Wellness & Population Health Allison Hess Vice President Health and Wellness
Aligning services to meet needs Chronic Health Case Advancing Condition Coaching Management Illness & Management Special Needs PRIMARY PREVENTION - CLOSING GAPS IN CARE – PHARMACY- SPECIALTY BASED SERVICES - SUPPORTED BY DATA ANALTYICS 2
ProvenHealth Navigator Serving as the foundation for population health • PCP-led team-delivered care, all members functioning at “top of the license” Patient-centered • Enhanced access; services guided by patient needs and preferences Primary Care • Member and family education & engagement • Population identification, segmentation and risk stratification Population Health • Chronic disease and preventive care optimized with EHR, clinical decision support Care Management • Care manager as core member within care team • Automated interventions triggered by gaps in care • 360 ° care systems – SNF, ED, hospitals, home health, pharmacy, etc. Medical • Physician profiling; preferred provider relationships Neighborhood • Transitions of care, community services integration • Patient and clinician satisfaction Performance • Cost of care, utilization, efficiency Management • Quality metrics, addressing variations in clinical care • Bridging the journey between FFS and pay for value Value-Based • Embracing payment models that support population accountability Reimbursement • Payments distributed on measured quality performance 3
Expanding the focus of Case Management Facility Based Specialty Remote Based Telephonic Technology Assisted Primary Care Based Remote Telephonic Primary Care Technology – Assisted Specialty Facility Telephonic based Embedded RN CMs Bluetooth scales for HF Oncology Inpatient Hospital • • • • • RNs, Social Workers (advanced medical home) and ESRD High-risk OB Emergency • • (SW) and Linked to SWs and CHAs Interactive Voice High-risk Pediatrics Department • • • Community health Access to EHR Response (IVR) for TOC “Transitions” for high- Skilled Nursing • • • assistants (CHA) Seen as part of the practice In-home video connectivity risk children Facilities • • care team COPD, HF, and ICU • embedded RN CMs 4
Individualized care team Case Manager Community Health Peer Support Assistant Mobile Wellness Health Coaches Paramedic Health ED Case Manager Manger Respiratory Social Worker Therapist Pharmacist 5
Tele-monitoring tools Bluetooth Transmits daily Managing scales weight to EHR HF Nurse sees Diuretic titration Trending weight in real protocols time Interactive Voice Outbound calls HF IVR Response (IVR) post discharge Bluetooth blood pressure cuff 6
ReDS™ Technology See-through-wall technology Radar (RF) monitoring and imaging Military see-through-wall technology ReDS™ System technology Direct, absolute, safe and actionable measurement of lung fluid 7
At home telehealth program: current state Community Health Provider assesses patient Worker deployed to remotely (i.e. wound patient’s home with iPad assessment, edema, etc.) Community Health Worker calls the Provider via secured Skype connection 8
Multiple factors impact health Health outcomes - Socioeconomic factors: 40% - Education - Job status - Family/social support - Incoming - Community safety - Health behaviors: 30% - Tobacco use - Diet and exercise - Alcohol - Sexual activity - Health care and access: 20% - Physical environment/genetics: 10% 9
Strategies target members in their communities and homes Strategies target members in their communities and homes Air medical Mental Health Micro Hospital My Hospice Geisinger Urgent Care Primary Wellness Care and Care The solution: Preventio managers n Care closer i to home Home Nurse Telemedicin Triage e Community Hospital Urgent Mobil Care e Care Tertiary/Quantern ary Hospital 10
Creating a care model in our communities Supporting those with serious & significant health conditions Geisinger at Home Longitudinal Integrated Acute Advanced Medical Care Social & BH Care Illness Comprehensive • Social determinants Mobile Plan of care • • • assessment of of health paramedics disease burden Symptom • Behavioral health Case management • • Condition • Management optimization & Palliative care • management Home Health • Timely transition to • Close coordination • hospice with PCP/SCPs 11
New and innovative programs between clinical and community-based partners to impact health 12
Robust wellness resources for employers Comprehensive, Incentive Dedicated customizable program wellness wellness plan specialist administration Programs, Consumer health Reporting screenings education & and & presentations communications recommendations 13
Developing a unique program Post-event Demographics reporting Claims Program data evaluation Customized Population Ongoing wellness needs/interest consultation program 14
Services snapshot Body fat Spirometry index Blood Body mass pressure index Health fairs Health Lab draws coaching Wellness Bone challenges density Sun damage awareness Seminars and courses Grip strength 15
Wellness online resources NCQA accredited Health Assessment Tracking/logging tools Meal planning/recipes Exercise plans and examples Interactive modules and health education library Customizable wellness portal 16
Example program – participation and design Registration: 78% subscribers registered • 64% employee participation • +12% from 2016 to 2018 • Goals: 72% of participants reach goal • Personal Health Healthy Health Assessment Screening Activities Goals 17
Example program – metric goals Tobacco Self-reported no tobacco use • If using tobacco, completion of cessation program • BMI (Body Mass Index) Less than 30, or 5% decrease in weight up to 12lbs. • Blood Pressure Less than 130/80 mm Hg • Glucose Fasting blood sugar of less than 100 or A1C < 5.7 • Diagnosed with diabetes, A1C of less than 8 • LDL With no risk factors, fasting LDL of less than 160 • Diagnosed with diabetes/coronary artery disease, • less than 100 18
Example program – health coaching efficacy Health Participation Engagement Results coaching 7,678 health Average # of 85% of health coaching sessions per coaching interventions person: participants 3.8 met goal 19
Example program – key clinical outcomes Tobacco Body Mass Pre-diabetes Blood cessation Index (BMI) pressure 1,983 (59%) 59% of tobacco 36,994 lbs. of participants 24% increase users enrolled lost in 2018 in pre-diabetic in participants in a tobacco range meeting cessation 112,125 lbs. decreased to recommended program (30% lost since 2015 normal blood AHA blood reported quit) (54% glucose pressure range sustained) 27% decrease 12.9% of in self-identified 41% of population in tobacco users participants pre-diabetic with a BMI > 30 range (33.9% lost weight national avg.) 20
Together with the help of our broker partners… Manage Promote Prevent Close Maintain chronic future health health, highest care conditions & issues and starting with quality of gaps complex complications the employee life health issues For healthier, happier employees 21
Questions? 22
“Nothing looks as good as being healthy feels ” - Anonymous
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