P&C Global Practices: AI, Data, & Cognitive Sciences, Organization & Human Capital, Strategy & Innovation
Engagement Overview: Transforming Post-Acute Care
Facing escalating Medicare penalties and growing clinical complexity, one of the nation’s largest nonprofit health systems—spanning 140+ hospitals and over 1,000 care sites—recognized a critical need to transform how it managed post-acute care for its most vulnerable patients. Known for its legacy of clinical excellence, the organization recognized that addressing persistent 30-day readmission rates, particularly among patients with chronic heart failure and post-surgical needs, was essential to elevating patient outcomes and value-based care performance.
Rather than relying on incremental fixes, the system embraced the need for a bold, integrated approach. It reframed persistent challenges such as rising readmission rates, medication non-adherence, and fragmented care coordination, not as obstacles, but as catalysts for enterprise-wide innovation. Leadership pivoted from reactive problem-solving to proactive, data-driven care strategies designed to empower clinical teams and streamline operations—without increasing administrative burden or disrupting frontline workflows.
In undertaking this transformation, the organization affirmed its commitment to sustainable, system-level change—prioritizing seamless care coordination and more effective recovery pathways for its most vulnerable populations.
Predictive Care for Proactive Patient Management
P&C Global brought together a cross-functional coalition of experts from its AI, Data & Cognitive Sciences, Digital Transformation, and Strategy & Innovation teams to architect and deliver a comprehensive, enterprise-ready solution.
- Predictive Risk Modeling: Using years of clinical and social determinant data, P&C Global built a machine learning model to flag patients at high risk of readmission. The algorithm was embedded into existing Electronic Health Record (EHR) workflows, enabling clinicians to act decisively at the point of discharge—without disrupting care routines.
- Personalized Outreach Protocols: High-risk patients triggered alerts that activated immediate outreach by nurse care managers or health coaches. Within 48 hours of discharge, patients received virtual check-ins, medication support, and symptom monitoring. Pharmacists and care coordinators used AI tools to prevent avoidable complications.
- Whole-Person Care Design: The platform also accounted for social risk factors—such as housing or food insecurity—linking patients to community resources through embedded care navigation. This multidisciplinary model aligned clinical care with behavioral and social support.
Execution at Scale: Integration, Adoption, and Impact
Implementing the solution across an extensive hospital network required careful orchestration. P&C Global addressed three primary challenges:
- Workflow Integration: Collaboration with the client’s IT team and EHR vendor enabled the seamless embedding of AI outputs into clinician-facing tools. Pilots tested usability and impact before full deployment. Alerts were delivered at the point of discharge planning, ensuring timely, actionable insights.
- Change Management: AI skepticism was met with education, transparency, and frontline engagement. Clinical teams received training on model functionality and relevance, while peer “champions” played a pivotal role in fostering adoption. A data governance structure reinforced ethical use and accountability.
- Process Redesign: To support evolving workflows, routine tasks were automated, and discharge protocols were co-developed to align with established clinical practices. Initial playbooks developed for pilot hospitals were then tailored to adapt to subsequent facilities involving slightly different processes and patient populations. Care team incentives were aligned with outcome-based metrics, including reduced readmissions and increased patient engagement.
Year-One Impact: Clinical Gains, Financial Returns
This initiative produced measurable outcomes across every dimension of enterprise healthcare performance:
- 15% Reduction in Readmissions: Among high-risk patients, 30-day readmissions dropped significantly amongst the targeted high-risk patient cohort, achieving five times the reductions typically achieved by conventional interventions. This translated into thousands of avoided hospitalizations and millions in cost savings.
- 20% Improvement in Medication Adherence: Enhanced digital engagement, pharmacist interventions, and simplified regimens helped patients fill and follow prescriptions more consistently, improving chronic condition management and lowering relapse risk.
- Over $25M in Net Annual Savings: Leaner workflows, fewer preventable admissions, and improved care coordination delivered a 5:1 return on investment—paying for the program within its first 12 months.
- 30% Boost in Care Team Productivity: AI-powered task prioritization enabled teams to manage significantly more patients without sacrificing quality—sharpening precision and freeing clinical capacity.
- 92% Patient Satisfaction: Discharged patients reported greater confidence in their care plans, leading to elevated satisfaction and deeper engagement across follow-up touchpoints.
- National Recognition & Strategic Momentum: Multiple hospitals earned CMS 5-star ratings—a distinction held by fewer than 10% of U.S. hospitals. The system also received “Digital Health Most Wired” honors and expanded partnerships with leading technology and AI innovators.
This was more than a success—it was a self-funding transformation that continues to generate exponential value, both financially and reputationally.
What Set This Program Apart
P&C Global’s integrated approach stood out in four key areas:
- Custom Analytics, Not One-Size-Fits-All: Tailored models delivered more accurate predictions than off-the-shelf tools, reducing false alarms and missed cases.
- Embedded Workflows, Not Side Tools: Risk insights appeared in EHRs at the moment of discharge, unlike peer tools that lived in separate systems and were often ignored.
- Cross-Functional Execution: Strategy, data science, and clinical operations worked hand-in-hand—versus siloed initiatives at peer institutions.
- Enterprise-Wide Scale: Standardized a unified but flexible model for proactive care across all 140+ sites, achieving consistency while respecting local variation.
Lasting Value Beyond Technology
This engagement was a catalyst for enterprise transformation—blending advanced analytics, clinical innovation, and cultural change. The client now leads with AI-powered precision care, operational resiliency, and elevated patient trust.
The program accelerated the client’s strategic shift toward value-based care. It improved patient safety, strengthened its brand, and opened doors to new partnerships and talent recruitment. In the words of the health system’s Chief Clinical Officer: “This initiative has fundamentally changed how we care for our most vulnerable patients. Instead of reacting to problems, we’re preventing them.”
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