NEURO NET: A Continuum Care Model for Those with Catastrophic Brain and Spinal Cord Injury

Date of Recording: May 2018

The future of healthcare services, whether through bundled payments or accountable care organizations, is challenged to meet the triple aim of healthcare by providing good outcomes at a reasonable price and with satisfied consumers. NEURO-NET is an innovative program providing a continuum of care model designed for persons with catastrophic brain and spinal cord injury. We have long known the creation of a clinically integrated expert continuum of care for persons suffering catastrophic neurological injuries was needed. The vast majority of these patients are currently treated in separate and often fragmented systems that do not provide good clinical integration. The result can be poor outcomes resulting in higher costs and compromised health for these patients.

Four expert providers of catastrophic care joined forces through an innovation pilot to begin such a continuum. They are Santa Clara Valley Medical Center, Level 1 Trauma and Acute Inpatient Rehabilitation; CareMeridian, subacute care; Learning Services, a residential and day treatment facility for persons with brain injury; and Rehab Without Walls, a rehabilitative treatment in the home and community. NEURO-NET is a private/public partnership, combining healthcare providers with different cultures, payment systems, and outcomes methodologies. This presentation will include an overview of the coordination of care model managed by a nurse case manager. Admission and clinical protocols and procedures, a shared medical records system, and the outcomes measurement system will be presented. Preliminary data from the first 70 participants, including treatment gains, re-hospitalization, and consumer satisfaction and input, will be presented. Outcomes will be compared to those not participating in a continuum of care model and compared with national averages. We will discuss the challenges in designing and implementing such a model as well as future directions and replicability.