A Novel Approach to ICU Survivor Care: A Population Health Quality Improvement Project.

OBJECTIVES: Deliver a novel interdisciplinary care process for ICU survivor care and their primary family caregivers, and assess mortality, readmission rates, and economic impact compared with usual care. DESIGN: Population health quality improvement comparative study with retrospective data analysis. SETTING: A single tertiary care rural hospital with medical/surgical, neuroscience, trauma, and cardiac ICUs. PATIENTS: ICU survivors. INTERVENTIONS: Reorganization of existing post discharge health care delivery resources to form an ICU survivor clinic care process and compare this new process to post discharge usual care process. MEASUREMENTS AND MAIN RESULTS: Demographic data, Acute Physiology and Chronic Health Evaluation IV scores, and Charlson Comorbidity Index scores were extracted from the electronic health record. Additional data was extracted from the care manager database. Economic data were extracted from the Geisinger Health Plan database and analyzed by a health economist. During 13-month period analyzed, patients in the ICU survivor care had reduced mortality compared with usual care, as determined by the Kaplan-Meier method (ICU survivor care 0.89 vs usual care 0.71; log-rank p = 0.0108) and risk-adjusted stabilized inverse probability of treatment weighting (hazard ratio, 0.157; 95% CI, 0.058-0.427). Readmission for ICU survivor care versus usual care: at 30 days (10.4% vs 26.3%; stabilized inverse probability of treatment weighting hazard ratio, 0.539; 95% CI, 0.224-1.297) and at 60 days (16.7% vs 34.7%; stabilized inverse probability of treatment weighting hazard ratio, 0.525; 95% CI, 0.240-1.145). Financial data analysis indicates estimated annual cost savings to Geisinger Health Plan ranges from $247,052 to $424,846 during the time period analyzed. CONCLUSIONS: Our ICU survivor care process results in decreased mortality and a net annual cost savings to the insurer compared with usual care processes. There was no statistically significant difference in readmission rates.

An Analysis of a Biometric Screening and Premium Incentive-Based Employee Wellness Program: Enrollment Patterns, Cost, and Outcome.

Since 2012, a large health care system has offered an employee wellness program providing premium discounts for those who voluntarily undergo biometric screenings and meet goals. This study evaluates the program impact on care utilization and total cost of care, taking into account employee self-selection into the program. A retrospective claims data analysis of 6453 employees between 2011 and 2015 was conducted, categorizing the sample into 3 mutually exclusive subgroups: Subgroup 1 enrolled and met goals in all years, Subgroup 2 enrolled or met goals in some years but not all, and Subgroup 3 never enrolled. Each subgroup was compared to a cohort of employees in other employer groups (N = 24,061). Using a difference-in-difference method, significant reductions in total medical cost (14.2%; P = 0.014) and emergency department (ED) visits (11.2%; P = 0.058) were observed only among Subgroup 2 in 2015. No significant impact was detected among those in Subgroup 1. Those in Subgroup 1 were less likely to have chronic conditions at baseline. The results indicate that the wellness program enrollment was characterized by self-selection of healthier employees, among whom the program appeared to have no significant impact. Yet, cost savings and reductions in ED visits were observed among the subset of employees who enrolled or met goal in some years but not all, suggesting a potential link between the wellness program and positive behavior changes among certain subsets of the employee population.

Impact of a Complex Care Management Model on Cost and Utilization Among Adolescents and Young Adults with Special Care and Health Needs.

Adolescents and young adults with special care and health needs in the United States-many of whom have Medicaid coverage-at the transition phase between pediatric and adult care often experience critical care gaps. To address this challenge, a new model-referred to as Comprehensive Care Clinic (CCC)-has been developed and implemented by Geisinger Health System since 2012. CCC comprises a care team, consisting of a generalist physician, advanced practitioner, pharmacist, and a nurse case manager, that develops and closely follows a coordinated care plan. This study examines the CCC impact on total cost of care and utilization by analyzing Geisinger Health Plan claims data obtained from 83 Medicaid patients enrolled in CCC. A set of multivariate regression models with patient fixed effects was estimated to obtain adjusted differences in cost and acute care utilization between the months in which the patients were enrolled and the months not enrolled in CCC. The results indicate that CCC enrollment was associated with a 28% reduction in per-member-per-month total cost ($3931 observed vs. $5451 expected; P = 0.028), driven by reductions in hospitalization and emergency department visits. This finding suggests a clinical redesign focused on adolescent and young adults with complex care needs can potentially reduce total cost and acute care utilization among such patients.

