Care managers do condition screenings, monitor symptoms, assess the patients’ or their families’ ability to manage the medication regimen, and catalyze as much patient activation and engagement as possible. In addition, the care managers are tasked with closing all gaps in care, particularly with high-prevalence chronic diseases such as diabetes, asthma, hypertension, osteoporosis, coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure, and reactive depression.
A Day in the Life of a Care Manager
A typical day in the life of a care manager is anything but typical. It usually starts with a review of various computer programs to check the status of hospitalized and discharged patients, but it can go in a number of directions depending on patient needs on any given day. The care manager reviews this information and prioritizes phone calls to patients.
Care managers usually contact patients discharged from the hospital first because that transition of care is hugely important. That is followed by contacting, either by phone or in person by visiting their homes or skilled nursing facilities, those patients who have been in the hospital within the past 30 days. It’s important to get out into the field and see patients in person and in their home setting. Phone contact is effective, but care managers can often learn more when they actually see patients.
Care managers have the opportunity to interact with many different people throughout the day—not just patients, but also their family members. That interaction is most often favorable because patients and families identify the care manager as someone who is going to help them. Occasionally, patients and family members are not happy about something, and care managers point them in the right direction to address concerns.
Care managers also interact frequently with physicians and other care team members. This is often done via computer so as not to interrupt the physicians’ workflow. For pressing matters, of course, the care manager seeks out the physician and discusses the situation. The front office staff and clinic nurses also see the care managers as important colleagues who can step in and help answer patient questions or solve problems.
In addition, the care manager interacts regularly with various people in the community including staff at nursing homes, home health agencies, area agencies on the aging, durable medical equipment suppliers, and others.
The work day is nearly done by the time the care manager’s urgent calls, weekly calls, visits, and personal interactions have been completed. The end of the day is often spent returning calls received while the care manager was out of the office and reaching out to patients the care manager hasn’t spoken with for some time. Although these patients usually are doing well and haven’t had any issues lately, it’s still important to check in with them and remind them of what they need to be doing for health and well-being.
The next day brings a new set of issues and circumstances, but the care managers’ ongoing relationships with patients and familiarity with their medical histories helps them make a positive difference for people in need.
We also employ advanced care management, reserved for patients identified through predictive modeling (done on the payer side) to be at highest risk for acute care utilization. Most of the data is from medical claims and pharmacy; however, a significant amount of concurrent data also comes from the EHR and through our data warehousing and provider-side analytics. Targeted populations most often include the prevalent chronic disease aggregates: cancer, end-stage renal disease, high-risk pregnancy, special populations such as those with multiple sclerosis, cerebral palsy, and cystic fibrosis, and in general the frail elderly. The embedded advanced care managers also are asked to assess the social and behavioral issues associated with the medical diagnoses aggregations. We do this to better understand the link between physical and psychological gaps in care and to more effectively work with patients, their families, and social supports in determining how to create real behavior change in the caregiver/patient partnership.
Patients being discharged or transferred from acute care facilities are an additional target population across all of our risk stratifications and represent a particular challenge if they do not already have a PCP in our system.
The care management solution for non-Geisinger providers entails either training and onboarding care managers for the provider’s system or creating care management outsourcing solutions embedded as a turnkey operation. (See Figure 9.4.)
FIGURE 9.4 Our Approach to Advanced Care Management
THE MEDICAL NEIGHBORHOOD
The medical neighborhood, the final core component in PHN, is an attempt to create a 360-degree care system including skilled nursing facilities, the acute care hospital before transition into the ambulatory setting, home health, and pharmacy. It involves defining resource utilization differences between employed and nonemployed physicians, selective specialty referrals, a systematic process attempting to create efficient transitions of care processes, and integration with community services.
The key is to create a fundamentally different relationship between the hospital-based specialists and the community practitioner team located near where the patients and their families live. The other equally important change is to create a relationship between the community practitioners and an enhanced care model that includes skilled nursing facilities and non-doctor’s-office social resources. (See Figure 9.5.)
FIGURE 9.5 Optimizing the Primary Care Physician and Specialist Connection
Two basic concepts are important. The first is that specialists and PCPs work together to determine the algorithms and the commitments to bundle best practice for patients with prevalent chronic diseases. Second, in the event of a diabetes or a congestive heart failure patient in crisis, most of the time health systems considering themselves responsive would simply figure out how to open up the daily schedules of the hospital-based specialists and subspecialists so patients could come to them and be seen the same day. Geisinger didn’t think that aspiration was good enough, and what we did was have the specialists and subspecialists available 24/7 to take either phone calls or electronic communication from the PCPs. Most often this solved the issue. Only about 15 to 25 percent of the time was there still a residual need for patients to come in to be seen by the specialist or subspecialist.
