Zoom Logo

VBC HomeLAN Webinar Series: Featuring Geisinger at Home - Shared screen with speaker view
Ben Sherman
29:06
Does the cost of care population breakdown include ESRD?
Caroline (Carrie) Hodge
33:17
this is beautiful work. I'm curious what tech/software platforms you are using to deliver this home care...in particular what is used to coordinate the field staff/schedule and charting. Thank you!
ajharding2
34:53
Currently we utilize EPIC as our EHR. For route optimization and logistics I will be transparent and say this is has been a challenge and one of the largest learning obstacles. We are currently looking to invest in a scheduling platform. We currently utilize EPIC's Cadence scheduling for our visits, however, I would not recommend to anyone starting this work.
Caroline (Carrie) Hodge
35:49
got it, thank you
ajharding2
35:52
Cost of care does include ESRD, however, for most Medicare Advantage members once they hit dialysis they switch over to Medicare Fee for Service so we do not have a large ESRD/Dialysis population
Pamela Saenger
37:36
It looks like it takes a (large, interdisciplinary) village to provide this care - are all team members Geisinger employees, or do you use partners or vendors to fill certain roles?
Caroline (Carrie) Hodge
39:31
pamela- was going to ask the same:)
Alex Binder
39:35
How do you determine who will be the "quarterback"? As you layer in additional resources, the degree of coordination/communication/collaboration becomes a bit tricky -- and can become counterproductive on some level.
Anthony Wylie TRN04
41:45
Pamela - All are Geisinger employees. We do leverage home health for the right care (longitudinal wound care for example), as well as, mobile imaging. Hope that helps!
Anthony Wylie TRN04
43:17
Alex - Great question and it's been an evolution. Direct communication in the EHR along with secure texting via TigerConnect is how we iron that out. Really the "quarterback" is the team of our APPs and RN Case Managers.
Caroline (Carrie) Hodge
44:20
I see that your ancillary visits decreased in 2020, that includes mental health. Do you expect that number to increase for 2021 and beyond. If so, how are you going to accommodate?
ajharding2
45:14
Our ancillary HOME visits decreased in 2020; that was intentional due to us identifying the care can be delivered as effectively via phone for those other disciplines.
ajharding2
45:38
the total scheduled patient interactions for our ancillary team actually increased in 2020
ajharding2
48:02
The advanced practitioner and CM certainly "quarterback" the plan of care for the patient. I would say a cornerstone to not having too many people involved is having a well documented plan of care and exacerbation plan in the electronic health record. Our patients have a 1-800 number that is dedicated for Geisinger at HOme patients that connects them to our dedicated nurse triage team. It is imperative that the plan of care and exacerbation plan is well documented for adequate triage to ensure we are not deploying resources unnecessarily.
Amy Stuck
48:42
Amen to that Andrea!
Omar
49:33
What RPM manufacturer are you partnering with?
Adam Perry
50:28
Are you utilizing advanced home diagnostics such as iStat or point of care ultrasound in the home?
Anthony Wylie TRN04
51:50
Omar - We really have 3 levels: "Non-Bluetooth" kits w/ a pulse ox and thermometer, AMC for Bluetooth scales/BP cuff/pulse ox for intermittent and longitudinal monitoring, Current Health for our continuous monitoring (pilot)
Anthony Wylie TRN04
52:29
Adam - We're exploring those options including piloting 6L mobile EKG uses
Ross Colt- West PACE
53:10
Does the telehealth number include audio-only telehealth or are these all video-telehealth visits?
Omar
53:38
Thank you for your response!
Kinza Shaikh
54:06
How do you manage telehealth for acute reasons?
ajharding2
56:18
For acute purposes it is two-fold; our patients call in to a 1-800 nurse triage number and we can send out our Community Health Assistant to the home OR do a BYOD (Bring yoru own device) visit to allow the RN a more enhanced assessment to provide advice via phone OR we can send out the community health assistant to connect to a provider and do a more intense assessment. WE have also had our nurses connect our providers in while doing an acute visit to give the patients additional reassurance
Kinza Shaikh
58:09
Thank you for the response!
Adam Perry
01:00:11
For patients who require an emergency department evaluation, does the team have a process for coordinating care with the Emergency Department to facilitate discharge and further outpatient care?
ajharding2
01:02:02
If a patient requires ED evaluation or intervention, we would coordinate with the ED prior to sending them; In many instances if we feel someone needs to be admitted we direct admit to avoid the ED. IF someone does go to the ED without our knowledge we actually get an automated tiger text that goes out our RN triage team that allows us real time coordination to facilitate a discharge plan and prevent admission. This certainly is an evolution and we have not completely worked out the kinks but the foundation is there
Anthony Wylie TRN04
01:06:10
To build on what Andrea said, we do several things current state. First, we utilize our system's global placement system to speak directly with the ED attending or system triage officer. Second, our triage nurses get a secure text alert any time one of our patients signs into one of our platform's EDs. They then coordinate with either an ED case manager or one of our GHP case managers to identify potential for disposition home. Our medical director that is Remote Medical Command often gets pulled in to communicate directly with the ED attending. Hope that helps!
Amy Stuck
01:08:12
Really fabulous presentation!
Caroline (Carrie) Hodge
01:08:23
thank you!
Kinza Shaikh
01:08:28
great presentation!
Ross Colt- West PACE
01:08:30
Thanks so much for the great presentation!
Pamela Saenger
01:09:38
What certifications if any do CHAs have, and how long is their training/onboarding with the program?
Pamela Saenger
01:13:14
thank you!
Pamela Saenger
01:13:33
great presentation, thanks for sharing your knowledge and best practices!
Anthony Wylie TRN04
01:13:37
Andrea - you were awesome!
Jane Carmody The John A. Hartford Foundation
01:13:45
Thank you! wow, Geisinger !!
Amy Stuck
01:13:48
Rock Stars!
ajharding2
01:13:54
As are you Anthony!!!
Sonal Chandler
01:13:58
thank you!