Medical Home Model (Proven Health Navigator System) Interview with Joann Sciandra of Geisinger Health System

We recently had an opportunity to Joann Sciandra is the Director of Case Managment and Strategic Development for the Geisinger Health Plan.  In 2006, GHP and Geisinger Health System initiated a Medical Home model, or Proven Health Navigator system, to help provide GHP patients and those within the Geisinger Health System and inclusive opportunity for care.  It has helped provide a higher quality of life for those with chronic disease or discharging from the hospital by lessening the readmissions back to the hospital.  In addition, this model is saving the health plan and the health system money but preventing acute episodes.  Joann feels that this is a modelthat should and can be duplicate to help better healthcare in America.

Joann offered a lot of valuable information on this model and why it’s an interesting example for healthcare in America:

See the full transcript below:


Interviewer:  Can you please introduce yourself, your position and tell us a little bit about Geisinger Health Plan?

Joann Sciandra:  Hello. My name is Joann Sciandra and I’m the director of case management and strategic planning for Geisinger Health Plan. Geisinger Health Plan is a not‑for‑profit health plan that’s located in Danville, Pennsylvania. We cover 42 counties that are located in central and north east PA. Our membership is 275,000. Of that 275,000 we have 63,000 Medicare Advantage patients.

Interviewer:  A few years back Geisinger Health Plan instituted a Medical Home model. Can you please tell us a little bit about that?

Joann:  In 2006 Geisinger Health Plan, in our community practice service line, which are our doctor’s offices, sat down and looked at the way we were providing care to our members and our patients. We were doing a good job and patients were having good outcomes. But we knew as healthcare changes occurred over the next couple years, we had to change things for the better. So this partnership and this collaboration was the result of what we call our Proven Health Navigator, or what is commonly known as Medical Home. Currently, we have a total of 42 Medical Home sites, that are located throughout the Geisinger system. Of this 42 Medical Home sites, a majority of them are Geisinger owned sites. But we do have several sites that are doctor’s offices that we do not own.

So we have patients or health plan members that go to these doctor’s offices and we have a Medical Home there. The purpose of Medical Home was to really look at the quality of care that we were providing our patients. And can we improve quality and in turn decrease cost? And this cost savings would not only be evident for the health plan, but this cost savings would also be evident to our members and would affect our members who were now experiencing some cost sharing through their insurance plan.

So how it worked was we actually went out into the doctor’s offices, met with them, and looked at the whole structure. So the whole doctor’s office becomes a Medical Home. But what is every player on that team doing and are they doing the right role to impact care? And what we found were that we could make some changes for the better, and to improve the care that we were providing our patients.

One of the things that we did was that we built in a template. So within our electronic medical record, we built in a schedule that every day there would be appointments available to patients post‑discharge. So when a patient would go to the hospital, on discharge we want them seen by their primary care doc within three to five days.

The reason for this is that we noted at the health plan about one in five patients were going back to the hospital within 30 days of discharge. So we got them in to see their primary care doc early on, and the impact of that was a reduction of what we would call the readmission rate, the patients going back to the hospital. So we built that in.

We also built in what we would call acute visits. So when a patient calls the office and has a problem, we want to take care of that problem the same day. Patients don’t want to go to the emergency room and we want to do our best to meet those needs within the clinic. We also looked at the Medical Home sites to see if there were procedures that we currently were not doing, that we could safely do within the clinic, and there were.

And our patients, really from patient satisfaction surveys, have been very satisfied with the level of care that we’ve been able to provide at the clinic setting. So really looking at what you would call maybe even like a one‑stop shopping. So every patient within a Medical Home site is touched. Meaning that we have a group of patients that are well, so we manage them. We get their flu shots, their pneumonia shots, their mammograms, their preventative screening, their PSAs.

Then we also have a population that has complex health problems. This is the population that might have heart failure, diabetes, COPD, patients that have cancer diagnoses. How are we going to manage their care and what do we need to put in place to help these patients navigate a very complex healthcare system?

We introduced the concept of a case manager. We embedded or we placed a nurse, a registered nurse case manager within the doctor’s office at the Medical Home site. These nurses are highly skilled, highly trained, with a lot of clinical background. These nurses work side by side with the primary care physician in managing the healthcare needs of a complex population.

We also had a population of patients that might have one or two conditions, be it diabetes, heart disease, hypertension. How are we going to provide services and care to these patients? How are we going to provide education and management and making sure they were getting what they were needing?

We introduced a health manager or disease manager that meets with the patients within the primary care site. What our patients like about this is they don’t have to be going to the hospital. They don’t have to be going to other areas. They can get everything right at their Medical Home. So their Medical Home really becomes their main contact for their healthcare needs.