Obstacles Experienced by Care Managers in Managing Information for the Care of Chronically Ill Patients.

Care managers play a key role in coordinating care, especially for patients with chronic conditions. They use multiple health information technology application in order to access, process and communicate patient-related information. Using the work system model and its extension, the SEIPS model (Carayon et al., 2006a; Smith and Carayon-Sainfort, 1989), we describe obstacles experienced by care manager in managing patient-related information. A web-based questionnaire was used to collect data from 80 care managers (61% response rate) located in clinics, hospitals and a call center. Care managers were more likely to consider 'inefficiencies in access to patient-related information' and 'having to use multiple information systems' as major obstacles than 'lack of computer training and support' and 'inefficient use of case management software.' Care managers who reported inefficient use of software as an obstacle were more likely to report high workload. Future research should explore strategies used by care managers' to address obstacles, and efforts should be targeted at improving the health information technologies used by care managers.

The impact of a regional patient-centered medical home initiative on cost of care among commercially insured population in the US.

The impact of a patient-centered medical home (PCMH) in reducing total cost of care remains a subject of debate, particularly among the non-elderly adult population. This study examines a 6-year experience of a large integrated regional health care delivery system in the US implementing PCMH among its commercially insured population. A regional health plan's claims data from 2008 through 2013 among its commercially insured members were obtained and analyzed. Over the 6-year period, the PCMH implementation beyond the first 6 months of exposure was associated with a lower total cost of care of ∼9% (P<0.05). The largest reduction was observed in outpatient costs (12%; P<0.05). This study suggests that PCMH implementation among the non-elderly adult population can potentially lead to cost savings. Future studies are necessary to identify the drivers of the cost savings and examine if similar results can be replicated elsewhere by other health care delivery systems.

Medicaid Managed Care in an Integrated Health Care Delivery System: Lessons from Geisinger's Early Experience.

Many states in the United States, including Pennsylvania, have opted to rely on private managed care organizations to provide health insurance coverage for their Medicaid population in recent years. Geisinger Health System has been one such organization since 2013. Based on its existing care management model involving data-driven population management, advanced patient-centered medical homes, and targeted case management, Geisinger's Medicaid management efforts have been redesigned specifically to accommodate those with complex health care issues and social service needs to facilitate early intervention, effective and efficient care support, and ultimately, a positive impact on health care outcomes. An analysis of Geisinger's claims data suggests that during the first 19 months since beginning Medicaid member enrollment, Geisinger's Medicaid members, particularly those eligible for the supplemental security income benefits, have incurred lower inpatient, outpatient, and professional costs of care compared to expected levels. However, the total cost savings were partially offset by the higher prescription drug costs. These early data suggest that an integrated Medicaid care management effort may achieve significant cost of care savings. (Population Health Management 2016;19:257-263).

Perceived Impact of Care Managers' Work on Patient and Clinician Outcomes.

OBJECTIVES: The aim of this study is to assess the contributions of care management as perceived by care managers themselves. STUDY DESIGN: Focus groups and interviews with care managers who coordinate care for chronic obstructive pulmonary disease and congestive heart failure patients, as well as patients undergoing major surgery. METHODS: We collected data in focus groups and interviews with 12 care managers working in the Keystone Beacon Community project, including 5 care managers working in hospitals, 2 employed in outpatient clinics and 4 telephoning discharged patients from a Transitions of Care (TOC) call center. RESULTS: Inpatient care managers believe that (1) ensuring primary care provider follow-up, (2) coordinating appropriate services, (3) providing patient education, and (4) ensuring accurate medication reconciliation have the greatest impact on patient clinical outcomes. In contrast, outpatient and TOC care managers believe that (1) teaching patients the signs and symptoms of acute exacerbations and (2) building effective relationships with patients improve patient outcomes most. Some care management activities were perceived to have greater impact on patients with certain conditions (e.g., outpatient and TOC care managers saw effective relationships as having more impact on patients with COPD). All care managers believed that relationships with patients have the greatest impact on patient satisfaction, while the support they provide clinicians has the greatest impact on clinician satisfaction. CONCLUSIONS: These findings may improve best practice for care managers by focusing interventions on the most effective activities for patients with specific medical conditions.

