Daunting questions swirled in the 79-year-old patient’s mind.
What will happen once I’m home? How will I know whether my recovery is pacing appropriately? When will things feel normal again?
He was anxious. He understood the risks and benefits of his upcoming cardiac procedure — his daughter and son-in-law, both physicians, helped him make sense of what was about to happen — but heart surgery has a way of surfacing the existential, no matter who you are.
Anxiety is common in patients preparing for cardiac surgery, Atrium Health Sanger Heart & Vascular Institute nurse navigator Maya Gantt explained. The best way she knows to address it: introduce patients to the Perfect Care initiative. That’s what she did with this patient. The program brought him preoperative education and a strong connection to his care team that persisted long after his discharge from the hospital.
“If you’ve got a question, you can call us, you can send us a message. I think knowing that eased his anxiety going into surgery and made it easier for him to come out,” Gantt said of the patient.
Better Care Beyond Hospital Walls
With Perfect Care, the provider-patient relationship isn’t limited by the hospital’s walls. People can heal from complex heart surgery at home, while maintaining crucial virtual connections with the clinicians they depend on.
In the past — and in many other hospitals today — postoperative cardiac patients were discharged with a vague understanding of what recovery entailed. Uncertainty could lead to preventable poor outcomes and readmissions for issues that could’ve been managed in the outpatient setting.
Perfect Care is the antidote to these problems. It runs on solutions like Carium, an end-to-end platform that provides a complete ecosystem for virtual care that ensures patients remain connected with their care teams — and that care teams remain connected with invaluable patient data, which improves clinical decision-making.
In short: patients receive — and providers deliver — comprehensive care at home.
Real Results
Five years after its implementation, the initiative is already driving impressive results for patients and the health system. Perfect Care is “truly priceless,” said Marsha Pruitt, a patient who underwent cardiac surgery and recovered at home with regular virtual guidance from her nurse navigator. Providers, meanwhile, report improved patient relationships and more reliable access to timely, relevant patient data that surfaces insights when and where they’re needed.
Perfect Care streamlines operations, benefiting patient outcomes and bottom lines. Thanks to the program, Atrium Health reduced 30-day readmissions by 40% and the average length of stay by a day. Clinical outcomes are equally impressive. The 30-day mortality rate for coronary artery bypass grafting is about 0.5% across the system, but that number is almost zero for patients in the virtual care program, Atrium Health Sanger Heart & Vascular Institute Chief of Cardiovascular Surgery, Dr. John Frederick, explained. The national average, according to the Society for Thoracic Surgery, is 2.5%.
“To offer a platform where we’re really never going to take our eyes off you, that’s really rewarding for us as providers, and I think it enhances our relationship with patients,” he said.
Nurse navigators agree. Before Perfect Care, finding time to connect with patients amid hectic hospital schedules was difficult, Gantt said. She worried that she was just going through the motions — and that patients were picking up on the disconnect.
With virtual visits, however, patients and providers build real relationships. Speaking about one patient in the program, Gantt said: “I know he has a daughter and a sweet, sweet wife who he’s been married to for a very long time, and that he loves walking outside. There are so many different things that I’ve learned about him and about his progress through this surgery.”
This rapport doesn’t just make for a more empathetic and satisfying working environment. Nurse navigators use important details about patients’ families, schedules, and moods to personalize their treatment and bolster the patient experience.
Patients tend to better understand complex information about their recovery when it’s tailored — and when they receive it at home, away from the bustle of the hospital, Gantt said. Patients in Perfect Care had fewer medication adherence issues, she noticed, in part because they learn about their prescriptions in a familiar environment.
Engagement among patients and care teams climbed because patients knew help was always a call or text message away. The impact of individual touchpoints was remarkable, advanced practice provider Yolanda Cousen said. She received a call from a woman who, during recovery, was worried she would die in her sleep. Should she head to the emergency department? After a chat with Cousen, her stress melted away. “I’ll see you next week,” the patient said before the call ended.
Tools for Accountability
As providers build stronger relationships with patients, biosensors collect actionable data that supports evidence-based decision-making. Collecting biometric data before remote monitoring meant nurse navigators had to rely on patients to manually record and report the information. “I felt like I was riding blind and that I couldn’t do everything I wanted to do to fix the problems,” Gantt said.
Now, data flows seamlessly among patients and providers.
Clinicians don’t need to sift through digital files in the electronic health record to make sense of it. Virtual care software automatically surfaces critical insights and signals thresholds, making it easier for the care team to know when interventions are required — and when they’re not.
A real-time view of patient data removes blind spots in the continuum of care. Is my patient responding to the change in medication? Has their blood pressure normalized? Is their surgical wound healing correctly? Clinicians can find answers in the application and use them to tailor treatment plans.
“It makes us more confident in clinical decision-making,” Cousen said. “We can just go on the computer and pull it up.”
Clinicians spend less time digging for relevant data and more time using that data to improve outcomes — a critical development in an era of pervasive burnout. The system also helps care teams map the recovery journey, establishing check-in dates and milestones everyone can work toward.
“I have all this information to help us make an informed decision of whether you need to go to the hospital or whether we think we can troubleshoot it on the outpatient side,” Cousen said.
Thanks to the Perfect Care program:
Average length of stay after cardiac surgery is down by a day
Readmissions have dropped by 40%
Providers spend less time on administrative tasks
A steady flow of biometric data facilitates postoperative care
Patient-provider relationships have strengthened
The patient experience has improved
Rural patients and those lacking support networks maintain important connections with their care teams
“We’re taking better care of people at a lower cost and keeping them out of the hospital,” Dr. Frederick said. “We’re really proud of that work.”
Patients enrolled in the Perfect Care initiative have reason to be proud, too. Nurse navigators notice that many take more active roles in their recovery, which helps outcomes and satisfaction. They enjoy sharing their metrics and often use monitoring devices after the 90-day observation period. And for patients who feel like they lost control over their lives after surgery, participating in monitoring helps restore autonomy.
“People take accountability for their health when we give them all the tools to do so,” said Gantt.
Beyond the Hospital Walls, Beyond Cardiac Care
Given Perfect Care’s results in cardiac surgery, Atrium Health expanded the program across its weight management, stroke, diabetes, and hypertension programs, and is exploring broader implementation.
“There is no question that it should be the standard going forward for patients who are undergoing complex surgical care, especially in the cardiovascular space,” Dr. Frederick said.
How much simpler would it be if it were the standard? One patient’s story provides a powerful illustration.
The man was at home recovering from cardiac surgery when his smartwatch alerted him to an abnormal heart rate. He told his wife, and together they called Cousen. She opened his records and determined that a slight change in his medication would help solve the problem. Just to be safe, she scheduled an outpatient visit to the clinic for further tests.
“His wife was so grateful,” Cousen said. “They understood that if we needed to send him to the emergency room, we would. But let’s try these other options first.”
No rushed emergency visit, no undue panic, and no reservations about which decision was the right one to make in a crucial moment. With Perfect Care, clinicians simplified a potentially complex situation, managed remotely in just a moment.
On top of these amazing results, Atrium Health's Perfect Care delivers an incredible patient experience. Hear directly from one of their patients, Marsha Pruitt, about her experience.
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