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ProvenHealth Navigator: A Patient Centered Primary Care Model Duane Davis, MD, VP, Chief Medical Officer Janet Tomcavage, RN, MSN, VP, Health Services PowerPoint PPT Presentation


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ProvenHealth Navigator: A Patient Centered Primary Care Model Duane Davis, MD, VP, Chief Medical Officer Janet Tomcavage, RN, MSN, VP, Health Services Geisinger Health Plan. 1. 1. Geisinger Health System: Danville, Pa Geisinger Clinic: 700 Physicians 41 Community Practice Sites

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ProvenHealth Navigator: A Patient Centered Primary Care Model Duane Davis, MD, VP, Chief Medical Officer Janet Tomcavage, RN, MSN, VP, Health Services

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ProvenHealth Navigator:

A Patient Centered Primary Care Model

Duane Davis, MD, VP, Chief Medical Officer

Janet Tomcavage, RN, MSN, VP, Health Services

Geisinger Health Plan

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Geisinger Health System: Danville, Pa

Geisinger Clinic:

700 Physicians

41 Community Practice Sites

Geisinger Medical Centers - 3 Acute Care Hospitals

Geisinger Health Plan:

80 Hospitals

16,000 Providers

215,000 Members


Better Value for health care spend is the goal

Someone needs to be charged with delivering value

Medical Home/Chronic care models will cost more

Any delivery system changes must deliver savings today

Proven Health Navigator is GHS value agent


Proven Health NavigatorStrategy

  • Deliver optimal health status for individuals and population based value outcomes via a partnership between PCP’s and GHP that provides 360 degree, 24/7 care and guidance to the practice population.


Value is defined as hitting target metrics in the domains of:

  • Patient experience

  • Quality outcomes

  • Efficiency outcomes


ProvenHealthNavigator Pilot Goals

  • Improve patient experience and health status

  • Improve quality and efficiency across the entire spectrum of care

  • Transform primary care from transaction to value focus

  • Provide meaningful coordination across all of Health Care

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The System has five functional components

  • Patient Centered Primary Care

  • Integrated Population Management

  • Care Systems

  • Quality Outcomes Program

  • Value Reimbursement Program


1. Patient Centered Primary Care: expanding primary care capabilities

  • Acute and chronic illness care

  • Expanded scope of services

  • Team based care

  • Patient and family engagement & education

  • Rx management program

  • Chronic disease and preventive care optimization via EMR embedded triggers


2. Population Management: giving PCP’s ability to see and impact a population

Predictive Modeling

Population profiling and segmentation

Health promotion

Case Management on site

Disease Management education

Patient specific intervention plans

Remote monitoring

Pharmaceutical management


3. Value Care Systems:keeping patients in line of sight across the care continuum

  • Micro-delivery referral systems

    • High volume specialties

    • Ancillary services – Radiology, Lab

  • 360 degree care systems

    • Hospital care

    • Home Health

    • SNF’s

    • ER coverage


4. Quality Outcomes Program: tracking outcomes and continually improving

  • Patient Satisfaction Metrics

  • Chronic Disease Metrics

    • Diabetes, CHF, Coronary Disease, Hypertension

  • Preventive Services Metrics

    • HEDIS Influenza, Pneumoccal


5. Value Reimbursement Program: Aligning payment with value outcomes

  • Fee For Service

  • Practice transformation stipends

    - Physician

    - Infrastructure

  • Value Based incentive payments

    • Opportunity based on efficiency results

    • Payments based on quality metrics

12


Initial Results are promising

Quality – improved outcomes

Efficiency – improved medical trend

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Proven Health Navigator Quality Metrics


Efficiency Results at initial ProvenHealth Navigator sites are positive

* Risk Adjusted


Experience to date has led to 5 implementation priorities

  • Predictive Modeling to stratify Population

  • Make Case Manager key member of care team

  • Manage transitions of care – post acute hospital

  • Manage SNF admissions

  • Use EPIC reporting and decision support to drive QI

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Q & A

Discussion

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