Reduced acute inpatient care was largest savings component of Geisinger Health System's patient-centered medical home.

Early evidence suggests that the patient-centered medical home has the potential to improve patient outcomes while reducing the cost of care. However, it is unclear how this care model achieves such desirable results, particularly its impact on cost. We estimated cost savings associated with Geisinger Health System's patient-centered medical home clinics by examining longitudinal clinic-level claims data from elderly Medicare patients attending the clinics over a ninety-month period (2006 through the first half of 2013). We also used these data to deconstruct savings into its main components (inpatient, outpatient, professional, and prescription drugs). During this period, total costs associated with patient-centered medical home exposure declined by approximately 7.9 percent; the largest source of this savings was acute inpatient care ($34, or 19 percent savings per member per month), which accounts for about 64 percent of the total estimated savings. This finding is further supported by the fact that longer exposure was also associated with lower acute inpatient admission rates. The results of this study suggest that patient-centered medical homes can lead to sustainable, long-term improvements in patient health outcomes and the cost of care.

Impact of a value-based insurance design for back pain on health plan member satisfaction and its implications for patient outcomes.

Back pain is one of the most common reasons for seeking care, and physical therapy (PT) can be an effective treatment option. However, PT coverage for back pain varies widely among private health plans, usually requiring high cost sharing, thereby potentially leading to member dissatisfaction and worse outcomes. In this study, a quasi-experimental design was used to estimate the impact of a new value-based insurance design for back pain-related PT on selected Consumer Assessment of Healthcare Providers and Systems survey items. Under this design, eligible members receive a bundle of 5 PT sessions for a 1-time co-payment; if deemed necessary, the bundle is renewable for 1 additional co-payment. The results indicate that the proportion of members reporting the highest satisfaction rating was higher by about 6 to 10 percentage points among those who received the PT bundle. The data also indicate that those PT bundle members who reported the highest satisfaction rating had improvements in their functional status scores that were roughly 3 to 4 times higher than those who reported a lower satisfaction rating. These findings suggest that providing a value-based insurance design for back pain-related PT can potentially improve health plan members' care experiences and their overall satisfaction. Further study is needed to determine its impact on back pain-related medical care utilization and cost of care.

Can telemonitoring reduce hospitalization and cost of care? A health plan's experience in managing patients with heart failure.

Telemonitoring provides a potentially useful tool for disease and case management of those patients who are likely to benefit from frequent and regular monitoring by health care providers. Since 2008, Geisinger Health Plan (GHP) has implemented a telemonitoring program that specifically targets those members with heart failure. This study assesses the impact of this telemonitoring program by examining claims data of those GHP Medicare Advantage plan members who were enrolled in the program, measuring its impact in terms of all-cause hospital admission rates, readmission rates, and total cost of care. The results indicate significant reductions in probability of all-cause admission (odds ratio [OR] 0.77; P<0.01), 30-day and 90-day readmission (OR 0.56, 0.62; P<0.05), and cost of care (11.3%; P<0.05). The estimated return on investment was 3.3. These findings imply that telemonitoring can be an effective add-on tool for managing elderly patients with heart failure.

Can health insurance improve employee health outcome and reduce cost? An evaluation of Geisinger's employee health and wellness program.

OBJECTIVE: To evaluate the impact of a health plan-driven employee health and wellness program (known as MyHealth Rewards) on health outcomes (stroke and myocardial infarction) and cost of care. METHODS: A cohort of Geisinger Health Plan members who were Geisinger Health System (GHS) employees throughout the study period (2007 to 2011) was compared with a comparison group consisting of Geisinger Health Plan members who were non-GHS employees. RESULT: The GHS employee cohort experienced a stroke or myocardial infarction later than the non-GHS comparison group (hazard ratios of 0.73 and 0.56; P < 0.01). There was also a 10% to 13% cost reduction (P < 0.05) during the second and third years of the program. The cumulative return on investment was approximately 1.6. CONCLUSION: Health plan-driven employee health and wellness programs similarly designed as MyHealth Rewards can potentially have a desirable impact on employee health and cost.

Improving patient experience by transforming primary care: evidence from Geisinger's patient-centered medical homes.

