Onsite Clinical Support
The Care COORDINATE solution provides onsite clinical support to operationalize our programs in collaboration with the provider’s existing teams. Care Navigation Services has designed proprietary, proven models that optimize case management, social work and care transition teams across the continuum.
Registered Nurse (RN) Transitional Advocate
Care Navigation Services staffs acute and post-acute facilities with an RN Transitional Advocate to improve overall patient experience. The RN Transitional Advocate facilitates a personalized and seamless transition to the next level of care.
Our acute model aims to enhance case management efficiency by providing a resource to manage hard-to-place patients transitioning to skilled nursing. This timely post-acute referral placement positively impacts avoidable inpatient days. In the post-acute setting, the RN Transitional Advocate is focused on engaging patients in their own self-care by providing disease-specific education, personalized clinical-quality coaching and post-discharge coordination.
The RN Transitional Advocate program guarantees patients have access to necessary resources and tools, empowering them to take a more active role in their recovery process and ongoing disease management.
Proven Outcomes
On-site one-on-one time between Transitional Advocate and patient enhances overall quality of care and patient satisfaction, while reducing unnecessary returns to an acute care hospital.
- 47% Decrease in Avoidable Hospital Days
- 100% Patients Educated on Disease Process
- 90% Patients Engaged within 72 Hours of Admission
- 63% Patients Assisted with Scheduling PCP Appointment
- 8% Decrease in Patient-Reported Return-to-Acute (RTA)
Address value-based goals and elevate overall quality of care
Nurse Navigator
Care Navigation Services staffs RN Navigators to facilitate patient education and care coordination for alternative payment programs including Bundle Payment for Care Improvement – Advanced (BPCI-A), Comprehensive Care for Joint Replacement (CJR) and other value-based initiatives. In collaboration with providers, the Nurse Navigator proactively engages the patient to support the entire risk period (30-90 days) with strategies such as clinical coaching and “teach-back” methods, patient-specific education, and follow-up phones calls at home.
The Care Navigation team can help manage preferred provider networks within the program to promote a value-based culture throughout the network. We’ve found that well-engaged clinical teams is a key component for long-term clinical-quality and financial success of alternative payment models.
Proven Outcomes
Program outcomes demonstrate overall reduced average length of stay, unnecessary healthcare utilization, and hospital readmissions, ultimately reducing cost of patient care and generating savings for our clients.
- $7,000 per episode savings for BPCI Model 2
- $11,000 Savings Per Acute Care Patient
- 58% decrease in SNF utilization
- 56% decrease in SNF length of stay
- 47% reduction in 90-day readmissions
Personalized care plans and patient support to improve outcomes
Senior Living Resident Advocate
Care Navigation Services provides a resident advocate solution utilizing a clinical professional to enhance overall care coordination and meet the higher acuity needs of the growing senior population. This service affords Senior Living residents access to a wide-range of services designed to encourage an informed and proactive approach to safely aging in place.
The assigned clinical professional serves as a resident advocate within the community and can extend advocacy services to other care settings should the resident temporarily return to a higher level of care. This added clinical support helps ensure a smooth, safe transition back into the community, showing acute providers your community prioritizes resident care.
CLIENT SATISFACTION RESULTS
The result is improved overall quality of care and resident satisfaction with a decrease in unnecessary care utilization.
- 100% Resident Satisfaction
- 100% Provider Satisfaction
Proactive clinical concierge to support safely aging in place
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