Welcome to the Group Practice Improvement Network

GPIN is a nonprofit organization created in 1993 by the founders of the Institute for Healthcare Improvement to provide a vehicle through which medical groups achieve and sustain performance excellence by sharing knowledge of best practices.

Our Mission

GPIN serves as a catalyst for large multi-specialty group practices to achieve performance excellence through shared learning.

Our Vision

GPIN member groups will be leaders in quality of care, patient experience and cost effectiveness.

GPIN Membership Information

Interested in an overview of GPIN? Click here to review a short presentation.

Click here for GPIN member Frequently Asked Questions.

Click here for GPIN website orientation documents and video recordings.

GPIN Members in the News

Fresh Food By Prescription: This Health Care Firm Is Trimming Costs — And Waistlines
May 8, 2017

The advice to eat a healthy diet is not new. Back around 400 B.C., Hippocrates, the Greek doctor, had this missive: Let food be thy medicine.

But as a society, we've got a long way to go. About one out of every two deaths from heart disease, stroke and Type 2 diabetes in the U.S. is linked to a poor diet. That's about 1,000 deaths a day.

There are lots of places to lay the blame. Calories are cheap, and indulgent foods full of salt, sugar and fat are usually within our reach 24/7.

So, how best to turn this around? Consider Tom Shicowich's story. It begins with a toe. His left pinky toe.

"One day I looked down and it was a different color ... kind of blue," Shicowich says. And he began to feel sick. "I thought I was coming down with the flu."

The next day he was on the operating table. A surgeon amputated his toe, and it took two weeks of intravenous antibiotics to fend off the infection.

All told, he spent a month in the hospital and a rehab facility. "Oh, I tell you, it was a bad year," Shicowich recalls.

But this wasn't just bad luck. His toe emergency was somewhat predictable. Foot infections are a common complication of Type 2 diabetes — often due to nerve damage and poor blood flow, especially when the disease isn't well controlled.

He racked up about $200,000 in medical charges from his toe emergency. The portion he had to pay out-of-pocket drained his savings account. "I did shell out $23,000 to the hospital, so that was a kick in the head," Shicowich tells us.

It was also a wake-up call.

Shicowich was more than 100 pounds overweight. He was was fighting nerve damage, high blood pressure and kidney problems — all complications of diabetes.

"So I knew it was time for a change," he told me. And last year, he found the help — and the motivation — he was looking for: a new food pharmacy program that has helped him overhaul how he eats.

Welcome to the food pharmacy

"Folks, good morning, and welcome to the ribbon cutting and opening of the Fresh Food Pharmacy," intoned Sam Balukoff, the master of ceremonies at Geisinger Health System's recent debut of a new food pharmacy located on the grounds of a hospital in central Pennsylvania.

At this event, Shicowich was one of the stars of the show. Over the last year, he and about 180 patients with Type 2 diabetes have been participating in a pilot program aimed at getting them to to change their diets and lose weight. They receive free groceries of healthy foods every week.

Shicowich has lost about 45 pounds, and he's now much more active.

Each week, Shicowich and the other participants come to the food pharmacy. In its new incarnation, it looks more like a grocery, with neatly stocked shelves filled with healthy staples such as whole grain pasta and beans. The refrigerators are full of fresh produce, greens, low-fat dairy, lean meats and fish.

The participants meet one-on-one with a registered dietitian. They're given recipes and hands-on instruction on how to prepare healthy meals. Then, they go home with a very different kind of prescription: five days' worth of free, fresh food.

Shicowich says it's a huge change from his old habit. "I would stop at a Burger King or a McDonald's or buy a frozen Hungry-Man dinner, basic bachelor food, you know, heat and eat."

But those days are over. Now, he and his girlfriend cook meals at home. He says now it's much easier to climb a flight of stairs or take a walk with his girlfriend.

'It's life-changing'

Shicowich's health has improved. His blood sugar and blood pressure have dropped so much that if he keeps on track, his doctors say they'll reduce his medications.

"It's life-changing," David Feinberg, the president and CEO of Geisinger Health System, says of the results they've seen.

