Page 31 - Samaritas Quality Report 2017

Care Management

Our Care Management model uses a Care Navigator (registered talization, the Care Navigator begins to work toward a timely
nurse or Master’s level social worker) to integrate and coordinate discharge, identifying barriers to recovery. Social service needs, Care Management
services for patients as they navigate through different levels of (such as meals, housing or medication assistance) and health
care in our continuum. care needs (such as Medicare certified home health and coordina-
tion of appointments) are seamlessly coordinated by the Naviga-
In 2015, Samaritas began to participate in a bundling pilot tor. The patient is closely monitored and supported for 90 days to
through Centers for Medicare and Medicaid Services (CMS) prevent re-hospitalization and to ensure adherence to the
targeting specific diagnoses to improve the quality and de- physician’s plan of care.
crease the cost of care. As persons with these diagnoses enter
our skilled nursing communities for rehabilitation after hospi-

Average Number of Target is 2016 2017 Change
Days in Care Less Than from 2016
to 2017
Senior Living Saginaw
Program COPD 31 23 0 * 29

Outcomes Congestive Heart Failure 21 9.5 9 65%

Major Joint Replacement 9 13.7 17 524%
Persons Served
Revision (ex. Hip Replacement) 35 7 0 *

Urinary Tract Infection 29 20.7 23 511%

Sepsis 37 20 16 620%

Senior Living Cadillac

COPD 20 22.3 20 610%
Urinary Tract Infection 18 35.5 19.4 645%
*We did not serve
Revision (ex. Hip Replacement) 35 34 0 * this diagnosis in the
program in 2017.
30