Whole-Person Health and Value-Based Care at CenterWell

Appointments that aren’t rushed.
Taking care of seniors is complicated. Seniors often have multiple chronic conditions and more complex health issues than other patients. They may need more time to ask questions and understand all the information and factors impacting their health. CenterWell Senior Primary Care’s healthcare model is recognized for intentionally giving our teams up to 50% more time with patients, so they can answer those questions and address gaps in care.

In a longer appointment, doctors, nurse practitioners and the entire integrated care team at CenterWell Senior Primary Care spend more time with patients, building better relationships and focusing beyond the one issue or concern that brought the patient in that day.

Many seniors see additional specialists, so we have teams of professionals specifically trained to help senior patients navigate the complex, fragmented healthcare system. Our staff specifically helps coordinate appointments and ensures that our patients maximize use of their health benefits.

Care team dedicated to patients’ whole health.
I mentioned our unique care model, and we bring it to life through interdisciplinary team meetings to discuss high risk patients, with multiple members of the team reporting updates to the group, looking to eliminate gaps in care or coverage. Care teams include nurses, social workers, community health workers, pharmacists and behavioral health specialists, just to name a few. These medical professionals work together in ways that are changing the lives of seniors. And this is not just limited to patients expected to be in the center that day – our CenterWell daily huddles also focus on patients who are currently in the hospital, a post-acute facility, or under the care of home health. This integrated approach ensures the entire care team is working toward better outcomes for all the patients under our care. There is no opportunity or incentive in traditional fee-for-service medicine to spend time thinking about patients who aren’t being seen that day – that is the magic of value-based care when done right.

In our communities with CenterWell Senior Primary Care and CenterWell Home Health, clinicians from both organizations can work together to assess and meet a patient’s needs. We recently saw this in Las Vegas when the entire care team came together to lower a patient’s blood sugar back to healthy levels AND address other factors that prevented the patient from achieving their best health at home.

Care centered on the patient.
“Center” is part of our name. Everything we do aims to keep patients at the center of their care. Transforming care and putting health first is possible when a healthcare team looks after the whole person, taking into account their physical, emotional and social wellness. And we have the results to prove it.

Here’s what Humana Medicare Advantage health plan members experience from their value-based care providers, including CenterWell and other providers in value-based arrangements:

• 251,000 fewer days spent in the hospital
• 90,000 fewer emergency room visits in the past year
• ·$500 each on average saved in the past year (based on Humana’s ability to invest in better plan benefits and lower premiums with the costs saved on value-based care)

Humana quality measures also drive better health outcomes for its Medicare Advantage members:

• 900,000 additional members receiving preventive screenings in the past 5 years
• 97% compliant with diabetic kidney disease monitoring
• 88% adherent with cholesterol medications
• 84% with diabetic blood sugar under control
• 81% compliant with colorectal cancer screenings

Numbers showing how value-based care is improving the lives of our patients are so important for the work we do, but real patient stories drive home the personal impact of what our providers are doing every day. I can’t thank our team of professionals enough for their focus on our patients, every day.

Our CenterWell teams include:

Social workers and community health workers who address social determinants of health and connect patients with food, transportation, and housing needs. Earlier this year a patient was struggling with food and housing insecurity. CenterWell Resource Coordinator, Priscilla Perez, linked the senior with a local food bank to receive a monthly box of groceries. She also helped her apply for housing in a local residence that was close to family and had a short waitlist, walking her through the paperwork process to completion. This patient is now moved into her own apartment AND no longer struggling with food insecurity. Thank you, Priscilla!

Behavioral health specialists who assess patients and refer them for needed care. Another CenterWell patient suffered from significant social anxiety, causing her to avoid seeing a primary care provider for years. Medical Assistants Dina Luke and Kimberly Ochoa put together a plan to get this patient to an exam room immediately upon arrival. Dr. Laura Ling and Nurse Practitioner Ashlie Sloan teamed up with Behavioral Health Specialist Madison Davis to address the patient’s fears, discuss medication options, and help assess and manage ongoing anxiety symptoms. Care is ongoing and the patient now reports feeling optimistic and comfortable leaving her home more often. Thank you for a true integrated team effort to improve this senior’s outlook on life!

Nurses who are by your side during a hospital stay and recovery after discharge. Success looks different for everyone, but for one 80-year-old patient who was hospitalized last month with restrictive lung disease, it means having three consecutive days of feeling her best. Thanks to CenterWell Nurse Care Coach Alex Brydon for helping coordinate in-home physical therapy for this patient and connecting her with the behavioral health specialist to cope with life changes; this patient is now having fewer episodes of shortness of breath and lightheadedness. This patient reports feeling excited to continue working on her health and is now able to have time with friends, because she has “an army” caring for her and cheering her on. Thank you, Alex and Madison, for your continued dedication to your patients.

I’m confident the entire team of talented CenterWell clinicians is transforming the healthcare experience for our patients. I’m proud to work alongside all of these amazing professionals working to improve the lives of seniors.

We are continuing to grow our capabilities at CenterWell and are always looking for more clinicians to join us. To learn more about how you can join our team, visit centerwellcareers.com/physicians.