Like many health systems, Danville, Pennsylvania-based Geisinger cares for a large population of older patients with complex needs. Many of these vulnerable patients are home-bound and struggle with food insecurity, social isolation, lack of transportation and other difficulties. This limits their access to essential care and contributes to alarming increases in their overall cost of care.
To tackle these challenges, just over 18 months ago Geisinger launched a novel delivery model called Geisinger at Home that moves comprehensive care upstream and into the homes of this dependent population. Working closely with patients’ primary care physicians, a team of doctors, nurses, dieticians, case managers, pharmacists, mobile paramedics, and other support staff bring care to frail, medically complex patients where they live. In addition to providing services such as regular home assessments, necessary testing, acute care and wound care the program offers specialty care as needed. Unlike hospital-at-home models, which typically provide episodic care for three to five days, ours is longitudinal, starting with a comprehensive in-home assessment and care plan and coordinating with primary care and providing ongoing clinical services as needed.
The results have been dramatic: For the more than 5,000 patients that have been enrolled in the program we’ve seen a 35% drop in emergency department visits, a 40% decline in hospital admissions, and an average annual reduction in spending per patient of almost $8,000. Most important for patients is their improved quality of life.
Outcomes that matter
Consider the case of a patient we’ll call Jack, a 79-year-old man who suffered from heart failure and COPD and was missing his specialty care visits. His primary care team at first thought he was simply non-compliant and asked the Geisinger at Home staff to evaluate him for enrollment in the program. An in-home visit revealed the problem; Jack had become so sick that his wife had moved his bed to the living room where he ate, slept, bathed and watched TV. His breathing was labored although he used a portable oxygen unit, his appetite was dwindling, and because he could no longer walk or even stand he had to wear a diaper.
The team huddled and put a plan into action: immediately administer IV steroids, increase oxygen, and change the nebulizer to use both ipratropium bromide and albuterol. Then, using a secured communication link, the team called Jack’s pulmonary specialist from his living room to review his case, adding oral antibiotics and corticosteroids to the plan. The team arranged for additional in-home physical therapy and nutritional guidance and got Jack to agree to a flu shot (a vaccination he had long refused). With regular in-home visits and secure daily and weekly communications across the team, Jack made wondrous progress. Soon he could walk into the kitchen and feed himself, could get to the bathroom with minimal help, and gained 10 pounds thanks to his high-protein diet. Ultimately, he was able to make an in-person visit with his pulmonary specialist and primary care doctors.
How we work
Among the program’s critical elements is careful patient selection – identifying those most in need of intervention. Using medical claims data, the team evaluated Medicare Advantage members within Geisinger’s own health plan by utilization and chronic medical conditions to find these high-risk patients. Half of eligible patients had heart failure, 40% had chronic lung disease, and a third had diabetes, many with related complications such as kidney disease. Their median age was 84, older than the team had imagined, with average annual costs exceeding $30,000; many had annual costs of over $100,000. Over the past six months, we have been taking referrals directly from primary and specialty care providers; these now account for almost 50% of our enrollment.
Starting in the spring of 2018 with one physician, one nurse, and community health worker in a small rural community, the program has grown to include over 100 clinicians covering more than 15 counties. One key to scaling has been to deploy the right skill set and “tag team,” with the physicians and advanced practitioners completing a comprehensive physical exam while the nurse or community health worker assesses the patient’s home – the food on hand, medications the patient is using (or failing to use) and safety issues. Sometimes simple interventions have a big impact; our community health workers, for example, focus on cost-effective measures such as fitting a shower rail or providing a rolling walker that can head off a debilitating hip fracture.
We’ve also leveraged technology to gather clinical data remotely. For example, we use Bluetooth scales that allow patients to transmit their daily weights, helping us to monitor potential fluid accumulation. And digitally transmitted wound images are allowing joint decision making with hospital-based surgical experts, eliminating transport and wait times. Most recently we have added post discharge telehealth visits in which a community health worker visits the patient at home and connects him or her virtually through an iPad that connects with peripherals such as a pulse oximeter, stethoscope and blood pressure cuff.
We’ve also focused on the most efficient and cost-effective ways to allocate staff. Can the pharmacist do a medication review from the office with the community health worker stationed in the home instead of traveling him or herself? Can mobile paramedics provide acute care services to free up nurses for other patients that need a more comprehensive assessment? The answer to both questions is yes.
During the planning phases, we underappreciated the work required for new enrollment, managing in-bound calls and other administrative tasks. As we grew we realized we needed a complementary stationary team, or triage staff, in the office to handle the growing number of calls (now about 1200 patient calls weekly), coordinate tests and visits, manage orders for medications and supplies and otherwise absorb an expanding number of administrative tasks. The triage staff now frees up the mobile team to spend more time with patients with fewer interruptions. (We’ve learned that our specialists prefer real-time communication using a secured messaging service. Our PCPs on the other hand prefer fewer text interruptions as long as they can review the visit notes in the EHR to stay on top of the care being provided.)
End of life
Working with Geisinger’s highest needs patients has meant directly providing care to a good number of dying patients. End-of-life discussions and coordinated care are as important as any other element of our work. For these critical patients, the staff engages in frequent discussions with both the patient and family about the patient’s prognosis, priorities and wishes. This has required that all team members become competent and comfortable with skills needed to help patients and families make decisions regarding end of life. Specialized training incorporates interactive sessions with role playing and case studies involving trained actors playing patients (so-called “standardized patients”). The Geisinger at Home team has worked with our EHR team to organize documentation and create a single location for information about the patient’s wishes, goals of care, and health care surrogate.
One Geisinger patient who had had surgery for bowel cancer was discharged home but in time developed metastatic disease. Recently the patient had developed skin breakdown due to declining health and had increasing difficulty leaving home. Her primary care case manager called the Geisinger at Home team to request a visit, and the team including a community health worker made an immediate trip to the home. The team addressed the new health issues and the CHW opened a telehealth connection with one of our regional medical directors. Given the patient’s recent decline, the virtual conversation that followed, which included several family members, turned to goals of care and the patient’s end-of-life wishes; the medical director raised the idea of hospice and discussed its benefits, and the patient and family agreed that it would be a help. The team arranged for hospice care to begin the next day. The patient was able to spend her remaining days at home, surrounded by family, and under the watchful eyes of the hospice and Geisinger at Home teams.
We’re now looking at technologies that can help us sustain and expand the program. For example, we’re working to better integrate claims and authorization data from the payor with the clinical data in the EHR, and we’re evaluating software to improve scheduling and decisions around field-team availability to assure rapid response to patients with acute care needs. We are establishing chronic care pathways and crisis protocols to optimize our workflow and the frequency of our interventions. And finally, we are working to optimize level of service patients need to assure the best outcome. This includes determining how often we need to visit, which members of the care team are required at each visit, and when we can scale back home visits and “graduate” patients, allowing them to return to their normal primary care teams.
Geisinger at Home clinicians need to expertly don many hats in this model. Our real strength lies in the flexibility team members have shown in adapting to new ways of working as the model evolves. The most important key to better care for complex, home-bound patients, we’ve found, is the one that opens the front door.
Janet F. Tomcavage
Janet F. Tomcavage, RN, MSN, is Chief Nursing Executive at Geisinger.
Jaewon Ryu, MD, is president and chief executive officer of Geisinger.
Sanjay Doddamani, MD, is a Senior Advisor at the Center for Medicare and Medicaid Innovation and former Chief Medical Officer of Geisinger at Home.
This article originally appeared on HBR.org and is being brought to you by Medtronic.