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Transitions of Care/Personal Health Navigator

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:

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Transitions of Care/Personal Health Navigator

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  1. Transitions of Care/Personal Health Navigator January 31, 2009

  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

  4. Gray’s Woods 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

  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

  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

  10. Personal Health Navigator Team Provides Patient Care and Navigation aka Medical Home 10

  11. Five Functional Components • Patient Centered Primary Care • Integrated Population Management • Value Care Systems • Quality Outcomes Program • Value Reimbursement Program

  12. Integrated Population Management • Population profiling and segmentation • Predictive Modeling • Health promotion • Case Management on site • Patient specific intervention plans • Disease Management • Remote monitoring • HF and transitions of care • Pharmaceutical management • Donut-hole

  13. Embedded PCP Case Managers are Key to Success • Embedded Case Manager (per 700-800 Medicare pts) • High risk patient case load 15 - 20% (125 - 150 pts) • Beyond disease education • Personal patient link • Comprehensive care review – medical, social support • Transitions follow up (acute/SNF discharges, ER visits) • Direct line access – questions, exacerbation protocols • Family support contact • Recognized site team member • Regular follow ups high risk patients • Facilitate access – PCP, specialist, ancillary • Facilitate special arrangements (emergency home care, hospice care) • Linked to Remote & Tele-monitoring for specific populations

  14. Case managers engage within 24 - 48 hours to manage transitions Frequent medication issues at care transitions Confused, do not fill prescriptions Discharge plan often unclear and not scheduled Follow up communication absent, incomplete, illegible PCP & Specialty appts not available per plan Community resources not realized Most patients not hospitalized at Geisinger

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