In a webinar hosted by Becker's Hospital Review, experts from xG Health discussed how Danville, Pa.-based Geisinger Health System took the concept of patient-centered care and turned it into a results-producing model.
The patient-centered medical home is a cornerstone of population health management. But health systems and medical practices may struggle with taking the model from its conceptual framework to a way of life for physicians, advanced practitioners, nurses and other practice staff members.
Three experts from xG Health Solutions and Geisinger Health System discussed Geisinger's approach, what they learned along the way and how other health systems can tailor the patient-centered medical home for clinicians while meeting the unique needs of their patients.
The secret sauce
Nearly a decade ago, Geisinger began its deliberate redesign of primary care delivery. It launched ProvenHealth Navigator in 2006, which enhanced patient access and facilitated more effective condition and complex case management. By decreasing avoidable hospitalizations and readmissions, the program has shown a positive return on investment of 1.7.
"While there are lots of models out there, we believe there are foundational examples of redesign that really have supported the triple aim," said Janet Tomcavage, MSN, RN, senior vice president and chief of value-based strategic initiatives for Geisinger Health System and chief of population health for xG Health Solutions.
For instance, when people ask xG Health executives about Geisinger's "secret sauce," they point to a few things, including practices' monthly team meetings. Many representatives from primary care practices attend these meetings, including physicians, office leads, case managers and front desk staff. "All those folks need to be at the table and an active part of discussion," said Ms. Tomcavage. "There is this notion of shared responsibility for the patients."
"Each meeting at each practice site lasts for 90 minutes," says Rick Martin, MD, chief of care continuum at Geisinger Health System. The teams brainstorm ways to alter care delivery to better target certain populations. One good example is diabetic patients, which many practices commonly target. "We looked at diabetics in our practice and developed targets and goals. We brainstormed a way to reach out to those who weren't at the goal and how we could bring them under better control. It's a really different way of thinking about targeting our populations," said Dr. Martin.
These monthly meetings are also used for training, performance reviews, shared leadership building and case reviews. The availability of practice-specific data is vital as it helps clinicians and practice staff better adjust their focus.
Data and case management
Speaking of specific data, Geisinger realized early on that practices were not the most informed about the populations they served. "Practices were very good at managing the one patient who showed up, but didn't necessarily think about managing the patients who didn't come or who fell through the cracks," said Ms. Tomcavage.
Thus, the system emphasized population-specific care management through a variety of data sources, including predictive modeling, health risk assessments, EHR and HIEs, and medical claims. Practices targeted certain conditions and populations for case management, such as heart failure, chronic obstructive pulmonary disease, high-risk pregnancies and the frail elderly.
Case managers then focus on factors driving the condition or the unique situations each patient is facing. Case managers approach their work as a full-time job, as they are the link between a patient and the physician. They exercise a "fairly aggressive follow-up program," ensuring patients make it back to appointments and know what step is next in their episodes of care.
It takes about a year of in-depth training before a case manager feels comfortable in his or her role, and about 4-5 years of experience "before they really feel like they are a well-performing case manager," said Ms. Tomcavage. "It's not a one-week training program; it's almost a several-year commitment." There are other staffing considerations depending on the practice's patient population. Managing the health of a commercial population is different from a Medicare population, for instance.
While Ms. Tomcavage did note the investment of RN case managers can be expensive, she said the PCMH model's ROI proves their worth in the care continuum. "I think upfront, getting some staff in place and focused on Medicare [patients] would be a good place to get started. Go to some of your payers and put some things on the table for outcomes you could deliver if you had a payment model that improved your case management program," said Ms. Tomcavage.
Geisinger is also trying to add a layer of non-licensed FTEs who have special training and can extend their reach, alleviating some of the workload for the RNs. These FTEs can conduct home visits, follow up with patients and ensure they keep their appointments.
The bigger picture
PCMHs also need a fine-tuned understanding of their broader medical neighborhood, which can include skilled nursing facilities, emergency departments, hospitals, home health agencies, durable medical equipment (DME) vendors and other sites of care or vendors. Which DME company will deliver oxygen at 4 p.m. on a Friday? Which home health agencies can check in on your patient on a Sunday? This type of textured knowledge is a must for a high-value referral system and smoother transitions across care settings.
"Look for community partners," said Ms. Tomcavage. "Get out, pay a visit, get to know your partners in the medical neighborhood." Geisinger staff visit their partners early on in the process, and then twice per year to review data and talk about the partnership.
Something that cannot be emphasized enough is that the PCMH is not a "reengineering" of care delivery, but a change for the long haul, says Dr. Martin. "Transformation to value-based care is not a project. It's not something we'll do this month, quarter or year. It's really a continuous process, a culture change and a lifestyle commitment for the life of that practice," he said.
One webinar attendee asked how the Geisinger model holds up in other parts of the country for other health systems. Gordon Norman, MD, CMO of xG Health, said he's seen promising results. "We're confident the model does adapt well to a variety of settings and circumstances," he said. Even Geisinger's system is somewhat disparate itself, comprised of 46 practice locations situated around more than 30 counties, some of which are not near a Geisinger hospital.
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