Uncoordinated care is one reason more than one-fifth of health care spending in the U.S. goes to 1 percent of patients, but Geisinger Health System is among those working to solve the problem, American Medical News reports.
Geisinger Health Plan's sickest patients -- those with heart failure, pulmonary disease, diabetes and other conditions -- are enrolled in its patient-centered medical home program called Proven Health Navigator, said Thomas Graf, MD, Geisinger Health System's associate chief medical officer for population health.
Proven Health Navigator patients in active case management maintain close contact with their case managers, who are registered nurses. The RNs examine patients' medical and social support needs and maintain close phone contact. Some heart failure patients have remote monitoring in their homes. The machines allow them to send their weights, prescribed medications and dosages, and symptoms such as shortness of breath to their primary care teams electronically.
Dr. Graf said the medical home program is reducing Geisinger's costs by at least $1.20 for every dollar invested, in part through decreased hospitalizations. "You don't have to avoid a lot of hospitalizations to pay for these management techniques," he said.
American Medical News
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