In addition to keeping patients out of the hospital emergency department unless there is a true emergency, preempting chronic disease management issues that lead to emergency situations, and providing care in our doctors’ offices, we also include the patients’ home settings in their overall care. We create an effective medical neighborhood to further develop the continuum of care by getting to the kitchen tables of patients who have four or five chronic diseases and take 15 to 20 medications daily. We visit patients in skilled nursing facilities and intervene before they experience a 5- to 10-pound weight gain and are transferred to the local hospital emergency department to handle their fluid retention.
DRIVING SUSTAINABLE OUTCOMES
Performance metrics are straightforward, with admissions per 1,000 and reduced readmission rates our primary endpoints. Metrics focused first on patient and clinician satisfaction, then on the cost of care before and after reengineering. Decreased acute hospital utilization was the first sign of success. Specific quality metrics addressing particular high-prevalence chronic disease outcomes improved. And we looked closely at how the reengineering could help bridge the movement from fee-for-service to pay-for-value as the dominant form of reimbursement transformation.
In our experience, success in scaling for both the Geisinger and non-Geisinger nonemployed physicians almost always has been obtained within a year, with a significant decrease in total cost of care based chiefly on decreased acute care days per 1,000 patients. Additional extraordinarily important outcome metrics include patient and physician satisfaction and improvement in chronic disease-specific process and outcome metrics. (See Figure 9.6.)
FIGURE 9.6 Effective Redesign and Care Coordination Delivers Rapid Impact
The most important benefit from the patient standpoint, in addition to a satisfying and effective relationship with the physicians in the newly reengineered community practices, is the effect on disease outcome. Some 99 percent of our patients believe working with a care manager is good, and 79 percent think the care they receive is better. For the type 2 diabetes patients who were involved in the reengineering, in fewer than three years, significant numbers of heart attacks, strokes, and retinopathy cases were prevented when compared to the practices before reengineering or to practices that had not been reengineered. (See Figure 9.7.)
FIGURE 9.7 ProvenCare Chronic Disease Value-Driven Care Outcome Improvements
In scaling to non-Geisinger practices in non-Geisinger markets, admissions, readmissions, and emergency department visits all were decreased significantly and sustainably within a year. Cost-of-care reductions obviously were affected by the hospital-centric finance officers’ tendency to increase price per unit as volume decreased. Nevertheless, there was total reduction in cost of care per patient in a number of these scaling exercises. Finally, extension into the pioneer accountable care organizations was extraordinarily gratifying and affirmed. The value in decreasing hospital admissions was the primary benefit to both patients and their families, as well as to the financial total cost of care endpoint. We believe that a huge amount of our PHN redesign and our bundled best practice beneficial effect on chronic disease patients was, in fact, the seed for attempting to recapitulate a payer-provider interaction like the Geisinger fiduciary structure in many other types of payer-provider relationships throughout the country, most predominantly the Centers for Medicare and Medicaid Services Pioneer Accountable Care Organization (ACO) model and other ACOs.
Our most obvious gratification was not just that we were a model for this redesign, but also the fact that we had shown that we could get significantly better outcomes with a population of patients. The huge decreases in the need for hospitalization and rehospitalization were proof of the fact that quality and cost do relate (and that usually they are inversely related) so higher quality results in lower cost. Incidentally, our PHN redesign is also a win for doctors. Some 86 percent of our physicians believe they provide more comprehensive care with our advanced medical home, 82 percent believe timelier information is available regarding patients’ transitions of care, and 93 percent would recommend advanced medical home to other PCPs.
LEADERSHIP ISSUES
Leadership teamwork between the payer and provider sides of Geisinger was key to PHN success. This was a transformational relationship in which both the payer and provider asked how quality and value could be improved for their mutual constituency and was significantly more than simply changing the payment incentives from insurer to provider. It started with a strategic discussion involving clinical and payer leaders defining the single highest cost group of patients in the ambulatory setting. The assumption was that these almost always were those patients with the least successful outcomes. Once the high cost/poor outcome cohort was defined, leadership on both sides of the organization came to consensus on what would be considered an optimal outcome. Payer side analytics as well as the clinical enterprise healthcare data warehousing and analytic capabilities were employed in this exercise. How the caregiving could be redesigned for different patient groups with different severities of disease, different disease and living needs, and different utilization patterns was a fundamental benefit of payer and provider leadership working together to the benefit of their mutual constituency. This fundamentally different relationship and working partnership was never generalized to any of the non-Geisinger payers within our market areas.
