Value Based Care in an Era of Accountability · Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger

Heal • Teach • Discover • ServeCopyright Geisinger Health System 2014

Not for reuse or distribution without permission

Geisinger Health System Confidential and Proprietary

ProvenHealth Navigator®Value based care in an Era of Accountability

Thomas Graf MD

National Director, Population Health

The Chartis Group

Former

CMO, Population Health and Longitudinal Care Service Lines

Geisinger Health System




Implemented 90+ Medical Homes (2006-2013)50%+ Outside Geisinger

Sites# of Sites

Medicare AdvantageMembers

CommercialMembers

Fee-for-Service

Members

GeisingerHealth Plan

Family (Medical

AssistanceMembers)

Geisinger (owned,in PA)

42 23,328 61,206 42,715 26,708

Non-Geisinger(in PA)

40 5,939 18,762 0 8,595

West Virginia

3 0 4,835 0 0

Maine 6 0 1,717 3,000 0

Total 93 29,267 86,520 45,715 35,303

PA = Pennsylvania. Geisinger Advanced Medical Homes began in 2006 with 3 Pilot sites.

The three pilot sites started with: 5,000 Medicare Advantage , 4,100 Commercial, and 2,100 Medicare lives.

2

March 2014




Geisinger’s PHN model has five core components

Patient-centered

primary care

• Patient and family engagement & education

• Enhanced access and scope of services

• PCP led team-delivered care

• Chronic disease and preventive care optimized with HIT

Integrated

population

management

• Population segmentation and risk stratification

• Preventive care

• In-office case management

• Disease management

Medical

Neighborhood

• Micro-delivery referral systems

• 360°care systems – SNF, ED, hospitals, HH, etc

Performance

Management

• Patient satisfaction

• HEDIS and bundled chronic disease metrics

• Preventive services metrics

Value-based

reimbursement

• Fee-for-service with P4P payments for quality outcomes

• Physician and practice transformation stipends

• Value-based incentive payments

• Payments distributed on Quality Performance 3|




Redesign requires behavior change which can be led, managed

• Paradigm shift for leaders, clinicians & staff and leadership to population management by a collaborative care team

• Work behaviors must change (redesign) in order to effect outcomes

• Change process must be proactively managed

• Behavior Change “Catalysts”1. Proactive identification of patients at risk or with care

gaps

2. Embedded nurse case managers and extended team

3. Care team meetings which discuss patient care & performance reports

4|




5|

PHN Key Success Factors

• Manage the change, manage the change

• Establish leadership and teams to:

– Re-design the process; customize available tools; & allow teams

to innovate

• Embedded disease & case managers

• Proactive patient identification and stratification

• Monthly primary care team meetings

• Actionable data to drive interventions




Building Systems of Care

• All or none “Bundle” measure for Diabetes

• Clinical process redesign – Eliminate, Automate, Delegate, Incorporate, Activate

• Clinical decision support – Health Maintenance and Best Practice Alerts

• Patient specific strategies using registry report data

• Care Gaps

• Patient centered strategies – Patient report cards

• Compensation

6|




Monthly Care Team Meetings

• Foundational to success

• Shared leadership

• Case review

◦ Missed opportunities

◦ Pattern recognition

• Workflow gaps and redesign

• Performance monitoring

• Review of patient ID reports & performance outcomes

• Care Team training

7|




Care Approach by Patient Risk Status

Well

At-Risk

Chronic-Complex

• Advanced Primary Care •Practice redesign

•Automated prevention care gaps & interventions

•Health IT reinforces guidelines & best practices

•Patient education & activation

•Care team performance management meetings

•Chronic Disease Care

•All of the above

• ID & stratify

•Self management & education

•Close gaps in care

•Driving to goal

• Concentrated Care•All of the above plus

•Embedded Case Manager

•Predictive analytics

•Transitions

•Advanced clinical management

•Care coordination

8|




Embedded Case Management has been Core to our Success

Embedded Case ManagerPersonal Care LinkRecognized Team

Member

Patient, family support contact

-High risk patient case load - 15 - 20% Medicare- 5% commercial- 125 - 150 pts per CM

Facilitate special arrangements – home

care, hospice, AAA

TOC follow-up – acute care, SNF, ED

Comprehensive Care Review – medical, social

support

Direct phone access –questions, exacerbation

protocols

Facilitates access – PCP, specialist, ancillary

Links health care team to payer

Regular follow-up of high risk patients

- 1 CM per 800 Medicare lives- 1 CM per 5000 commercial lives- 1 CM per 3500 Medicaid lives

- Not disease management focused

- Focus on those at most risk- Focus on driving issue within the

case

9|




Transitions of Care

Inpatient

• IDTs

• Pharm D med reconciliation

• 24 hr D/C summary

• ED alerts thru HIE

• Scheduled f/up appts

SNF

• APRNs

• 24 hr initial assessment

• SNF on-call group

• First week “intensity”

• SNF Log

Outpatient

• CM 24 – 48 hr call

• Med reconciliation

• Action Plan

• < 7 day f/up

• IVR

• Home visits

2023




Why is Better PCP-Specialist Relationship Needed?

