heal teach discover serve geisinger health system confidential and proprietary 1 innovations in...

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


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


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


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


ProvenHealth Navigator®

Geisinger’s Value-based Patient-Centered Medical Home


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


Acute Admissions Show Improvement

Risk-adjusted acute admits/1000 (Medicare)


50 51 535541 3943 48

31

0

75

2006 2007 2008Medicare Comparison Phase 1 Sites Phase 2 Sites

Readmissions Show Improvement

Medicare Readmissions/1000


Spending Decreased Compared to Expected Trend

Spending (-8%)


ProvenCare - Chronic®

Chronic Disease Optimization


DM Best Practice Alert/Order Set


MyGeisingerPatient Reminder View


Patient Education

Letter


Patient Trend Report

Most recent values displayed

Therapeutic goals are stated

Clinical consequences are stated


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


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


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%


ProvenCare Acute®

Geisinger’s Bundled Episodic Care


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


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)


problem?


problem?


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


Process Redesign: Hardwiring


ProvenCare® CABG: Reliability

0%

10%

20%

30%

40%

50%60%

70%

80%

90%

100%

% patients receiving all ProvenCare components


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


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%


Other ProvenCare Acute Programs


ProvenEngagement®


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


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


HTN Patients Who Engage in Self-management Behaviors

Source: J.Hibbard, University of Oregon


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.


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”


Thank You.


ProvenTransitions®

Care Hand-off Optimization


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)


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


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


Patients Screened


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


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

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Documents

system of care

quality of health care

primary care

selfcare slide

medical home slide

embedded care management

high quality

chief innovation officer