Managed Care - March 2009 - (Page 39) by ensuring consistency in following clinic protocols and eliminating unnecessary services. Last year it implemented its ProvenCare program for coronary artery bypass surgery. The ProvenCare program offers a fixed price that covers complications and readmissions over a specified time period. ProvenCare attempts to improve quality and efficiency by eliminating unnecessary steps and closely, at each individual activity, it becomes obvious that there is a tremendous opportunity to improve both quality and efficiency,” says Gilfillan. “When you send home an elderly patient who was sundowning [becoming agitated and confused in the afternoon and evening] in the hospital, it’s no wonder that the follow-up care has gaps.” Gilfillan says that improvements have been made in the hos- When Geisinger put nurses in physician offices, it found that the transition from hospital to home or another venue went more smoothly and that readmissions were less common. variability in the process of care that can lead to costly additional services like reoperation or readmission. This concept has been expanded to cataract surgery, cardiac catheterization, and hip replacement. There are also pilot programs in back pain and bariatric surgery. ProvenCare reinforces the idea, intuitive for most people in health care, that it is easier to gain efficiency with one’s own provider system than with contracted providers. Experts say that the fee-forservice payment mechanism, with its incentive to increase volume and utilization, is a barrier to improving efficiency on a widespread basis. (See “Heart Program Produces Improved Clinical Measures,” page 36.) In another example in a prepaid group practice working with a not-for-profit health plan, Francis Crosson, MD, of Kaiser Permanente says that the Permanente Medical Group is improving efficiency as well as patient convenience by using the Internet. E-mail communication between patients and their doctors is replacing some face-to-face office visits. pital discharge planning process and in postdischarge follow-up by the nurses in physician practices. Geisinger has about 36,000 members in its Medicare Advantage plan, and its care transition initiative targets Medicare members who, according to MedPAC, have a 17.6 percent national readmission rate. Geisinger participates in Medicare’s physician group practice demonstration project, which encourages innovations in care transitions and reduction of readmissions. Care coordination nurses in physician practices make contact with patients to ensure that care plans are being followed or that follow-up physician office visits are scheduled. “A nurse in the practice makes a giant difference. It’s orders of magnitude. The advantage of transitions handled by nurses within a practice, in comparison to hospital discharge planning staff members, is that the nurses are available right then and there to handle problems or difficulties that patients may have after discharge,” says Gilfillan. The PricewaterhouseCoopers report says that consumer behaviors are the largest source of waste in the health care system. Geisinger’s ProvenHealth Navigator strategy and its medical home model, which involve placing nurses in practices, are attempts to change consumer behaviors and improve adherence by more fully integrating patients with their doctors. Gilfillan reports that the next item on the to-do list to promote improved efficiency and quality is an expanded effort to engage patients. MC Tom Reinke specializes in health and business topics. Focus on patient discharge The fourth initiative, also an effort to reengineer the delivery of services, targets the transition from inpatient to other settings. It involves Geisinger’s own doctors and hospitals plus its contracted hospitals and physicians. Gilfillan says the objective is to provide resources to improve the quality of patient education at discharge, clearer medication instructions, and definitive plans for follow-up care. Even though discharge planning has improved as the result of inpatient quality measures, Gilfillan says that Geisinger found that substantial additional improvements are still possible. “When you start to take a look at care transitions MARCH 2009 / MANAGED CARE 39
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