Patient-centered medical homes (PCMHs) have the potential to improve patient experience of care. Since 2006, Geisinger Health System has implemented its own version of an advanced PCMH model, referred to as ProvenHealth Navigator (PHN). To evaluate the impact of PHN on patient experience of care, the authors conducted a survey of patients whose primary care clinics had been transformed to "PHN sites" and were under case management at the time of the survey. A comparable survey of patients from non-PHN sites also was conducted for comparison. The results suggest that patients in PHN sites were significantly more likely to report positive changes in their care experience and quality; moreover, they were more likely to cite the physician's office as their usual source of care rather than the emergency room (83% vs. 68% for physician's office; 11% vs. 23% for emergency room). However, the results also suggest that there was no significant difference between PHN and non-PHN patients in their perceptions of access to care or primary care physician performance in terms of patient-centered care (eg, listening, explaining, involving patients in decision making). These findings are consistent with the expectation that transformation of primary care into PCMH can lead to improved patient experience of care.

Advancing the role of nursing in the medical home model.

The patient-centered primary care model has been positioned to improve patient outcomes, enhance patient satisfaction, and reduce health care costs. The role of nursing in this care transformation is evident in ProvenHealth Navigator-one of the organization's primary care models. ProvenHealth Navigator incorporates primary care practice redesign, including team-delivered care, as the foundation for its model. Case managers, as one of the components of the care team, have demonstrated their value in reducing fragmentation, enhancing care transitions, and coordinating care for the most complex patients.Combining the strengths of a clinical delivery system with the population management expertise of a health plan, ProvenHealth Navigator capitalizes on the strengths of an integrated health care system to stratify the population, enhance access, optimize outpatient treatment, provide near real-time reporting, and deploy additional disease/case management resources for those most in need of additional health care services. Operational since 2006, ProvenHealth Navigator has been associated with significant reductions in all-cause admissions, readmissions, and total cost of care. In addition, quality indicators for chronic conditions and preventive care improved and patient and clinician satisfaction is high. Optimizing the role of primary care teams and focusing on population management services provides one method of improving quality and reducing costs thus increasing health care value.

Value-based reengineering: twenty-first century chronic care models.

The need for improved models of chronic care is great and will become critical over the next years as the Medicare-aged population doubles. Many promising models have been developed by outstanding groups across the country. This article reviews key strategies used by successful models in chronic disease management and discusses in detail how Geisinger has evolved and organized its cohesive delivery model.

Reducing long-term cost by transforming primary care: evidence from Geisinger's medical home model.

OBJECTIVES: To estimate cost savings associated with ProvenHealth Navigator (PHN), which is an advanced model of patient-centered medical homes (PCMHs) developed by Geisinger Health System, and determine whether those savings increase over time. STUDY DESIGN: A retrospective claims data analysis of 43 primary care clinics that were converted into PHN sites between 2006 and 2010. The study population included Geisinger Health Plan's Medicare Advantage plan enrollees who were 65 years or older treated in these clinics (26,303 unique members). METHODS: Two patient-level multivariate regression models (with and without interaction effects between prescription drug coverage and PHN exposure) with member fixed effects were used to estimate the effect of members' exposure to PHN on per-member per-month total cost, controlling for member risk, seasonality, yearly trend, and a set of baseline clinic characteristics. RESULTS: In both models, a longer period of PHN exposure was significantly associated with a lower total cost. The total cumulative cost savings over the study period was 7.1% (95% confi dence interval [CI] 2.6-11.6) using the model with the prescription drug coverage interaction effects and 4.3% (95% CI 0.4-8.3) using the model without the interaction effects. Corresponding return on investment was 1.7 (95% CI 0.3-3.0) and 1.0 (95% Cl -0.1 to 2.0), respectively. CONCLUSIONS: Our finding suggests that PCMHs can lead to significant and sustainable cost savings over time.

Challenges to care coordination posed by the use of multiple health IT applications.

Coordinating care for hospitalized patients requires the use of multiple sources of information. Using a macroergonomic framework (i.e. the work system model), we conducted interviews and observations of care managers involved in care coordination across transitions of care. When information is distributed across multiple health IT applications, care managers experience a range of challenges, including organizational barriers, technology design problems, skills and knowledge issues, and task performance demands (i.e. issues related to individual information processing and management and sharing of information). These challenges can be used as a checklist to evaluate the proposed IT infrastructure that will allow the integration of multiple health IT applications and, therefore, support coordination across transitions of care.

Can a patient-centered medical home lead to better patient outcomes? The quality implications of Geisinger's ProvenHealth Navigator.

