Bon Secours Next Generation Healthcare: Smart Tools Tell Care Transitions, Chronic Care Management Stories

Thursday, February 4th, 2016
This post was written by Patricia Donovan

Next Generation Healthcare smart tools facilitate Bon Secours care plans for care transitions, chronic care management and Medicare wellness visits.


A key component of chronic care management is a comprehensive plan of care—the “refrigerator copy” patients can refer to, explains Robert Fortini, PNP, chief clinical officer for Bon Secours medical Group (BSMG).

Today, using smart tools built into its electronic medical record, Bon Secours nurse navigators document twelve-point care plans for the 50 patients they have enrolled via Medicare’s year-old Chronic Care Management (CCM) codes—a number Fortini expects will double this month.

The CCM assessment tool also captures frequently forgotten issues such as depression, pain and sleep problems that can derail care, Fortini said in a recent webinar on Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning.

Bon Secours’ seventy nurse navigators, embedded in physician practices, also tap these point-and-click smart tools to document transitions of care for patients recently discharged from the hospital. This Transition of Care smart note tracks 17 different aspects of patient care, including risk of readmission and medication reconciliation, and includes a placeholder for an advance medical directive.

Similar tools are in use for Medicare’s three types of wellness visits, he added.

“I have been in this business a long time, and the documentation that navigators produce using these workflows is extraordinary,” Fortini noted. “This is purposeful design. It tells a story and you have something actionable at the conclusion of reading it.”

The smart tools are but one aspect of Bon Secours’ Next Generation Healthcare initiative, which Fortini defined as “population health meets total access.” Next Generation Healthcare fortifies the team-based medical home foundation Bon Secours introduced six years ago with expanded care access and technology, among other components the organization leverages to improve clinical outcomes and value-based reimbursement.

In the Next Generation Healthcare model, the primary care physician is the quarterback of care, with embedded nurse navigators doing the “heavy lifting” of enrolling at-risk patients into care management, building comprehensive care plans, and scheduling Medicare beneficiaries for annual wellness visits, Fortini explained.

Additionally, Bon Secours has broadened its care access menu to include employee clinics, fast care and urgent care sites, self-scheduling, and virtual visits for primary care. The organization expects to expand virtual visits to specialist consultations and behavioral health in the near future, and also envisions virtual case management visits, allowing nurse navigators to conduct real-time medication reconciliations with at-home patients.

To round out its Next Generation Healthcare continuum, Bon Secours is training a portion of nurse navigators as facilitators in a Virginia advance care planning initiative called “Honoring Choices,” with the goal of formalizing the placement of advance directives in patients’ records.

Investing in resources necessary to manage end-of-life effectively is a critical aspect of Bon Secours’ strategic initiative, Fortini concluded. “Forty percent of Medicare spend occurs in the last two years of life, and the pain, suffering, and emotional angst that occurs for patients and their families is incredible.”

Listen to an interview with Robert Fortini in which he describes how Bon Secours nurse navigators have won over solo practitioners.

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