Title: Innovations in Reducing Cost and Improving Quality of Health Care:
1Innovations in Reducing Cost and Improving
Quality of Health Care Geisinger Health System
Example Ronald A. Paulus, MD EVP, Clinical
Operations and Chief Innovation Officer
2Geisinger Health System
Last updated 07/09/09
3Geisinger Transformation Infrastructure
4Clinical Decision Intelligence System (CDIS)
5Creating Real Value Geisingers 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
6ProvenHealth Navigator
- Geisingers Value-based Patient-Centered Medical
Home
7Functional Components
- Team-based, patient-centered primary care
(including embedded care management nurse) - Joint payor-provider population management
- High quality, efficient specialist identification
and referral - Quality Outcomes Program
- Value-based Reimbursement Program
- Baseline FFS
- Practice transformation stipends
- Quality-gated gain sharing
8Acute Admissions Show Improvement
Risk-adjusted acute admits/1000 (Medicare)
9Readmissions Show Improvement
Medicare Readmissions/1000
10Spending Decreased Compared to Expected Trend
Spending (-8)
11ProvenCare - Chronic
- Chronic Disease Optimization
12DM Best Practice Alert/Order Set
13MyGeisingerPatient Reminder View
14Patient Education Letter
15Patient Trend Report
Most recent values displayed
Therapeutic goals are stated
Clinical consequences are stated
16Diabetes Bundle Primary Care Average (n23,404)
17CAD Bundle Primary Care Average (n14,714)
18Adult Preventive Care (n209,090)
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 gt 35, F gt 45) 75 83
Diabetes Screening (Every 3 yr gt 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 gt65) 84 87
Influenza Immunization (Yearly Age gt50) 47 53
Chlamydia Screening (Yearly Age 18-25) 22 33
Osteoporosis Screening (every 3 yr Age gt 65) 52 66
Alcohol Intake Assessment 84 88
19ProvenCare Acute
- Geisingers Bundled Episodic Care
20GHS 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
21Process Redesign Work Flow
22Process Redesign Hardwiring
23ProvenCare CABG Reliability
24CABG Clinical Outcomes
Before
ProvenCare
ProvenCare Improvement
(n132)
(n321) In-hospital mortality
1.5 0.3 80 Patients
with any complication (STS) 38
33 13 Patients with gt1
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
25Hospital Financial Outcomes
Time Period Net Revenue Change Cost Change (Variable Direct/Total) Net Margin Change
July 2006 March 2009 7.8 -5.1 / -5.2 160
26Other ProvenCare Acute Programs
27ProvenEngagement
28The 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
29Population by Activation Level
12 of the population
29 of the population
37 of the population
22 of the population
Source J.Hibbard, University of Oregon
30HTN Patients Who Engage in Self-management
Behaviors
Source J.Hibbard, University of Oregon
31Patient 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.
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36Summary
- 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
37Thank You.
38ProvenTransitions
- Care Hand-off Optimization
39A Major Medicare Issue
- Potentially Preventable admissions account for
12 billion in Medicare spending (gt8 of 146B
total Part A spend in 2006)
30 Day Readmission Rate 60 Day Readmission Rate 90 Days Readmission Rate
18 35 67 (or dead)
40Drivers to Reduce Readmissions
DRIVERS
KEY TACTICS
GOAL
Early identification of readmission risk
Screening
Target interventions based on risk level
Early DC needs assessment of high risk pts
DC Planning choose best next care setting
Care Mgmt Inpatient/ Outpatient
Readmissions
Outreach to OP Care Mgmt based on risk level
Seamless transition between IP OP Care Mgt
Consistent documentation (location, content)
Team Communi-cations (IDTs)
Multi-disciplinary care coordination
Ready the patient for successful self-care
Multidisciplinary Teaching - patient and family
Patient Education/ Med Rec
Teach Who-What-When-Where if help needed
IP Pharmacist consult on high risk pts/meds
Post-DC Follow-up appt for EVERY patient
Post-Transition Care
Instant communication of hospital course and
follow-up needs to post-DC providers/agencies
MH with tele-monitoring, follow up phone calls,
SNF management
Social issues addressed (non-compliance, ability
to buy meds, advanced directives)
40
41ED Screening Instrument
- Based upon combination of literature review,
expert interviews, Geisinger data and clinician
experience
42Patients Screened
43FY 09 Final Results GWV
30 Day Readmission Rate
44Next 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