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Deaconess Care Integration – Clinical Integration Program: Care Transitions

Initiative Description

Deaconess Care Integration is committed to designing and implementing clinical programs that will result in achieving the ‘Three Part Aim’ objectives of providing better care for the individuals we serve, better health for the populations we care for, and doing so in a financially sustainable manner.

In support of these objectives, Deaconess Care Integration has created a clinically integrated program focused on our patients who are being discharged into a Post-Acute Setting. 

Deaconess Hospital, Deaconess Care Integration, & Participating Post-Acute Providers who agree to collaborate are eligible to participate in the program.  Current participating facilities are listed below:
  • Amber Manor Care Center (Petersburg)
  • Columbia Healthcare Center      
  • Fairfield Memorial Hospital (SNF facility)
  • Ferrell Hospital (swing beds)
  • Freelandville Community Home
  • Gibson General Hospital (SNF facility + swing beds)
  • Good Samaritan Home
  • Good Samaritan - Oakland City (ASC) 
  • Hamilton Pointe
  • Loogootee Nursing Center (Martin County)
  • Mt. Vernon Nursing & Rehab (ASC)
  • North Park Nursing Center (ASC)
  • Northwood Retirement Community (Jasper)
  • Park Terrace
  • Pine Haven Health & Rehabilitation Center
  • Premiere Healthcare of New Harmony
  • River Pointe Health Campus
  • Scenic Hills Care Center (Ferdinand)
  • Skilled Care Center (SCC) of Memorial Hospital
  • Solarbron
  • West River Health Campus
In recognition and support of the post-acute providers valuable contributions that ensure patients receive all appropriate care associated with the program, Deaconess Hospital will share an approved standard fee with providers who participate in the program and meet the readmission targets set forth in their contracts.  The Next Generation Model ACO Waiver shall be utilized for this arrangement.

Under this arrangement, clinicians will follow an approved clinical pathway that includes the following:
  • Clinical Protocols based on Best Practice
  • Patient-Centered, coordinated care throughout the continuum
  • A Deaconess Clinic Nurse Practitioner will be embedded at each participating post-acute provider
  • Standardization of care to support best practice and reduce unnecessary financial expenditures 
Better Experience of Care for Patients Better Health for Populations Reducing Health Care Expenditures
Improved communication and patient hand off between acute and post acute providers Decreased readmission rate Improved time to discharge to post-acute facility
Nurse Practitioner available at post acute facility Decreased post discharge ER utilization Reduced average length of stay at post acute provider
Care is patient-centered, less fragmentation & improved coordination Improved medication reconciliation and compliance
Clinical support to improve transition of care to post-acute setting Improved quality measures  
For specific questions regarding this Deaconess Care Integration program, please contact:
Shelly Evans

For general questions or additional information about Accountable Care Organizations, please visit The Medicare Site for ACO or call 1-800-MEDICARE (1-800-633-4227) TTY users should call 1-877-486-2048.
Deaconess Care Integration, LLC is open Monday – Friday 8AM to 5PM CST
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