• Communication between PCPs and specialists is:

– High volume

– Ineffective

– Expensive

• Access to many specialties is delayed

• Current mode of face to face consultation is

wasteful

| 11




Optimizing the PCP-Specialist Connection

Nephrology

RN CM on the nephrology team

Hospital & dialysis follow

ED connectivity to Fellow

Reduced admissions

Reduced re-admissions

Reduced ED Reduced PMPM

Modes of Care

Rheumatology & Pulmonary

Methods of communication

Ask-A-Doc vs First visit in specialty office and Tele-health visit with specialist in primary care office

Cardiology

Heart Failure EHR enabled

primary care decision support

Collaborative management plan

Acute care protocol – DTP

CM liaison between Cardiologist and PCP




Results from a Pilot Program




PROVENHEALTH NAVIGATOR®

Evaluating the Impact

| 14




010203040506070

Mammogram

Phase 1 Phase 3 Trend 2.8%

Phase 2 Trend 5.4%

Phase 4 Trend -0.5%

Phase 5 Trend2.1%

Phase 6 Trend18.6%

ProvenHealth Navigator® Quality Outcomes

0

5

10

15

20

Diabetes Bundle

Phase 6 Trend

161.5%

Phase 1 Trend

Phase 3 Trend 4.8%

Phase 2 Trend 9.8%

Phase 4 Trend 3.0%

Phase 5 Trend 21.0%

0

10

20

30

40

50

60

A1C Less than 7%

Phase 1 Trend

Phase 3 Trend 0.5%

Phase 2 Trend 3.5%

Phase 4 Trend 2.2%

Phase 5 Trend -3.2%

Phase 6 Trend -17.1%

0

5

10

15

20

25

30

CAD

Phase 1 Trend

Phase 3 Trend 12.2%

Phase 2 Trend 5.5%

Phase 4 Trend 5.1%

Phase 5 Trend 16.1%

Phase 6 Trend

119.8%

0

10

20

30

40

50

60

LDL at Goal

Phase 1 Trend

Phase 3 Trend 9.6%

Phase 2 Trend 5.9%

Phase 4 Trend 9.8%

Phase 5 Trend 14.2%

Phase 6 Trend 25.8%

05

101520253035

Preventive Care

Phase 1 Trend

Phase 3 Trend -3.4%

Phase 2 Trend 9.9%



Phase 6 Trend -

13.5%




3 Year Results in 25,000 DM Patients

305 MI’s Prevented

NNT to prevent one

(1) MI

82 patients

140 Strokes

Prevented

NNT to prevent one (1) Stroke

170 patients

166 Cases of Retinopathy

Prevented

NNT to prevent one (1) case of

Retinopathy

152 patients| 16




264250

239 246236 235 236

309 309 315300 298 291 288

266297

0

50

100

150

200

250

300

350

2006 2007 2008 2009 2010 2011 2012 2013

PHN Non-PHN 99 Current PHN Sites

Medicare Risk Adjusted Acute Admissions Per 1000




Medicare Risk Adjusted Readmissions/1000

42

3235 35

32 31 31

47 4749

4543 44

45

37

44

0

10

20

30

40

50

60

2006 2007 2008 2009 2010 2011 2012 2013





Medicare Risk Adjusted ER Visits/1000

302

272 265273 280

298319

264 257275

293302

342358

375

266

0

50

100

150

200

250

300

350

400

2006 2007 2008 2009 2010 2011 2012 2013





185 176192

172 179194 187

227 230 238 233249

270 275

204

0

50

100

150

200

250

300

2007 2008 2009 2010 2011 2012 2013


Commercial Risk Adjusted ER Visits/1000




PHN Results for Medicare

(Am J Manag Care. 2010;16(8):607-614)| 21




PHN Return On Investment

| 22

Documents

Value Based Care in an Era of Accountability · Heal • Teach • Discover • Serve Copyright Geisinger Health System 2014 Not for reuse or distribution without permission Geisinger