Page 33 - Samaritas Quality Report 2018

Care Management

Our Care Management model used a Care Navigator (registered the Care Navigator worked toward a timely discharge, identi-
nurse or Master’s level social worker) to integrate and coordinate fying barriers to recovery. Social service needs, (such as meals, Care Management
services for patients as they navigate through different levels of housing or medication assistance) and health care needs (such
care in our continuum. as Medicare certified home health and coordination of appoint-
ments) were seamlessly coordinated by the Navigator. The pa-
In 2015, Samaritas began to participate in a bundling pilot tient was closely monitored and supported for 90 days to prevent
through Centers for Medicare and Medicaid Services (CMS) re-hospitalization and to ensure adherence to the physician’s
targeting specific diagnoses to improve the quality and decrease plan of care. Our bundling pilot ended in September of 2018.
the cost of care. As persons with these diagnoses entered our
skilled nursing facilities for rehabilitation after hospitalization,

Average Number of Target is 2017 2018 Change
Days in Care Less Than from 2017
to 2018
Senior Living Saginaw
Program COPD 31 0 12.5 * 26

Outcomes Congestive Heart Failure 21 9 12.0 533.3%

Major Joint Replacement 9 17 15 611.8% Persons Served

Revision (ex. Hip Replacement) 35 0 0 *

Urinary Tract Infection 29 23 11.5 650%

Sepsis 37 16 21.8 536%

Senior Living Cadillac

COPD 20 20 14.8 626%
Urinary Tract Infection 18 19.4 20.3 54.6% *We did not serve
this diagnosis in
the program in 2017
Revision (ex. Hip Replacement) 35 0 0 * or 2018.

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