ProvenHealth Navigator: A Patient Centered Primary Care Model

1. ProvenHealth Navigator: A Patient Centered Primary Care Model Duane Davis, MD, VP, Chief Medical Officer Janet Tomcavage, RN, MSN, VP, Health Services Geisinger Health Plan 1 1

2. Geisinger Health System: Danville, Pa Geisinger Clinic: 700 Physicians 41 Community Practice Sites Geisinger Medical Centers - 3 Acute Care Hospitals Geisinger Health Plan: 80 Hospitals 16,000 Providers 215,000 Members

3. Better Value for health care spend is the goal Someone needs to be charged with delivering value Medical Home/Chronic care models will cost more Any delivery system changes must deliver savings today Proven Health Navigator is GHS value agent

4. Proven Health NavigatorStrategy • Deliver optimal health status for individuals and population based value outcomes via a partnership between PCP’s and GHP that provides 360 degree, 24/7 care and guidance to the practice population.

5. Value is defined as hitting target metrics in the domains of: • Patient experience • Quality outcomes • Efficiency outcomes

6. ProvenHealthNavigator Pilot Goals • Improve patient experience and health status • Improve quality and efficiency across the entire spectrum of care • Transform primary care from transaction to value focus • Provide meaningful coordination across all of Health Care 6

7. The System has five functional components • Patient Centered Primary Care • Integrated Population Management • Care Systems • Quality Outcomes Program • Value Reimbursement Program

8. 1. Patient Centered Primary Care: expanding primary care capabilities • Acute and chronic illness care • Expanded scope of services • Team based care • Patient and family engagement & education • Rx management program • Chronic disease and preventive care optimization via EMR embedded triggers

9. 2. Population Management: giving PCP’s ability to see and impact a population Predictive Modeling Population profiling and segmentation Health promotion Case Management on site Disease Management education Patient specific intervention plans Remote monitoring Pharmaceutical management

10. 3. Value Care Systems:keeping patients in line of sight across the care continuum • Micro-delivery referral systems • High volume specialties • Ancillary services – Radiology, Lab • 360 degree care systems • Hospital care • Home Health • SNF’s • ER coverage

11. 4. Quality Outcomes Program: tracking outcomes and continually improving • Patient Satisfaction Metrics • Chronic Disease Metrics • Diabetes, CHF, Coronary Disease, Hypertension • Preventive Services Metrics • HEDIS Influenza, Pneumoccal

12. 5. Value Reimbursement Program: Aligning payment with value outcomes • Fee For Service • Practice transformation stipends - Physician - Infrastructure • Value Based incentive payments • Opportunity based on efficiency results • Payments based on quality metrics 12

13. Initial Results are promising Quality – improved outcomes Efficiency – improved medical trend 13

14. Proven Health Navigator Quality Metrics

15. Efficiency Results at initial ProvenHealth Navigator sites are positive * Risk Adjusted

16. Experience to date has led to 5 implementation priorities • Predictive Modeling to stratify Population • Make Case Manager key member of care team • Manage transitions of care – post acute hospital • Manage SNF admissions • Use EPIC reporting and decision support to drive QI 16

17. Q & A Discussion 17 17