Care Navigation Services Value-Based Experience
In 2012 while employed at a large health system, Care Navigation Services President, Shannon Clifton, and Senior Vice President, Ellen Ford-Barton were presented with an opportunity to pilot an emerging technology, remote patient monitoring (RPM), to address unnecessary 30-day readmissions among chronic, complex patients. Neither were prepared for time and effort it would take to operationalize their health system’s first RPM program.
“I often think back to when we were first asked to pilot the RPM tool and realize how much we did not know. Had we understood then what we know now about the resources, time commitment, operations processes and project management required for healthcare providers to successfully implement a readmissions prevention program, we might have walked away. We have benefitted from many learned lessons over the years to develop results-focused patient management solutions, both with and without the use of technology, for our provider-partners today at Care Navigation Services,” states Shannon.
Ellen adds, “At Care Navigation Services, we do not simply recommend a program and walk away… we develop customized workflows, provide the clinical staff, program management and quality reporting to ensure long-term success.”
Shannon joined Care Navigation Services in 2015 and Ellen followed in 2016; both brought their knowledge in operationalizing patient-centric, value based solutions.
To-date, their combined experience, coupled with a dynamic team, has afforded the opportunity to manage a variety of high-risk populations, including:
• Institutional Review Board governed mobile health program for CHF patients
• 5-year DSRIP (Delivery System Reform Incentive Payment Program) funded mobile health program for chronic, complex underinsured patients
• Rural clinic mobile health program to minimize unnecessary Emergency Department utilization among Diabetics
• Associate health mobile health program incorporating patient-centered medical homes
• Medicare Shared Savings mobile health program targeting CHF, Diabetes, COPD and Pneumonia patients
• Post-acute transitional care mobile health program to decrease home care readmissions
• School-based telemedicine program to improve access to primary care among students and employees at 16 underserved schools
• Tele-Neurology program to enhance care continuity and increase access to specialists
• RN Navigation and care coordination program to address Bundled Payments for Care Improvement (BPCI) patients
• Hospital-based RN Transitional advocate program to reduce avoidable days and facilitate seamless post-acute transitions
• Transitional care mobile health program targeting CHF, COPD and Pneumonia patients