He says, so far, all the patients in the pilot program have made similar improvements. "It's mind-blowing," he says. And he says the range of support patients are offered — everything from dietary counseling to wellness classes and workshops — can help them succeed.

Take, for instance, the significant declines in patients' hemoglobin A1C levels. This is a blood test used to track how well patients with diabetes are controlling their blood sugar.

A year ago, Shicovich's A1C was close to 11. Now it's down in the high-6 range. Anything under 6.5 is considered below the threshold of Type 2 diabetes, according to the Mayo Clinic. Feinberg says this means that Shicowich — and other participants in the program — have a much better chance of avoiding many complications of Type 2 diabetes if they can maintain their A1C levels down in this range.

"[They] won't go blind, [they] won't have kidney disease, amputations," Feinberg says. "The list goes on and on."

Cheaper than paying for complications

When this program started, some questioned the premise of giving away free, fresh food to patients with diabetes. But keep in mind, the costs associated with diabetes in the U.S. now exceed $240 billion a year.

Once you consider that price tag, Geisinger's program can look like a bargain. Over the course of a year, the company will spend about $1,000 on each Fresh Food Pharmacy patient. All of the participants in the program are low-income, so the gift of the food eliminated a key obstacle to eating well.

But would this lead to a reduction in health care costs?

Feinberg says as his team tracks hemoglobin AIC levels in the pilot participants, they're also assessing the number of medical visits, sicknesses and the overall cost of caring for these patients.

It's still early days, and they plan to fully analyze their first year of data. But here's what they estimate so far: "A decrease in hemoglobin A1C of one point saves us [about] $8,000," Feinberg says.

And many of the participants have seen a decline in hemoglobin A1C of about three points. "So that's [about] $24,000 we're saving in health care costs," Feinberg says. "It's a really good value." Geisinger is now in the process of expanding the program to new locations within Pennsylvania.

Is prevention medicine the future?

This program is an example of the booming interest in prevention-oriented medicine.

The current health care system in the U.S. is often more aptly described as a disease-care system. "It's reactive," says Mitesh Patel, a physician and assistant professor of health-care management at The Wharton School at the University of Pennsylvania. "We wait until people get sick and then spend lot of resources helping them get better."

But Patel says there are signs this is beginning to change. "I think the paradigm shift has already begun," he told us. Patel's take on Geisinger's new Fresh Food Pharmacy program: It includes the kind of financial and social incentives that can help motivate people to make changes.

For instance, the Fresh Food Pharmacy gives free, fresh food not just to the patients enrolled but to everyone in their household as well.

"The way we behave is really influenced by others around us," says Patel. So, promoting a group effort could "make the program a lot more sticky and more likely to succeed."

It's always a challenge to get people to maintain lifestyle changes over the long term. But, Patel says, "If you get the entire family to change the way they eat, you're much more likely to improve health."

The evidence that lifestyle-modification programs can reduce health care costs is starting to accumulate.

Earlier this year, researchers published findings in the journal Health Affairs that evaluated the medical expenses of Medicare patients with prediabetes. The patients had completed a one-year diabetes prevention program focused on healthy eating and increased physical activity. The researchers found, overall, the average health-care savings was about $300 per person, per quarter — compared with patients who hadn't been through the program.

Study: Integrating Mental and Physical Healthcare Services Leads to Better Outcomes, Lower Costs
August 29, 2016 by Heather Landi
Patients receiving care in team-based practices that integrated mental and physical healthcare services had better clinical outcomes, lower total costs and used fewer healthcare services, according to a 10-year study conducted by Intermountain Healthcare researchers.

Intermountain Healthcare researchers conducted a 10-year study on the impact of delivering integrated mental and physical healthcare in team-based primary care settings, and the study was recently published in theJournal of the American Medical Association. Brent James, M.D., Intermountain’s chief quality officer and executive director of the Intermountain Institute for Healthcare Delivery Research, led the study and researchers measured 113,452 adult patients who received care from 2003 through 2013 in 113 primary care practices at Intermountain, including 27 team-based medical practices and 75 traditional practices.

