Medicare patients transitioning to home from hospitals or skilled nursing facilities are at a high risk for readmission, and while part of that risk is physical, it is also educational. Upon discharge, seniors are often adrift. They don’t necessarily know their own health needs, nor do they fully understand the next steps that promote care continuity and mitigate avoidable readmissions.

There might also be a disconnect with the health care providers who can otherwise fill in the knowledge gaps for those patients. And when no one is on the same page, everyone suffers.

With its home-based Care CONNECT solution, Care Navigation delivers telephonic patient support during the critical period immediately after discharge. The company serves health care providers throughout the continuum to extend care at home, supporting the patient post-discharge.

“Care CONNECT’s clinically-driven protocols engage patients and caregivers throughout the recovery process, while connecting with key providers for timely interventions,” says Shannon Clifton, president and CEO of Care Navigation. “Our outcomes demonstrate improved patient engagement, reduced gaps in care, and a healthy financial return for our provider partners.”

Here are four benefits of Care Navigation’s low-cost Care CONNECT solution that are driving value-based outcomes: patient engagement, care continuity, readmission mitigation services and connecting patients with the appropriate care.

Patient engagement

The heart of Care CONNECT is a call center for at-risk patients, staffed by registered nurses who provide customized education, and coach patients toward improved care plan compliance during scheduled health “check-ins.”

“Patients and caregivers are often unprepared to manage health conditions at home,” Clifton says. “Care CONNECT engages patients immediately after discharge and keeps them motivated to reach personal health goals. This patient-centered approach is driving impressive patient engagement figures.”

One such operator seeing impressive patient engagement figures is StoneGate Senior Living. Based in Lewisville, Texas, StoneGate operates 29 SNFs across Texas, Oklahoma and Colorado, and uses Care Navigation within its entire skilled nursing portfolio.

StoneGate’s engagement rate with Care Navigation’s program? About 84%.

“Our collaborative relationship with StoneGate fosters opportunities to optimize Care CONNECT’s reach, and yield a return on their program investment,” Clifton says.

Care continuity

While Care Navigation offers one path to patient engagement, it offers multiple roads to building continuity of care. The first is patient-centered.

“Care CONNECT augments providers’ patient education services to improve self-health management skills,” Clifton says. “If the home health provider hasn’t made contact after discharge, for instance, Care Navigation will coach patients or caregivers on appropriate next steps. This positions the patient as the active participant in his or her own care and minimizes a costly readmission.”

The second avenue to care continuity is near-time communication and a strong system of collaboration when patient recovery challenges are uncovered. The Care CONNECT team quickly notifies StoneGate’s facility staff when patient challenges are identified, allowing for a timely intervention to fill recovery gaps.

“Care CONNECT continues our established relationship with discharged residents,” says Angela Norris, Senior Vice President of Strategic Relations & Managed Care at StoneGate. “By positioning facility resources to fill gaps at home, Care CONNECT serves as a catalyst for a positive patient experience through a shared commitment to quality care.”

Readmission mitigation services

Obviously, though, avoiding that readmittance is the goal, and that is one area where Care Navigation through Care CONNECT has a great impact.

With a commitment to promote the right care at the right place and time, Care Navigation prioritizes coaching patients to their physician-directed care plan or involving clinical resources when recovery challenges are identified. Should patients continue to report health declines, Care Navigation’s proprietary workflow engages StoneGate in facilitating direct home-to-SNF readmissions.

This cost-efficient intervention strategy aligns with value-based directives and drives program ROI.

As a result, Care Navigation shows a post-SNF discharge, patient-reported readmission rate for all of StoneGate’s facilities at 11% for Medicare Fee-For-Service beneficiaries. That is lower than the figure cited in a 2018 Harvard Medical School-led study, which found that one in four re-admit to the hospital from home after a SNF stay. Also of note is Care Navigation’s 7% rate for discharged managed care patients. And both enhance StoneGate’s position as a referral partner.

“In a value-based referral system, the better customer service and clinical care you provide, the more likely you will become a preferred partner with that hospital system or physician group, whoever may be sending the referral,” Norris says. “Care Navigation is the methodology and partner we utilize to give us the cutting edge.”

Connecting patients with the appropriate care

In the end, StoneGate reached out to Care Navigation for one reason and one reason only: to provide quality, cost-efficient care to its discharged patients. As Clifton notes, “The patient engagement and reinforcement of care continuity creates partnerships and networks that ensure each patient will get quality care tailored to their needs.”

This in turn makes StoneGate and other Care Navigation post-acute clients preferred referral partners for acute-care providers.

“We constantly evaluate what we need to do for inclusion on a hospital’s preferred partnership lists, and Care Navigation has been pivotal for us,” Norris says. “I hope our experience sends a message that the SNF industry should consider such partnerships.”

To learn more about how Care Navigation and Care CONNECT can help your SNF, visit CareNavigationServices.com.