One of the primary goals of the patient-centered medical home (PCMH) is to provide higher quality care that leads to better patient outcomes. Currently, there is only limited evidence regarding the ability of PCMHs to achieve this goal. This article demonstrates the effect of PCMHs in improving certain clinical outcomes, as shown by the ProvenHealth Navigator (PHN), an advanced PCMH model developed and implemented by Geisinger Health System. In this study, the authors examined the claims data from Geisinger Health Plan between 2005 and 2009 and estimated the effect of PHN on reducing amputation rates among patients with diabetes, end-stage renal disease, myocardial infarction, and stroke. The results show that, despite its relatively short period of existence, PHN has led to significant improvements in certain outcomes, further illustrating its potential as a care delivery model to be adopted on a wider scale.

Postdischarge monitoring using interactive voice response system reduces 30-day readmission rates in a case-managed Medicare population.

BACKGROUND: Automated home monitoring systems have been used to coordinate care to improve patient outcomes and reduce rehospitalizations, but with little formal study of efficacy. The Geisinger Monitoring Program (GMP) interactive voice response protocol is a post-hospital discharge telemonitoring system used as an adjunct to existing case management in a primary care Medicare population to reduce emergency department visits and hospital readmissions. OBJECTIVES: To determine if use of GMP reduced 30-day hospital readmission rates among case-managed patients. RESEARCH DESIGN: A pre-post parallel quasi-experimental study. METHODS: A total of 875 Medicare patients who were enrolled in the combined case-management and GMP program were compared with 2420 matched control patients who were only case managed. Claims data were used to document an acute care admission followed by a readmission within 30 days in the preintervention and postintervention periods (ie, before and during 2009). Regression modeling was used to estimate the within-patient effect of the intervention on readmission rates. RESULTS: The use of GMP with case management was associated with a 44% reduction in 30-day readmissions in the study cohort (95% confidence interval, 23%-60%, P=0.0004), when using the control group to control for secular trends. Similar estimates were obtained when using different propensity score adjustment methods or different approaches to handling dropout observations. CONCLUSIONS: Investing in automated monitoring systems may reduce hospital readmission rates among primary care case-managed patients. Evidence from this quasi-experimental study demonstrates that the combination of telemonitoring and case management, as compared with case management alone, may significantly reduce readmissions in a Medicare Advantage population.

How Geisinger's advanced medical home model argues the case for rapid-cycle innovation.

The Patient Protection and Affordable Care Act of 2010 provides for a number of major payment and delivery system initiatives. These potential changes need to be tested, scaled, and adapted with an urgency not evident in previous demonstration projects of the Centers for Medicare and Medicaid Services. We discuss lessons learned from our iterative tests of care reengineering at Geisinger--specifically, through our advanced medical home model, ProvenHealth Navigator, and the way we continuously modified the model to improve quality and value. We hypothesize that the most important ingredient in our model has been the embedding of nurse case managers into our community practices and the real-time feedback of data on the use of health services by the most complex patients.

Value and the medical home: effects of transformed primary care.

BACKGROUND: The primary care medical home has been promoted to integrate and improve patient care while reducing healthcare spending, but with little formal study of the model or evidence of its efficacy. ProvenHealth Navigator (PHN), an intensive multidimensional medical home model that addresses care delivery and financing, was introduced into 11 different primary care practices. The goals were to improve the quality, efficiency, and patient experience of care. OBJECTIVE: To evaluate the ability of a medical home model to improve the efficiency of care for Medicare beneficiaries. STUDY DESIGN: Observational study using regression modeling based on preintervention and postintervention data and a propensity-selected control cohort. METHODS: Four years of claims data for Medicare patients at 11 intervention sites and 75 control groups were analyzed to compute hospital admission and readmission rates, and the total cost of care. Regression modeling was used to establish predicted rates and costs in the absence of the intervention. Actual results were compared with predicted results to compute changes attributable to the PHN model. RESULTS: ProvenHealth Navigator was associated with an 18% (P <.01) cumulative reduction in inpatient admissions and a 36% (P = .02) cumulative reduction in readmissions across the total population over the study period. CONCLUSIONS: Investing in the capabilities of primary care practices to serve as medical homes may increase healthcare value by improving the efficiency of care. This study demonstrates that the PHN model is capable of significantly reducing admissions and readmissions for Medicare Advantage members.