In our version of advanced medical home, we’ve developed a sophisticated combination of technology and people. While our redesign of care may be technology-enabled, it is based on our view that a long-term human relationship between the patient, the patient’s family, and a care manager (the healthcare quarterback paying attention to all the details) is imperative for success.
For example, when Robert stepped on a Bluetooth-enabled scale at home, his weight was transmitted to his doctor’s office, where care manager Anita McCole noticed the slightest increase. Well aware of Robert’s medical condition, she called to ensure he was OK. When he mentioned weakness in his legs, Anita was able to facilitate physical therapy to build strength. From their multiple conversations over time, Anita and Robert developed a rapport, and he was comfortable talking with her about his health issues.
In addition to managing chronic illness, our nurse care managers ensure that patients are safe in their homes, have the necessary transportation to get to their appointments, are eating well and taking medications as prescribed, and are complying overall with their care plans. The care managers confirm that their patients schedule tests and procedures and receive their flu, pneumonia, and shingles vaccines. In essence, the care manager becomes the patient’s partner and ally to connect the patient with the healthcare team. Keeping patients as healthy as possible saves money by decreasing the need for expensive hospitalizations, but most importantly it is beneficial to our patients and their families.
Results are what matter, and we are pleased with PHN’s ability to improve care while reducing hospital admissions. (See Figure 9.1.)
FIGURE 9.1 Admission and Readmission Metrics
In addition, our advanced medical home program has demonstrated improvement in the risk of heart attack, stroke, and retinopathy in individuals with diabetes. Our three-year results for 25,000 patients found that PHN prevented 305 myocardial infarctions, 140 strokes, and 166 cases of retinopathy. While emergency department visits remained flat, acute care admissions decreased 27.5 percent and all cause 30-day readmissions decreased 34 percent. Further, 72 percent of patients say quality of care improved when they worked with a care manager.
PHN was developed as part of Geisinger’s response to the national problem of not having enough primary care physicians (PCPs) available to meet patient demand, especially with the aging of the baby boom generation and the increase in patient volume associated with the 2010 Patient Protection and Affordable Care Act. PHN has three major components: primary care redesign, population health management, and the medical neighborhood.
PRIMARY CARE REDESIGN
The typical response to the physician shortage, attempting to train and hire more PCPs and to pay them more, is totally inadequate. Simply hiring more is impossible, because there aren’t enough at the present time, and it will take 10 to 15 years for any significant increase because of training latency. Higher pay redistributes rather than solves the problem, creating market imbalance somewhere else.
Redefining the role of the PCP is another inadequate response. In various parts of the United States, we’ve seen the specialty-based disciplines of obstetrics/gynecology, cardiology, medical oncology, and even general surgery claim that chronic disease management for a certain component of patients is best done by the specialist. Such claims may have credibility, but this doesn’t solve the problem for most patients, who need a team captain for the multitude of specialty- and subspecialty-linked medical problems generally associated with the increasing aggregation of chronic diseases of aging, such as the fragile diabetes patient or the extreme congestive heart failure patient with hypertension and reactive depression.
Geisinger fundamentally reengineered the primary care process, relocating as much of the patient’s care as possible into our community-based practices and changing the relationship between our community-based primary physician team and our specialists, who more often than not are located in hospital-centric clinics. We did this by utilizing payer side data based on previous claims to identify patients who needed more hands-on care, stratifying the tasks of the community practices, adding the embedded nurse manager, and enabling that nurse to be the concierge care and triage caregiver for a group of the sickest patients in each practice. The other patients, based on decreased past utilization and expected decreased future utilization, were assigned to other members of the team for specific care. A good example is our algorithm-driven approach to managing hypertension run by a pharmacy tech, as opposed to a nonspecific accountability for helping to optimize blood pressure control that typically resided with the PCP. In the latter scenario, nothing usually was accomplished in between the patient’s yearly doctor visits, and the hypertension remained a continuing problem. We also encourage and expect our nurse managers to go outside the doctors’ offices as necessary, into patient homes or skilled nursing facilities where patients with the highest utilization often reside.
Four main components undergirded our primary care redesign: a PCP-led team delivering care, with all members of the team functioning at the top of their licenses; enhanced access for patients and their families; services guided by patient needs and preferences; and significantly enhanced patient and family involvement in caregiving outside of doctors’ offices. Again, the payer data and stratification of patient needs is essential to redesigning not only the care itself, but also who provides it. And the expectation that our concierge care commando nurses leave the offices and visit the highest-need patients in person helps the at-home caregivers become more involved, for instance, in the daily monitoring of weight and other appropriate tasks.
