Geisinger Health Plan

Transitions of care helping patients transition through levels of care, from hospital to home, is an important component of ensuring comprehensive and high quality healthcare services. Geisinger has implemented new strategies within the hospital and primary and specialty settings to anticipate patient needs and coordinate services to assure timely and safe transitions. These strategies incorporated timely communication from the hospital to primary care providers, leveraged data from electronic Health records & claims to identify risk and used case managers to provide early follow up services. Geisinger's efforts around transitions have demonstrated more coordinated follow through after discharge and reductions in readmissions. Electronic Health record (ehr) Geisinger is on the forefront in the development and use of the ehr. Ghp helped support the 100 million invested in ehr over the last several years. Endless possibilities exist for improving the quality of care with the ehr. Ghp uses the ehr to communicate with members who are involved in medical or disease management programs and their physicians. Geisinger allows community hospitals and physicians to access patient information to care for their patients. Disease and case management services to improve the Health of members, ghp provides disease and case management programs and services to coordinate care for those with chronic conditions. The programs are focused on congestive heart failure, hypertension, diabetes, coronary artery disease, osteoporosis, chronic obstructive pulmonary disease, chronic kidney disease, asthma, tobacco cessation and weight management. These programs were the result of a collaboration of expertise between ghp and Geisinger providers and have attained national recognition by Health management organizations & industry groups. This successful collaboration is an example of how this unique relationship benefits the community. Community Health, education and outreach ghp employees provide the public with information on topics such as insurance education, advance directives, dental and hand hygiene, asthma care, the importance of screenings & immunizations and wellness. Ghp provided information to 64,809 individuals at 1,765 events including Health fairs, school based presentations, seminars and organizational meetings. This education included: 1.169 Health education events for children were held covering dental, nutrition & physical activity, hand hygiene and sun safety topics. More than 2,165 children attended the events. 2.over 375 events supported evidence based chronic disease programming, reaching a total participation of nearly 250 individuals. 3.over 1,220 wellness activities were held at employer groups and community events. All of our programs are available to our commercial members which represent approximately 142,523 individuals. 4.more than 164 employer group and community flu events were held, providing 6,561 flu shots. Ghp educates the general public, members, employer groups, brokers, participating providers and office personnel on Health and wellness topics ranging from women's Health to cold and flu prevention. The information is available in a variety of formats including newspaper articles, newsletters, emails, brochures and posters. Ghp supports many local organizations through community sponsorships. The organizations included local chambers of commerce and the boy scouts of america. The cost of community Health, education and outreach activities was 4.8m during 2022. Health equity at Geisinger, we strive to ensure we create a culture of belonging and inclusion where the workforce reflects the people we serve, and our leaders reflect our overall workforce. In 2021, Geisinger hired its first chief diversity, equity and inclusion (dei) officer and developed a system-wide de&i council, de&i team, and Health equity steering committee (hesc) that supports the clinical enterprise and Geisinger Health Plan. Our approach to achieving this goal is through a multi-year strategy and infrastructure that reinforces our culture of inclusion and belonging. The main pillars of the diversity, equity and inclusion strategy focus on culture, talent, community, supplier diversity, and Health equity. The output of the strategy and continual progress is seen annually in the following results: 1.increased diversity of people in the organization. 2.increased employee engagement and sentiments about diversity, equity, and inclusion. 3.decreased turnover of historically minoritized employees 4.increased engagement and confidence in Geisinger among the black and latino communities. A separate steering committee will be developed in january 2023 to support workflows and processes unique to the Health Plan. Starting in 2019, as an integrated Health delivery system, we defined data elements, clinical workflows, and organizational practice in our electronic Health record to ask patients and members their race, ethnicity, language preference, sex, gender identity, sex assigned at birth, organ inventory, and affirmation history, pronouns and sexual orientation, as well as veteran status. The questions are either answered by the patients in advance of a visit or asked in clinical settings. The responses are used to help clinicians and staff have appropriate and culturally responsive conversations with patients and members. In our Health Plan, we have adopted the same data elements around demographics and equity. In 2023 will be working to identify pathways to ask members demographic and Health equity information, develop workflows and organizational practices, surface needs and address disparities in our membership population in order to develop new and target interventions and programming. To ensure Geisinger and Health plans staff are trained, the de&i office has developed a suite of training programs, materials, and resources for all staff to help build our knowledge around dei as well as support the current dei strategic initiatives at Geisinger. For example, training topics include: unconscious bias, sexual orientation and gender identity, sexual harassment, and cultural competence, proactive and inclusive policies that ensure diversity is considered in all strategic management initiatives. Social determinants of Health Geisinger is proactively addressing social determinants of Health and Health disparities in a variety of ways. We have moved beyond traditional medical care to provide coordinated social services and opportunities to our patients and Health Plan members while connecting them with community- based organizations. We are working across sectors to find creative, innovative ways to help individuals address the social and environmental factors that impact their Health. Our sdoh strategy aligns data, community engagement, connection to resources, and sustained outcomes to help the needs of our patients, members, and Geisinger communities. Community Health benefit fund while stable housing, fresh fruits, vegetables, and transportation options are often not deemed Health care needs, they, along with other necessities, are vital to positive Health outcomes. The community Health benefit fund was established to provide community organizations with resources and services needed to foster positive Health outcomes. The key areas with funding needs identified include: 1.food insecurity 2.transportation 3.housing stability 4.opioid prevention and treatment 5.combatting pediatric obesity 6.access to dental care 7.behavioral Health fund recipients are chosen by the community Health benefit fund committee who meet quarterly to discuss needs and submit approval of allocated funding within the Geisinger footprint. Food insecurity & sdoh screening started in november 2018, as a Health Plan member enrolled with our care teams, or special needs unit (snu) are screened for sdoh needs using a universal assessment. Questions are asked around economic stability, food security, education, social and community context, access to Health care, transportation and environmental conditions. All new medicaid members are screened for Health disparities after enrollment and connected to resources. From june 2018-june 2021, our patients and members were also screened for food insecurity annually during the patient rooming process in primary care, pediatrics, internal medicine, as well as urgent care; those identified are referred to a social service partner. Identification of needs: we have been screening our members and patients for social needs since 2018 and most recently in 2021 implemented a new social needs screening to identify urgent needs with members and patients went live in july 2021. The new screening includes 13 questions across 11 domains: food insecurity, Health care/medical access/affordability, housing, transportation, childcare, employment, utilities, clothing, financial strain, connections (social isolation), and safety. The screening is designed to surface the