Transcript Document
Transitions of Care/Personal Health Navigator Heal • Teach • Discover • Serve Geisinger Value 1 Agenda • Geisinger Overview • Transitions of Care • Personal Health Navigator aka Medical Home Heal • Teach • Discover • Serve Geisinger Value 2 Overview of Geisinger System • Geisinger Clinic: – 750 Physicians – 42+ Community Practice Sites • Three Acute Care Hospitals: – Geisinger Medical Center – Geisinger Wyoming Valley – Geisinger South Wilkes-Barre • Geisinger Health Plan: – 80 Hospitals, 17,000 Providers • Clinical Innovation Strategy – – – – – ProvenCare Chronic Disease Optimization Personal Health Navigator Transitions of Care EPIC enabled Heal • Teach • Discover • Serve tm Geisinger Value 3 Geisinger Health System Gray’s Woods Geisinger Inpatient Facilities Heal • TeachMedical • Discover • Serve Geisinger Groups Geisinger Health System Hub and Spoke Market Area Careworks Convenient Healthcare Geisinger Value Geisinger Health Plan Service Area Non-Geisinger Physicians With EHR 4 Geisinger Transitions of Care (“TOC”) Project • Started in January, 2008 as a joint quality-efficiency initiative complementing the medical home – Eliminate unnecessary readmissions – Free up capacity for more acutely ill medical and surgical patients • Seeks to build on the disease-specific readmissions work performed at numerous institutions over the last decade, with several key differences: – System-wide vs. narrow population – Multiple pilots to test impact of different interventions – Focused primarily on quality enhancement and future economic positioning, with limited/no current negative impact Heal • Teach • Discover • Serve Geisinger Value 5 Transition Patient Flow Design Preadmission/ ED Admission Inpatient Stay Discharge Post Acute PCP Appt. Proactive Outreach Screening Detailed for High Risk Assessment Interdisciplinary Rounds Pre-Hospital Care Mgmt for Elective Pts Early Nurse Care Activation Teach Back Discharge Synopsis Discharge Plan Palliative Care Heal • Teach • Discover • Serve Geisinger Value Enhanced Nsg. Home Clinical Capabilities 6 Admission Checklist • • • • • • • • Screening Care Management Assessment Expected Length of Stay Planned Disposition Medication History PT/OT Needs Wound Care Diabetes Heal • Teach • Discover • Serve Geisinger Value 7 Interdisciplinary Team Rounds Today’s discharges: • Confirm that all plans are being executed for a timely discharge • Outstanding issues Patients being readied for transition: • What is the planned discharge date? – What is keeping the patient from going home or to a lower level of care? – Can anything be implemented today to expedite the discharge date? • Is there a risk for readmission? What can be implemented to reduce that risk? – Are activities of daily living (walking, eating, elimination) at an appropriate level to prepare for transition? – Need Nutrition/PT/OT/Diabetes/Wound intervention? PICC line for post acute infusion? – Is the patient and family teaching completed in preparation for transition? – Referrals/insurance authorizations needed? Placement arranged? – Is the family and home ready for transition? Are there any patient safety considerations? Heal • Teach • Discover • Serve Geisinger Value 8 Discharge/Proactive Outreach • PCP Appointment Scheduled Before Discharge • Discharge Synopsis to PCP • Inpatient Screening leading to Post Acute Care Management – – – – Medication Reconciliation and Teaching Physician Appointment Follow Up Home Care and DME in Place Trigger Management Heal • Teach • Discover • Serve Geisinger Value 9