Our primary care redesign was matrixed with “all-or-none” bundling of care measures for patients with prevalent chronic diseases, similar to what we used to reengineer care of type 2 diabetes patients in creating ProvenCare Chronic. We agree with Donald M. Berwick, a leading advocate of high-quality healthcare and former administrator of the Centers for Medicare and Medicaid Services, who supported the all-or-none bundle commitment because it more closely reflects the interests and desires of patients, fosters a systems approach to achieving goals, and provides a more sensitive scale for assessing improvements.2
In addition to activating patients and their families to become partners, we also concentrated on eliminating, automating, delegating, and incorporating what was easiest into the normal patient flow and provider caregiving. In short, we combined the redesign of the primary care based on specific payer data with the stratification of assignments to the various team members. Plus, we committed to achieving all the known best practices, as socialized by our PCPs and hospital-based specialists and subspecialists, for the most optimal outcomes for patients with type 2 diabetes, coronary artery disease, congestive heart failure, and other chronic conditions.
It was this combination of our commitment to individual high-prevalence chronic disease optimization plus our primary-care reengineering that led to Geisinger’s overall decrease in hospitalization per thousand. The bundled best practice plus PHN as an integrated force changed the cost of care in two ways: getting better outcomes for chronic disease patients and reorganizing how care is provided to these patients so they are better cared for and able to avoid those all-too-frequent weekend visits to the emergency room. This ultimately decreases their need for hospitalization.
We charged everyone to go for out-of-the-box transformational change, rather than incremental redesign. To do so, we:
• Asked outrageous questions
• Made outlandish suggestions for consideration
• Became comfortable taking risks
• Anticipated, managed, and promoted emotional connections
• Celebrated successes and learned from failures
At the same time, we watched carefully and didn’t readily accept the familiar reasons people use to resist change. This included making sure that routine needs were handled and communicated via the electronic health record (EHR) prior to the physician seeing the patient so the v
isit with the doctor could focus on solving problems as opposed to simply gathering data. It also included fundamental changes, such as the patients being brought into the examining rooms by team members not involved in actual caregiving. When these team members “room” the patients, doctors and nurses can spend their time and effort appropriately solving issues to benefit patients.
Our 20 percent of compensation based on achieving care transformation goals directly linked to top strategic innovation commitments also was doing something different than before. These goals were not related to relative value units, panel size, or the other usual fee-for-service volume-based productivity units. The providers’ performance in caring for the entire universe of patients in their given practices, as well as in the overall community practice service line, is fed back almost in real time to the payer. Analysis on the payer side produces a bell-shaped curve representing how individual providers vary in their use of resources and in patient outcomes, particularly related to hospital admissions and readmissions.
Use of this two-way data flow comes into play in determining best practice. We can see who is doing the best job with type 2 diabetes, coronary artery disease, or congestive heart failure patients, or with those patients who have multiple chronic diseases. We also can see where the best job is being done among our community practice sites. The obvious systemwide commitment, particularly among the leadership and community practice, is to scale and generalize from the individual physicians and the individual practices doing the best in terms of high quality and low cost.
The initial test for community practice reengineering at Geisinger involved our sweet spot: the overlap between members of our commercial, Medicare Advantage, and Medicaid managed care insurance plans and the patients cared for by Geisinger and nonemployed panel providers in Geisinger-owned hospitals. (See Figure 9.2.)
FIGURE 9.2 Sweet Spot for Partnership and Innovation
The structural and cultural aspects of the overlap between payer and provider were fundamental in enabling the significant behavior changes necessary for both providers and patients. The two-way change in data flow and in the way that providers and payers worked together to modify the processes of care went significantly beyond simply altering how the insurance company paid the providers. Individual tasks for general internists, PCPs, nurses, nurse practitioners, physician assistants, and pharmacists all changed. Interactions also changed between those who were providing care in community settings and our specialists, who were for the most part located in the hospital-centric clinical specialty locations. An explicitly different interface between the specialists, who are most often hospital-based clinicians, and the community practitioners was required to achieve bundled best practice for patients. This was linked to the Geisinger commitment to provide care as much as possible close to where the patients live. This is in distinct contrast to simply asking the specialists to open up their hospital-based clinic scheduling so patients and their families could travel to the hub. About 75 to 80 percent of patient issues can be handled efficiently simply by having immediate open access to specialists to answer questions either electronically or by phone, obviating the physical interaction that normally means patients going to see the specialists.
In addition, all of the best practice algorithms, particularly for the bundled best practice, were socialized by having specialists work with the PCPs. For example, PCPs and endocrinologists collaborated to determine the metrics to be achieved for all type 2 diabetes patients; similarly, cardiologists worked with PCPs in determining the bundled best practice for coronary artery disease and congestive heart failure. This fundamental interaction was socialized to obtain the bundled best practice algorithms for each prevalent chronic disease and to attain buy-in from both primary care and specialist physicians.