Sustainability of our payer/provider sweet spot may come under stress as overall Geisinger leadership throughout the organization evolves, leaders assume additional operational duties, and clinical and insurance markets become more stringent. From our scaling experiments outside the traditional Geisinger market into Delaware, Maine, and West Virginia, clinical enterprise commitment without sustaining commitment from a dominant payer in the volume-to-value reimbursement transition has demonstrated that most positive outcomes are not sustainable long-term, despite early success.
LESSONS LEARNED
• Provide dedicated care managers enabled by both claims and clinical data.
• Implement a best practice team with proper staff allocation and be willing to change what people do.
• Be sure to have data up front.
• Provide training for all involved in advanced medical home.
• Accept that it’s not just reengineering; be in it for the long haul.
• Build a strong infrastructure with guidelines for accountability.
• Pay for better patient outcomes, not filling hospital beds.
• Define outcome by individual provider and by each community practice group.
• Spread what you learn from the most successful to the least successful.
• Enable continuous innovation with some room for failure.
• ProvenHealth Navigator’s success simultaneously means better health outcomes and lower total costs of care.
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Leading and Managing a Successful Practice Transformation
The primary goal in reengineering care and implementing ProvenHealth Navigator (PHN) was enhancing patient care. That’s the first question we always explore. PHN and other Geisinger innovations also have made things better for providers, an important consideration and benefit for any healthcare organization looking to innovate.
BEFORE PROVENHEALTH NAVIGATOR
The professional life of a physician 15 years ago and prior to PHN was controlled chaos. Doctors sort of had a budget, mostly dependent on the goals and ambition of the individual provider and how many patients he or she was willing to see in a day. Schedules frequently were uncontrolled, with patients added on or double-booked indiscriminately. It was difficult and stressful to spend appropriate time with each patient knowing that other patients, scheduled for the same time, were waiting.
Patient communication predominantly was via the telephone, which was overwhelming, and sometimes by fax or snail mail, which was slow and inefficient. Just imagine the mechanics of writing and mailing a note to your doctor and waiting for a response. Documentation of care was via paper chart, which served as notes for the physician to keep and review during subsequent episodes of care for the individual patient: a series of scribbles or perhaps checklists with no ability for flow charts or meaningful care plans unless manually produced and, in general, lacking organization. Office-based care then was mostly a cash business, and there was no oversight or need to review the memorialization of an office visit by outside agencies or insurance reviewers. The flow of information from inpatient to outpatient environments and vice versa was slow, inefficient, and inadequately managed, setting the stage for poor transitions of care, missed opportunities, errors, and overall care that was not as good as it could and should be.
When Geisinger implemented its electronic health record (EHR), it was used primarily as a typewriter or word processer for the first five years. Notes became more legible, accurate, and comprehensive as time passed, and we began to take advantage of additional EHR features such as prompts to ensure various tests were completed at appropriate intervals, prescription reminders, electronic referrals, and more.
But that wasn’t the case in the beginning, when even the scheduling of patient appointments was uncontrolled. Paper-based schedule books commonly were used, but individual physicians had the ability to design their own templates. So doctors would have many different appointment types: 5 minutes for one, 20 minutes for another, or 60 minutes for an annual visit. There was no ability to assess or analyze the value of time spent for each of the various appointment lengths or time lost by not filling the schedule completely. There also was less control because physicians thought the phone staff and other schedulers would just add patients between the lines as needed to satisfy patient
or physician requests for return visits. Due to the inability to establish firm scheduling guidelines, physicians often felt like they were running on a nonstop treadmill, trying to do the right thing, but knowing that there was always someone waiting in the next exam room.
There really was no unified direction as we attempted to provide the best evidence-based, comprehensive care. Individual doctors had their own repertoire of evidence-based care depending on the latest journal article read or educational conference attended. We all thought our unique care models were the best, but there was no ideal method to measure outcomes to provide evidence to alter practice styles or reduce variation in recommended treatment for patients with chronic conditions.
The delivery of care was laid directly on the shoulders of physicians. Support staff members answered phones, placed names on schedules, escorted patients to exam rooms, and perhaps took blood pressures, but were responsible for few other clinical interventions. That was accepted practice. The physician was expected to be in charge and in control. In many cases, the doctors didn’t even want others to intervene clinically. That was their job.
There also was no accountability for quality or efficiency. No one knew outcomes, either intermediate, such as blood pressure control or diabetes management control across a practice, or endpoint, such as diabetes patients with retinal, renal, or vascular complications. Paid for volume, hospitals loved the big admitters. Pharmaceutical utilization went unchecked; for example, polypharmacy had no checks and balances and off-label use was not challenged or monitored. But we did our best, given the available tools and resources at the time. (See Figure 10.1.)
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