As a result of the integrated mental healthcare model, Intermountain researchers found that a higher rate of patients in team-based practices were screened for depression, which enabled care providers to provide medical and behavioral interventions earlier, compared to patients in traditional practices. As a result, 46 percent of patients in team-based practices were diagnosed with active depression compared to 24 percent in traditional practices.

The study findings indicated that more patients in team-based practices adhered to diabetes care protocols, including regular blood glucose testing, specifically 24 percent compared to 19 percent in traditional practices. In addition, close to half (48 percent) of patients in team-based practices had a documented self-care plan to help them manage their health conditions, compared to 8 percent in traditional practices.

The researchers also found that the integrated mental healthcare resulted in lower rates of healthcare utilization, such as a reducing emergency room visits by 23 percent. Specifically the data showed that per 100 person years, the rate of emergency room visits was 18.1 for patients in team-based practices versus 23.5 visits for patients in traditional practices.

The rate of hospital admissions was 9.5 for patients in team-based practices versus 10.6 in traditional practices, which represents a reduction of 10.6 percent.

In addition, the number of primary care physician encounters was 232.8 for patients in team-based practices versus 250.4 for patients in traditional practices, which is a reduction of 7 percent.

And, researchers found that the integrated model resulted in lower total costs. Payments to providers were $3,400 for patients in team-based practices versus $3,515 for patients in traditional practices, which is a savings of 3.3 percent. According to the study authors, the payments were less than the investment costs Intermountain incurred in creating the team-based practice model.

Prior to this study, limited evidence was available to support the effectiveness of a care model that integrated mental health providers with primary care teams, according to the study authors.

“For patients, the bottom line of the study is that getting care in a team-based setting where medical providers work hand-in-hand with mental health professionals results in higher screening rates, more proactive treatment, and better clinical outcomes for complex chronic disease,” Intermountain Healthcare scientist Brenda Reiss-Brennan, PhD, APRN, one of the study's authors, said in a statement. “Team-based care means providers work together to care for all chronic conditions, mental and physical.”

Intermountain has embedded mental health screening and treatment within primary care physicians' offices since 2000.

“The study reinforces the value of coordinated team relationships within a delivery system and the importance of integrating physical and mental health care,” Reiss-Brennan said. “The study provides further evidence—from a mental health perspective—of Intermountain Healthcare's hypothesis that better care costs less.”

Sutter Health ranked in top five large health care systems
Sacramento’s Sutter Health and its Valley Area division have been named among the topperforming health systems in the country by Ann Arbor, Mich.-based Truven Health Analytics. The systems were named in Truven’s latest “15 Top Health Systems” study, with Sutter Health and its Valley division ranked among the nation’s top five large health care systems. Truven gathered data from 338 health systems and nearly 3,000 hospitals. Sutter Health is affiliated with Memorial Medical Center of Modesto, Sutter Tracy Community Hospital, Memorial Hospital Los Banos and the Sutter Gould Medical Foundation clinics.

Q&A: We know more about what's in a cereal box than the healthcare system, says Dartmouth-Hitchcock CEO
By Modern Healthcare  | March 19, 2016

Dr. James Weinstein, CEO of Dartmouth-Hitchcock health system in Lebanon, N.H., and a spine surgeon, was deeply involved in the deliberations leading up to the Affordable Care Act. He continues to press for delivery-system change. He recently sat down with Modern Healthcare editor Merrill Goozner to discuss the book he recently co-authored, Unraveled: Prescriptions to Repair a Broken Healthcare System, and what he sees as the next arenas ripe for reform. This is an edited transcript. 

Modern Healthcare: Why do you think there's something fundamentally broken about our healthcare system?
Dr. James Weinstein: There are serious issues with the health system that warrant serious solutions. At Dartmouth, for decades, we've looked at the variation in care across the country. It's our turn now to come up with solutions. We're working with colleagues across the country on projects related to what I like to call informed choice to help patients have better decisionmaking. To make informed choices, they need to be well-informed. We're working on the transparency around pricing and outcomes. It's not good enough to just say this is how much is being charged or this is how much something cost. What kind of value do you get from that charge or cost or from a procedure you might have? For value-based payments, it's critically important to have transparency about what it cost. We spent a great deal of time building an infrastructure to provide those kind of answers for our patients at Dartmouth-Hitchcock and we're working with colleagues across the nation to do the same thing.

