Proactive, Patient-Centered Strategies Demonstrate Positive Outcomes

With a massive shift in healthcare from volume to value-based care, well-engaged clinical teams, preferred provider networks, and strong support systems are a few of the key components for long-term clinical-quality and financial success. In January 2015, Panorama Orthopedics and Spine Center partnered with Care Navigation Services (CNS) to implement a proactive and holistic patient-centered strategy focused on enhanced care coordination.

Utilizing CNS’ Care Engage program, our RN Care Coordinator, in collaboration with Panorama physicians and preferred network of acute and post-acute providers, offers innovative and proactive patient engagement solutions that focus on a seamless transition to home. CNS’ contribution of clinical coaching, teach-back methods, patient specific education and follow-up phone calls are meant to facilitate a reduction in unnecessary post-surgery healthcare utilization and admissions. While this collaborative effort continues to evolve, results to-date demonstrate positive outcomes for all stakeholders:

• 44% reduction in 30-day acute readmissions (in comparison to baseline data)
• 45% reduction in 90-day acute readmissions (in comparison to baseline data)
• 30% reduction in surgical site infection (in comparison to baseline data)
• With aforementioned resulting in a savings of $5,000 per case (in comparison to baseline data)

To support program sustainability and scalability initiatives, the following offers our collaborative “lessons learned” on how providers can be successful:

1. Promote a value-based culture within the organization
2. Include physicians in every step of the process
3. Adopt a holistic patient management approach
4. Implement episode-based care coordination
5. Engage and empower the patient
6. Minimize unnecessary post-acute utilization
7. Empower post-acute provider network to contribute to each patient’s success
8. Allow data to drive your decisions