Testimony
House Healthcare Efficiencies Study Committee
Deb Woody, MSN, RN, CCM
Executive Director, Care Management
Paramount Health Care
Chairman Huffman and members of the House Healthcare Efficiencies Study Committee, thank you
for the opportunity to speak to you today. Paramount has long recognized that care management
services provide a critical opportunity to address the multidimensional needs of members, especially
those transitioning from one level of care to another. As members move from one care setting to
another, the risk of fragmented services increases. Transition of care often involves multiple
disciplines such as physicians, nurses, social workers, therapists, and others at both the sending and
receiving end of care as well as caregivers and family members. While all team members are vitally
important to a successful transition of care, this environment is fraught with potential for
communication breakdown leading to gaps in care and barriers that create a perfect storm scenario
that could lead to a failed transition.
To further complicate the transition process, members are extremely vulnerable during care
transitions. Challenges such as declining health due to acute or chronic illness, changes in functional
status, potential loss of independence, and certain social determinants make the transition period
highly perilous.
An integrated cohesive health care team is able to support the member through the discharge planning
process to meet the member’s unique care needs and support the member and caregiver/family
through the handoff process to the next care setting.
Paramount is part of a large integrated health care system (ProMedica Health System), which
embraces integrated care and includes system-wide analysis of stop points throughout care transitions
to prevent fragmentation.
The ProMedica Care Management Collaborative (CMC) was developed as a strategic system-wide
intervention to define transitional processes, improve communication, avoid duplication of services,
and stratify members according to risk, into one of five levels. The CMC embraces a holistic health
approach to provide comprehensive care, including acute care, chronic care, preventive services, and
end of life care. A partnership is developed with the member across all episodes of care to ensure
safe transition and care.
Members may transition up or down in level of need based on condition severity with organized hand
off to the appropriate health team staff, as appropriate. Level one is defined as the highest
stratification risk and level five, the lowest.
Level one members work one-on-one with a transitional care navigator in the inpatient setting and
face-to-face with an ambulatory care navigator in the office setting. Depending on individual needs,
level two members transition between telephonic case management and face-to-face care navigation.
Members stratified into level three, receive less intensive case management and/or disease
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management services. Members in the level four and five risk groups may receive wellness coaching,
and written education.
Organized workflow processes and procedures were a direct result of the intensive collaboration
through the CMC, between inpatient and outpatient care, and care management services at Paramount.
Implementation of these processes exceeded first year expectations for Paramount members, with
statistically significant decreases in all acute care utilization metrics and medical costs.
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Significant 37% reduction in emergency room visits
Significant 56% reduction in hospital admissions
Significant 25% reduction in hospital readmissions within 30 days
Significant 33% decrease in preventable emergency room/ambulatory visits
Significantly lower medical costs of $710 per member per month
While outcomes have exceeded expectations, they cannot adequately reflect the unquantifiable value
of successful transitions of care resulting in optimal quality of life.
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