MH: Patients tend to be more conservative if they're given a role in making the choices. How does a Dartmouth prepare for a world in which you're going to be getting less revenue?
Weinstein: We must do what's right for the patient and the consumer, not what's right for Dartmouth-Hitchcock. If you start with the premise of what the patient needs and what the population needs, you might actually build your health system in a very different way. You might actually do better work and make more revenue than you do today by trying to prevent things. Today, we're paid for doing things. Imagine what we could do if we could prevent things and I didn't have to have so many hospital beds with so many sick people. We have to get upstream. We have to start dealing with our nation's greatest problems in mental illness, drug abuse, childhood obesity. Smoking is still a problem.

MH: How does a healthcare system do that on a day-to-day basis?
Weinstein: First of all, we have a strategy that deals with our organization. We take part of our investment portfolio and invest it into the populations we serve in things they need most, which aren't reimbursed well, like mental illness, like end-of-life decisions, like having the ability to make your decisions before you're going to die about how you want your life to end. We build a technology infrastructure that makes care available closer to the home. We're trying to find ways to make care consumer-friendly, not hospital-friendly. We try to find ways to work with you after you leave the hospital to keep you from coming back. 

MH: You also formed an insurance arm with Harvard Pilgrim as a way of changing the reimbursement incentives inside your own system. 
Weinstein: We're very excited about our partnership in the insurance space. It brings us as a system into a space where we can get closer to our patients and their needs around the premium dollar. We want to lower the cost for the patient who's actually experiencing greater cost because of the change to high-deductible plans, where they have more out-of-pocket cost. We went into the market with a premium that was 15% lower than anything else in our region to lower their out-of-pocket cost upfront. Then we created networks with other partner systems so we get continuity of care where as you go from hospital to hospital, you do not have to retell the same story over and over again. We've worked to create the kind of quality of care and practices that are evidence-based across an integrated system that does the same work, has the same medical records structure, the same protocols and the same answers. But you don't have to come to Dartmouth-Hitchcock to get that. You can go to any of our partners in the health plan or in our network.

MH: Has this created conflict with physician practices or community hospitals that are excluded from your networks?
Weinstein: Networks always potentially create a problem, and therein lies another important solution: being transparent about your cost and your outcomes. There should be competition. This country was built on competition. But let's put out the information about what value one organization provides against others.

MH: The overarching theme of your book is that we really have to transform the healthcare system into being patient-centered. What is the biggest problem in achieving patient-centeredness?
Weinstein: The payment system interferes the most with transforming the healthcare system. Many healthcare systems are fearful that if they transform, they won't survive in a way that still provides meaningful healthcare. At Dartmouth-Hitchcock, we're trying to make a very measured approach in our population strategies to deal with those who are sickest in new and different ways. We're trying to change the services we offer and what kind of workforce offers that service. Maybe it's not a physician. It's a nurse or how we use technology. We have to figure out how to get out of the fee-for-service system and contract with patients where they don't have to provide more money out of pocket to get the services they need. The systems that have been built in this country have been built to sustain their revenue stream. It may not be the right thing for the patients. The transition is difficult. Each system has to determine how they're going to do it. Many fear that change will unravel the structure they have. We need to unravel some of them.

MH: Some would characterize efforts at delivery-system transformation over the past six years as experimental rather than transformational. Where do you see it going in the next five years?
Weinstein: I think it's been disruptive. Over the next five to 10 years, what we really need to do—and I don't care what the payment system is—is have transparency about cost and outcomes. Right now, it still seems like an effort to lower the spend, not to improve the outcomes of the healthcare system and for the individual patient. We haven't transformed the system so that people actually understand what the system provides. We know more about what's in a cereal box than we do about what's in the healthcare system. We have to have that kind of cereal box explanation for every system in this country so patients can make an informed choice about their care. We can then rationally decide what we're going to spend in this country as part of our GDP—not to ration healthcare, but to rationally decide based on good information what our spend should be.

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May 2-4, 2018

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