Having a health plan employee interacting effectively as part of the care team seemed revolutionary at the start of PHN. Our experience has shown that employees paid by the insurance company function well as part of the team in the doctors’ offices. The health plan representatives not only are directly responsible for managing high-utilizing patients, they are key enablers of smooth data flow between payer and provider.
We started with two beta sites, one in a Geisinger community practice in Lewistown and a second at our community practice office in Lewisburg. While the names of these two towns are similar, demographically they represent opposite ends of the socioeconomic strata. Only after we showed that we could obtain good results at both ends of the spectrum did we scale PHN throughout our entire system. In addition to learning how we could provide care and achieve results given such varying demographics, we also found that Lewisburg was close enough to the main Geisinger Medical Center hub that there was an interesting tension in determining which patients should be referred to this major hub and which should go to a non-Geisinger, but very good, community hospital within a mile of our Lewisburg practice. Lewistown, on the other hand, was more than 45 miles away from any Geisinger hub, and the only nearby hospital was a non-Geisinger facility that was, for most of the time until it joined the Geisinger family, relatively restricted in terms of resources, both human and capital. It was an interesting set of experiments with an overall commitment to keep patients as close to home as possible, even if they had significant health issues. What we learned, in essence, was that it could be done at both of these places with an early result of significant decreases in hospitalization needs and excellent patient and doctor satisfaction.
Internal scaling consisted of 42 Geisinger-owned primary care practices, 40 non-Geisinger-owned practices that were heavily reimbursed through Geisinger insurance products, and private practices that used Geisinger-owned hospitals when acute care was needed. Non-Geisinger primary care practices in California, Illinois, Maine, New York, West Virginia, Virginia, and Wisconsin have undergone similar successful PHN reengineering efforts.3
We learned as we scaled that unless we kept attentive to the data flow, both from payer to provider and provider to payer, and looked at variations in care almost on a real-time basis, there could be recidivism in either hitting the optimal metrics in the bundled best practice commitment for high-prevalence chronic disease or in the metrics of hospitalization per thousand. Recidivism was likely the default, which required our active participation to avoid. Another important lesson was that we could scale out to nonemployed, non-Geisinger community practices as long as those practices had an adequate volume of Geisinger insurance patients to justify getting the data into those practices and capturing the attention of the non-Geisinger practitioners. Although we had no direct leverage over their total compensation, we could add quality bonuses based on getting the same kind of population health benefit, which amounted to an increase of 15 percent or greater to their total compensation. This was certainly sufficient for them to do the same kind of PHN redesign and make the same kind of commitment to bundled best practice that we were able to achieve with a much greater and more direct leverage among employed Geisinger caregivers in our own community practices.
POPULATION HEALTH MANAGEMENT
Population health management, the second major component of PHN, involves identifying, segmenting, and risk-stratifying populations of our patients and insurance plan members by analyzing data provided by our insurance operations as close to real time as possible. Chronic disease and both primary and secondary preventive care are enhanced by clinical decision support communicated through the EHR. Gaps in care and the appropriate interventions are discovered and transmitted in real time to the provider team and also to patients and their families. We consider the EHR to be an important member of the team, but only as an enabler, not as the primary solution.
Effective population health management is founded on the ability to stratify patients with different risks based on past utilization: patients considered basically to be well; those considered at risk, with one or two chronic diseases; and chronic and complex patients with a multitude of chronic diseases and significant hi
story of multiple acute care admissions. (See Figure 9.3.) The latter group is the chief focus of the PHN care managers.
FIGURE 9.3 Care Approach by Patient Risk Status
Our embedded care managers are tasked with understanding past and managing concurrent utilization. Most of the time, the care managers are registered nurses. We specify the individual chiefly responsible for frequent follow-up with each patient and his or her family. Care managers are given variable caseloads, with approximately 300 at-risk patients and 125 to 150 complex chronic disease aggregate patients assigned to each care manager.
Although employed by our insurance company, the care managers work as members of the community practice team, providing information from the insurance company that is modified for immediate use by the entire team. The care managers are chiefly responsible for everything that happens to their caseload of patients, and everything is triaged through these managers.
Most of the time, this embedded care management entails daily interaction between some member of the provider team and the patient and family. It often means linking the primary care manager with the appropriate specialists, either physically or by phone, to address acute access issues, always to be coordinated by the care managers. They often are out of the office, directly interacting with patients and their families in their homes, skilled nursing facilities, or wherever their patients are receiving care.
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