Interviewer:  Now, Joann, you’ve probably touched on a lot of these, but are there any specific benefits? Whether it be for the patient, the health plan, or the hospitals and the clinics? And if so, does any one partner benefit more than the other?

Joann:  What we hear from our members and what we hear from our patients is the improvement in their quality of life. So the goal is to really improve quality care that they’re getting and to have better outcomes and so patients can really return to their normal daily lifestyle. So that’s the benefit to the patient. But there’s also a cost benefit to our members and to our patients. What we’re seeing in healthcare today is a lot more cost sharing. So if we can impact the number of times someone needs to go to the emergency room or to be hospitalized, it’s going to have a direct impact on the members and the patients.

At the health plan side, we do see an impact on total cost for the managing with our members. But what we’re able to do is to take that cost that we have and put it back into more programs and to hire more case managers and to develop more programs to meet the needs of our members.

Interviewer:  You touched on the growth of the program. Just roughly how successful do you think the program has been on a social standpoint and on a healthcare standpoint?

Joann:  Well, from talking to our members, and we actually do patient satisfaction surveys, it’s been very successful. Members have seen a change in the care that they’re receiving for the better. The members with chronic conditions really liked the idea of having that nurse as a resource and as that contact within their Medical Home site to help meet their healthcare needs. It’s been very effective in early identification of problems. Take a patient with heart failure. The health plan has partnered with what we would call a tele‑monitoring vendor. We actually put Bluetooth scales, so this is a scale that uses Bluetooth technology in our heart failure members’ homes. They get on the scale every day, their weight is transmitted to a web portal, so our nurse case managers can actually see their patients’ daily weights and it impacts the care of those patients if there’s any changes in their condition.

Interviewer:  That’s awesome. What would you say then if ‑‑ obviously this program is continuing to change as healthcare changes. What do you think the future of this program is? And is there anything on the horizon as far as changes or growth?

Joann:  We as a health plan and as a system are always looking for new innovations. And currently within our Proven Health Navigator, we’re looking at a process or actually a new ‑‑ and I don’t want to call it a program, because it’s not a program, and Medical Home is not a program. It’s a way that we’ve really changed our care delivery system. But one aspect that we’re looking at now is the patients that what we would call have complex or morbid conditions. These are patients that have multiple healthcare needs, multiple conditions, and really having the ability to have a case manager work a little bit closer with them and to follow them through each part of healthcare.

So if that patient’s in the hospital, the case manager makes a visit. If they’re in a nursing home, they would do home visits. Having a case manager even more readily available to what we would call the patients with more complex needs. We’re continuously looking at ways to improve what we’re doing.

Interviewer:  Do you believe that this is a system that other health systems and insurance companies should be looking to initiate?

Joann:  I do and I think we as an organization do. We’re seeing this. We’ve been working with several organizations in the United States. And actually we’re working with the health ministry in Singapore. They came to us, the health ministry in Singapore, and asked them to work with them on setting up Proven Health Navigator within Singapore. Within the United States we’re recently working with Hudson Valley, which is located in New York City. This is a healthcare system that came to us and said, you know, we really like what you’re doing. We like Proven Health Navigator and we want to do something like this for our doctor’s offices and for our patients.

So we’ve done a lot of education with them on site. We actually go out to Hudson Valley, go within their future Medical Home sites or Proven Health Navigator sites, and work with their doctors, look at the workflow. We’ve done training for their case managers. And we’re actually seeing more and more requests on a daily basis to help people to achieve this.

Interviewer:  How do you believe a structure like the Medical Home model, Geisinger Health Plan and Geisinger have will impact healthcare in America?

Joann:  I think it’s going to impact healthcare in several ways. I mean, one way it’s going to impact for quality of life. A patient who has a chronic condition like heart failure, does not have a quality life if they’re in and out of the hospital. That’s not living their life. So it’s going to impact the care that we provide, and it’s going to impact what a patient or what a person is able to do in their day to day life. But it’s also going to impact cost. It’s going to impact the cost for patients and for health plan members, what they have to really pay out of their pocket. And it’s going to, you know, give somebody like Geisinger the ability to have a cost savings and be able to build new programs.

Interviewer:  You provided us with a lot of great information on the Medical Home. Is there anything else that you would like to add?

Joann:  First of all I’d like to thank you for giving us this opportunity to talk about Medical Home and to talk about Proven Health Navigator and the success that we’ve had. It takes an organization to really take what I would call a leap of faith. So when I look at Geisinger Health Plan and what our leadership did back in 2006, it was a leap of faith. Was this going to be successful? And, you know, to be honest, there was money that had to be put up upfront to really look at the care structure and to hire what we currently have, 100 case managers and disease managers working with our patients and our members. So again, thank you for having me here and the opportunity to share our success.

Interviewer:  Thank you.

Joann:  Thank you.

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