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Transitions of Care/Personal Health Navigator. January 31, 2009. Agenda. Geisinger Overview Transitions of Care Personal Health Navigator aka Medical Home. Overview of Geisinger System. Geisinger Clinic: 750 Physicians 42+ Community Practice Sites Three Acute Care Hospitals: - PowerPoint PPT Presentation
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Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value1
Transitions of Care/Personal Health Navigator
January 31, 2009
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value2
Agenda
⢠Geisinger Overview⢠Transitions of Care⢠Personal Health Navigator aka Medical Home
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value3
Overview of Geisinger System
⢠Geisinger Clinic:â 750 Physicians â 42+ Community Practice Sites
⢠Three Acute Care Hospitals:â Geisinger Medical Centerâ Geisinger Wyoming Valleyâ Geisinger South Wilkes-Barre
⢠Geisinger Health Plan:â 80 Hospitals, 17,000 Providers
⢠Clinical Innovation Strategyâ ProvenCaretm
â Chronic Disease Optimizationâ Personal Health Navigatorâ Transitions of Careâ EPIC enabled
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value4
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
Grayâs Woods
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value5
Geisinger Transitions of Care (âTOCâ) Project
⢠Started in January, 2008 as a joint quality-efficiency initiative complementing the medical homeâ Eliminate unnecessary readmissionsâ 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:â System-wide vs. narrow populationâ Multiple pilots to test impact of different interventionsâ Focused primarily on quality enhancement and future
economic positioning, with limited/no current negative impact
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value6
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
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value7
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 Value8
Interdisciplinary Team Rounds
Todayâs 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?
â What is keeping the patient from going home or to a lower level of care?â Can anything be implemented today to expedite the discharge date?
⢠Is there a risk for readmission? What can be implemented to reduce that risk?
â Are activities of daily living (walking, eating, elimination) at an appropriate level to prepare for transition?
â Need Nutrition/PT/OT/Diabetes/Wound intervention? PICC line for post acute infusion?
â Is the patient and family teaching completed in preparation for transition?â Referrals/insurance authorizations needed? Placement arranged?â Is the family and home ready for transition? Are there any patient safety
considerations?
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value9
Discharge/Proactive Outreach
⢠PCP Appointment Scheduled Before Discharge
⢠Discharge Synopsis to PCP⢠Inpatient Screening leading to Post Acute
Care Managementâ Medication Reconciliation and Teachingâ Physician Appointment Follow Upâ Home Care and DME in Placeâ Trigger Management
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value10
10
Personal Health Navigator Team Provides Patient Care and Navigation
aka Medical Home
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Five Functional Components
⢠Patient Centered Primary Care⢠Integrated Population Management⢠Value Care Systems⢠Quality Outcomes Program⢠Value Reimbursement Program
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value12
Integrated Population Management
⢠Population profiling and segmentationâ Predictive Modeling
⢠Health promotion⢠Case Management on site
â Patient specific intervention plans
⢠Disease Management⢠Remote monitoring
â HF and transitions of care
⢠Pharmaceutical managementâ Donut-hole
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value13
Embedded PCP Case Managers are Key to Success
⢠Embedded Case Manager (per 700-800 Medicare pts)â High risk patient case load 15 - 20% (125 - 150 pts)â Beyond disease education
⢠Personal patient linkâ Comprehensive care review â medical, social supportâ Transitions follow up (acute/SNF discharges, ER visits)â Direct line access â questions, exacerbation protocolsâ Family support contact
⢠Recognized site team memberâ Regular follow ups high risk patientsâ Facilitate access â PCP, specialist, ancillary â Facilitate special arrangements (emergency home care, hospice care)
⢠Linked to Remote & Tele-monitoring for specific populations
Heal ⢠Teach ⢠Discover ⢠Serve Geisinger Value14
Case managers engage within 24 - 48 hours to manage transitions
⢠Frequent medication issues at care transitionsâ Confused, do not fill prescriptions
⢠Discharge plan often unclear and not scheduledâ Follow up communication absent, incomplete, illegibleâ PCP & Specialty appts not available per planâ Community resources not realized
⢠Most patients not hospitalized at Geisinger