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Clinical program highlights value-based care model

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Presbyterian's Complete Care program offers patients with serious illnesses a high-touch, value-based care approach that includes a 24/7 line to call for help, social work support, nurse case management, as well as primary, urgent, palliative and hospital-level care in their homes.

One Complete Care patient had uncontrolled diabetes, very limited vision, was not taking medications as prescribed and had visited the ED seven times in the year before he joined Complete Care.

Since joining the program in 2017, he has not returned to the ED and he has dramatically improved glycemic control. Thanks to the interventions of his social worker and care coordinator, he now has a functioning cooling system in his home. And, with his diabetes under control, he was able to take his first vacation in years.

The program demonstrates the effectiveness of a value-based care model. From January 2015 through December 2018, Complete Care reduced the cost of care by 38 percent compared with predicted costs for similar patients, and 98 percent of patients said they would recommend the program.

Patient wishes guide the care that Complete Care patients receive. Among those who died during the first four years of the program, 86 percent died at home, according to their wishes.

Complete Care's innovative approach is gaining attention. It was recently featured in Health Affairs and in a case study by the Duke University Margolis Center for Health Policy and Leavitt Partners.

"Complete Care's wrap-around approach helps patients get the help they need when they need it, and for lower cost," explains Dr. Nancy Guinn, Medical Director, Presbyterian Healthcare at Home.

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