to CRS
Instructions given to pt (meds & activity)
ECG, +/ lipid panel, +/-Hgb
A1C
Pt has established
PCP?
Provider performs cath
site exam
CK-MB Q8 hrs
Returns to PCP
Pt returns to floor
Yes
Pt returns home w/o f/u
Yes
No
No
HD #2
Pt d/c to home
Pt returns to clinic 2-12 weeks
Pt instructed to see PCP 1-4 wks & if pt has referring cardiologist,
schedule appt. in 8-12wks
Yes
No
PCI Performed
Cath done by outside MD & PCI requested or outside MD clinical assessment and/or + stress test
warrants diagnostic cath
Pt referred for Cath Direct
Hx done over phone by mid-level
or MD Yes
GMC Elective PCI Patient Flow
Yes
No
Devised 3/5/07Revised 5/30/07
No
Surgery recommended
?
Immediate surgery needed?
Seen by CT
surgery
Pt admitted, added to surgery schedule
Pt returns home w/appt in CTVS Clinic,
schedules surgery
Yes
No
Yes
Labs reviewed and informed
consent completed, if not
done
Referred back to cardiology for continued care?
No
Returns to cardiology clinic
for f/uYes
Proceed with PCI?
No
Pt scheduled for PCI
another day
PCI performed
today?
Yes
Yes
No
ECG, CBC, BMP
Cardiac rehab
offered
RN physical
Physical completed by cath lab team
personDoes the case
warrant a discussion w/pt, +/- another
MD?
No
Discussion with pt, +/- another MD
Yes
Pt accepted by surgery?
Yes
No
Does pt have a cath site
problem?
Does pt have increased CK-
MB levels?
Does pt have increased
creatinine?
Pt admitted/stays in hosptial
Pt ready for d/c?
No
No
No
No
Yes
No
No
Pt brought to
CRS
Isolation pt?No
Pt goes to floor
Pt returns to CRS or floor (isolation pt)
Does pt have a cath site
problem?
Does pt have a cath site
problem?
Does pt have a cath site
problem?
Yes
No
No
Yes
Reschedule GMC pt (underwent recent
diagnostic cath that warrants PCI)
Yes
Trx started
Trx started
Trx started
Obtain CK-MB, Triponin
Does pt have another
problem?
Trx given
Yes
Yes
Yes
Yes
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary22
Process Redesign: Hardwiring
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary23
ProvenCare® CABG: Reliability
0%
10%
20%
30%
40%
50%60%
70%
80%
90%
100%
% patients receiving all ProvenCare components
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary24
Before ProvenCare® ProvenCare® %
Improvement (n=132) (n=321)
In-hospital mortality 1.5 % 0.3 % 80 %Patients with any complication (STS) 38 % 33 % 13 %Patients with >1 complication 8.4 % 5.9 % 30 %Atrial fibrillation 24 % 21 % 13 %Neurologic complication 1.5 % 0.9 % 40 %Any pulmonary complication 7 % 5 % 29 %Re-intubation 2.3 % 0.9 % 61 %Blood products used 24 % 22 % 8 %Re-operation for bleeding 3.8 % 2.8 % 26 %Deep sternal wound infection 0.8 % 0.3 % 63 %Readmission within 30 days 6.9 % 5.6 % 20 %
CABG Clinical Outcomes
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary25
Hospital Financial Outcomes
Time PeriodNet
Revenue Change
Cost Change (Variable
Direct/Total)
Net Margin Change
July 2006 – March 2009
+7.8% -5.1% /-5.2%
+160%
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary26
Other ProvenCare Acute Programs
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
ProvenEngagement®
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary28
The Real Caregivers…
“People with chronic conditions are the principal care-givers. Each day, patients decide what they are going to eat, whether they will exercise and to what extent they will consume prescribed medicines.”
Bodenheimer et al, JAMA 2002
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary29
Population by Activation Level
Source: J.Hibbard, University of Oregon
12% of the population 29% of the population 37% of the population 22% of the population
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary30
HTN Patients Who Engage in Self-management Behaviors
Source: J.Hibbard, University of Oregon
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary31
Patient Data Capture Tools
• Give patient a voice • Structured data
– Higher Quality– Actionable
• Real time analytics– Guideline based
evaluation
• Guide patient-physician dialogue– Real time display of
advice
• Save time and money
– Why are you here?– What do you have?– What do you want?– How are you doing?– What are you taking?– How is your medicine working?– What are your risk factors?– What are your barriers to
improving outcomes?– … and the list goes on.
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary32
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary33
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary34
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary35
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary36
Summary
• Quality and efficiency are inextricably linked together
• Efficiency originates from the same place as quality – fundamental care model redesign
• At Geisinger, we are trying to reinvent many aspects of the care process
• Geisinger has many advantages due to our integrated delivery system and its “Sweet Spot”
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
Thank You.
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary
ProvenTransitions®
Care Hand-off Optimization
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary39
A Major Medicare Issue…
• “Potentially Preventable” admissions account for $12+ billion in Medicare spending (>8% of $146B total Part A spend in 2006)
30 Day Readmission
Rate
60 Day Readmission
Rate
90 DaysReadmission
Rate
18% 35% 67% (or dead)
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary40
40
Readmissions
DRIVERS KEY TACTICSGOAL
Screening
Care Mgmt: Inpatient/ Outpatient
Team Communi-
cations (IDTs)
Patient Education/ Med
Rec
Drivers to Reduce Readmissions
Post-Transition
Care
Early identification of readmission riskTarget interventions based on risk level
Early DC needs assessment of high risk ptsDC Planning – choose best next care setting
Seamless transition between IP & OP Care MgtOutreach to OP Care Mgmt based on risk level
Consistent documentation (location, content)
Multi-disciplinary care coordination
Social issues addressed (non-compliance, ability to buy meds, advanced directives)
Ready the patient for successful self-care
Teach Who-What-When-Where if help neededMultidisciplinary Teaching - patient and family
Post-DC Follow-up appt for EVERY patientInstant communication of hospital course and follow-
up needs to post-DC providers/agencies
IP Pharmacist consult on high risk pts/meds
MH with tele-monitoring, follow up phone calls, SNF management
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary41
ED Screening Instrument
Based upon combination of literature review, expert interviews, Geisinger data and clinician experience
11%
2%
4%
9%
9%
3%
0% 5% 10% 15%
High
Medium
Low
3M DSS
GWV % Readmissions
6/2008 – 8/2008
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary42
Patients Screened
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary43
FY 09 Final Results: GWV
GWV Readmission Rate ComparisonFY 08 vs. FY09
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
10.0%
MS05 MS5E MS06 GWV PilotTotal
GWV NonPilot Total
GWV Total
3M Readm FY08 3M Readm FY09
30 Day Readmission Rate
Heal • Teach • Discover • Serve Geisinger Health System Confidential and Proprietary44
Next Up: Bundled Readmission Payment
• Bundle proportion of historical readmission rate/payment into up-front DRG rate
• Step down the % of historical over a 3-5 year period (say, 95% to 60%)
• Key Advantages:– Provides a direct incentive to reduce rates– Enables hospitals to earn “windfall profits” during
early years– Avoid abrupt change with negative impact– Sets a high bar, that can be reconsidered– Even 60% is higher than best performing Medical
Home sites, so not unrealistic– Administratively simple