In an effort to improve coordination of care and create programs that result in achieving the “Three Part Aim” of providing improved care of patients, including without limitation, Medicare Fee-For-Service beneficiaries we serve; better health for the populations we care for; and doing so in a financially sustainable manner, Deaconess Illinois (a wholly owned company of Deaconess Health System), participating Critical Access Hospitals (CAH), in collaboration with DCI, in 2018, developed a program to enhance the quality and efficiency of health care services, participate in programs and initiatives designed to manage, coordinate, and promote accountability for quality, patient safety, cost and overall care of patients.
Under this arrangement, Deaconess Illinois, working in coordination with CAHs, provides a designated case manager at Deaconess Hospital and Deaconess Gateway Hospital to identify patients who meet criteria for swing bed services. The motivation is to help patients return home as quickly as possible, prevent hospital readmissions and to work collaboratively to improve quality at these CAH facilities. Each facility establishes a baseline of quality measures as well as disease specific outcomes measures as part of the participation agreement.
Deaconess Illinois works collaboratively with the CAHs to address any patient care issues, participate in process or clinical pathway improvement opportunities, and utilizes best practice models to support coordination of care and reduce unnecessary financial expenditures.
|ACHIEVING THE THREE PART AIM
|Better Experience of Care for Patients
||Better Health for Populations
||Reducing Health Care Expenditures
|Clinical support to identify and coordinate transition to CAH
||Decreased readmission rate
||Transition to appropriate level of care timely
|Consistent Case Manager available throughout acute episode of care transition
||Decrease costs due to better outcomes
|Care is patient-centered, less fragmentation and improved coordination
||Increased Functional Status
||Increased percentage of patients to home
||Improved Quality Measures
For specific questions regarding this or other Deaconess Care Integration programs, please contact:
Deaconess Care Integration
For general questions or additional information about Accountable Care Organizations, please visit www.medicare.gov/acos.html
or call 1-800-MEDICARE
(1-800-633-4227) TTY users should call 1-877-486-2048