Rising healthcare costs, increasing numbers of uninsured and uncertain quality are triggering renewed debate about the organization and delivery of healthcare in the U.S. Many have noted that Americans are not getting sufficient value for the $2 trillion spent annually on healthcare. More attention is now being paid to the role of care delivery systems in improving value. The need for a new delivery model is evident. We have an aging population, an increasing burden of chronic illness, a declining primary care physician base, overuse of emergency rooms, and a payer system that rewards the number of work units, rather than quality outcomes.

Wagner’s Chronic Care Model has been widely cited as a new approach to the care of patients with chronic illnesses. More recently, many authors have linked this model with the “medical home” model originally described by the American Academy of Pediatrics. Davis et al. further refined this approach as Patient Centered Primary Care in 2005. Closely following the Davis et al. model, the ACP, AAFP, AAP and AOA endorsed a joint set of principles for Patient Centered Primary Care (PCPC). 

A New Approach for Care Delivery

In 2006, Geisinger Health System (GHS) in Danville, Pa., acknowledged the need for healthcare redesign of both clinical care delivery and the supporting payment model. Several drivers influenced the redesign, including 1) the overwhelming fragmentation and lack of coordination in the nation’s healthcare system, 2) the extreme chronic disease burden in Medicare, 3) the declining primary care base, and 4) the need to position GHS for future changes in Medicare reimbursement.

To this end, GHS began development of a new care model referred to as ProvenHealth NavigatorSM. The model was piloted in two Geisinger primary care sites in January 2007, serving a total population of 3,000 members from Medicare Advantage ranks. 

This unique program required an integrated approach, one that included a cooperative partnership between Geisinger hospitals, its primary care network and its health plan. Each entity was charged with doing what it does best—from predictive modeling and case management to development and implementation of clinical best practices. The partnered approach allied the insurance company, patients and their families, and primary care providers. To further ensure the quality of care, other preferred community partners were identified, including home health agencies, skilled nursing facilities, outpatient/ancillary services, hospital facilities and community pharmacies.

Implementing a New Model

After the initial roll-out and early success were demonstrated, the program expanded to an additional nine practices. Today, PHN encompasses 32 Geisinger primary site locations plus five external, community-based physician practices that contract with Geisinger, all serving a population that includes Medicare Advantage members, fee-for-service Medicare beneficiaries and GHP commercial members. (See Table 1 for phased roll-out. Table 2 provides details related to the five core program components identified for implementation in Geisinger’s PHN model.)

Integrated Population Management

For this article, the author has chosen to focus on the activities of Integrated Population Management (IPM). GHP has provided extensive disease and case management services for almost 15 years. These services have been centralized within the health plan as are many payer-provided population management services. In PHN, many traditional health plan functions were moved directly into the provider’s office. Population management aligns resources for all patients along the healthcare continuum. Predictive modeling and other risk stratification tools identify risk, and segmentation-specific strategies are then aimed at those who are well, those with chronic conditions and those with multiple co-morbid, complex conditions.

Case Management

The function of case management has been a central feature of Geisinger’s PHN model with a deliberate focus on at-risk patients. Staffing ratios are established at one case manager per 800 Medicare members or 5,000 commercial members, with each RN managing a caseload of 125–150 high-risk patients. The case manager works directly with the primary care team to review and understand the practice population using GHP profiling reports and referrals from physicians. 

Working with the patient, family and physician, the case manager develops an individualized care plan. Social needs and family circumstances are assessed and incorporated into the plan. All patients admitted to acute care are referred to the case manager for transition of care management. Case managers contact patients within 24–48 hours post-discharge and focus on medication reconciliation, appropriate social services and follow up with the PCP. Case managers are connected to local community resources like Area Agency on Aging and Meals on Wheels, and they interact daily with office PCPs and staff to incorporate the “whole” patient view. They also take direct patient calls, work frequently with high-risk patients, coordinate specialty physician consults, and respond to physician requests to coordinate community services like home care.

Partnerships with the Medical Neighborhood

To improve quality and drive efficiency, it is also essential to address care beyond the primary care office. The goal of PHN is to keep patients in the “line of sight” of the primary care team, regardless of where services are provided. To this end, practices develop partnerships with other care systems, including home health, acute hospitals, skilled nursing facilities, community pharmacists, and emergency departments. Early in the deployment of PHN, the case managers spend time developing relationships with members of the medical neighborhood. The office-based case managers communicate directly with hospitals, emergency departments and discharge planners. This connection allows for prompt identification of patient needs and improves handoffs through the care transitions.

Currently, office case managers follow patients during nursing home admissions to ensure ongoing involvement in managing chronic conditions and careful discharge planning. Preferred partnerships with home health providers improve continuity of care management after discharge and during acute exacerbations. Finally, community-based pharmacists are chosen who will pre-fill medication boxes or provide home delivery of medications.

Demonstrating Positive Results

Early impact from care redesign and targeted case management was seen in transitions of care. Reduction in 30-day readmission rates was demonstrated within three months. Further impact is evident in the overall reduction of admissions. Targeting high-risk individuals with conditions like heart failure or COPD offers opportunities to arm patients with self-management action plans at home and identify and treat exacerbations earlier, thus reducing the need for unnecessary admissions. Finally, patient satisfaction is high with the new case management function. (See Figures 1-3.)

Lessons Learned

We learned many lessons along the way and incorporated a mindset of rapid cycle change as we expanded ProvenHealth Navigator. Those lessons can be summarized into several areas: practice, operational and strategic levels.

Practice-related lessons include:

• The need to involve every staff person at the site, particularly involving them in process redesign.
• Repetition of key messages.
• Physician engagement is critical.
• Real-time (or nearly) feedback of process and outcome measures.

Operational lessons include:

• Adequate staffing both from a case management and management level.
• Creating a true partnership between a health plan and clinical delivery system.
• Developing high performance partners in ancillaries, specialty, and skilled nursing facilities is critical.
• Each site is unique.
• Transition from innovation to normal operations requires 12-24 months but constant attention to prevent complacency and recidivism is needed.

Strategic lessons include:

• Start with high performance sites with significant at risk populations and strong local leadership.
• Careful expansion planning to prevent staffing gaps.
• Reintroduction and re-education are required as turnover occurs.
• Significant culture change requires ongoing senior and executive leadership support as friction with various parts of the health system develops.
• Data needs are significant and real time data is critical to success.
• Rapid cycle innovation is needed to drive outcomes.