What is the ProvenHealth^® Navigator (PHN)?

PHN is a true Patient Centered Medical Home with over five years of successful outcomes data highlighting its effectiveness. The success of the ProvenHealth^® Navigator model is its five-point framework that encompasses:

• Patient centered primary care
• Integrated population management
• Medical neighborhood
• Quality outcomes (HEDIS and bundled chronic disease metrics)
• Value-based reimbursement

What is an Practice-Based Case Manager?

The Practice-Based Case Managers are specially trained RNs that are the heart of the PHN model. The Practice-Based Case Manager works out of the primary care physician’s office and has direct access and interaction with the primary care physician, clinical personnel, and office staff. The Practice-Based Case Manager provides value to the patient by improving access, adherence to best practices, coordination of services, collaboration among the medical home team and the greater medical neighborhood, while value to the organization is derived from the prevention of costly and unnecessary acute care admissions, ED visits and reduction of readmissions.

What is the value of this training?

The value of the ProvenHealth Navigator Practice-Based Case Manager Certification Program is in its ability to prepare your case managers for their exciting new role to collaboratively implement and successfully support the Patient Centered Medical Home. The training includes:

• Direct access to and observation of Geisinger’s care team in ProvenHealth® Navigator primary care physician practices including assignment with experienced PHN Practice-Based Case Managers
• Attendance at key team meetings where performance reports and challenging patients are discussed
• Introduction to risk stratification tools and predictive modeling
• Direct access to Practice-Based Case Management workflows (e.g., referral to case closure) and the corresponding documentation tools utilized within the electronic health record
• Focus on targeted conditions such as COPD and HF, with emphasis on transitions of care
• Quality metrics and processes to capture data for measuring success of the Practice-Based Case Manager
• 124 Nursing Continuing Education Units and a Certificate of Completion

The Results are Proven

• 15% - 18% decrease in admissions annually
• 22% decrease in readmissions annually
• 72% of patients thought the quality of care was better after working with a PHN Practice-Based Case Manager
• ED visits remain flat for PHN managed patients while unmanaged patients ED visits increase

The difference between the ProvenHealth Navigator® model and those offered by other organizations is that Geisinger’s performance is evidence-based and supported by both provider and payer analytics.

For more information, or to enroll in the Practice-Based Case Manager Certification Program, contact Danielle Selleck at 570-214-5114 or email at innovconf@geisinger.edu. Click for course dates.