More Than Case Management: How Deacon Elevates Patient Care (Part 1)

Hospitals have long relied on in-house case management teams to guide patients through surgery and recovery. But with each case manager responsible for 30 to 40 patients or more—across a wide range of specialties—even the most dedicated teams can struggle to provide consistent, individualized attention. That leads to rushed transitions, communication breakdowns, and avoidable readmissions.

With CMS’s Transforming Episode Accountability Model (TEAM) on the horizon, the stakes are even higher. As hospitals take on risk for the full 30-day surgical episode, delivering the level of proactive, personalized support patients need becomes even more important.

In this two-part series, we’ll explore how Deacon’s episode-based model goes beyond traditional case management to improve outcomes for patients, providers, and hospitals. In Part 1, we focus on what makes our patient experience model different: real relationships, personalized support, and proactive engagement across the full care journey.

A Holistic Model for the Full Episode of Care

Unlike in-house teams that focus primarily on the inpatient stay, Deacon tracks the entire surgical episode—from pre-op through recovery. That includes transitions between every site of care, ensuring each patient receives the right level and amount of support at every step.

We’re with patients from their first pre-surgical interview through discharge and beyond. This isn’t longitudinal care management. It’s a defined, episode-based strategy that aligns directly with hospital goals under TEAM.

Our model brings together Patient Navigators (consistent, supportive points of contact throughout the episode) and Transition Navigators, who actively manage the post-acute space by monitoring progress, resolving issues, and guiding patients between care settings. Working in tandem, they form a proactive safety net that identifies high-risk patients early, intervenes before complications escalate, and prevents unnecessary hospitalizations or readmissions.

Personalized, Human-Centered Support

At the heart of our philosophy is consistent, personal engagement. We don’t just check boxes. We build relationships rooted in education, trust, continuity, accessibility, and customization.

Education

Surgical recovery can be overwhelming, especially when patients don’t fully understand their care plan. At Deacon, we prioritize education from the start. Our navigators break down complex medical terminology into plain language and make sure every patient knows what to expect, how to stay on track, and when to ask for help.

"Education is a huge piece of what we do,” says Kayla Cross, RN, a Deacon Patient Navigator. “I can hear it in a patient’s voice when they don’t really understand something. I can break down the ‘medical speak’ and help patients truly understand what’s ahead and offer comfort and guidance along the way."

By prioritizing education, we empower patients to participate in their own recovery.

Trust

Trust is essential every step of the healing journey. Deacon builds that trust through consistent, frequent communication and familiarity. Our navigators become a familiar voice, a reliable resource, and often, a confidant.

"Because we talk on a very routine schedule, I get to know the patients and their families,” Kayla notes. “This allows them to open up and ask questions they may be embarrassed to ask a doctor."

Patients who trust their care coordinators are more likely to raise concerns, follow care instructions, and prevent avoidable setbacks.

Continuity

Care doesn’t stop after leaving the hospital. Deacon supports patients throughout the entire 30-day episode of care with pre- and post-surgical communication that fills gaps and smooths transitions.

Before surgery, we take time to understand each patient’s clinical, social, and economic background. That allows us to flag risk factors (i.e. lack of transportation or limited caregiver support) that could delay recovery or lead to complications. After surgery, we continue to monitor and engage, ensuring patients receive the right level and amount of care.

We also proactively follow up on:

• Medication side effects
• Pain management
• Post-procedure concerns
• Recovery milestones and warning signs

This ongoing engagement allows us to intervene early, before minor issues become major ones.

Accessibility

Even the best care plan falls apart if patients don’t have someone to call when something goes wrong. That’s why Deacon provides 24/7 access to real, knowledgeable navigators—not a call center queue.

Whether it’s a late-night medication concern or a question about symptoms, patients can reach someone they know and trust.

"It really comforts patients to know they have a real person, a dedicated resource on their team that they can call 24/7 about any issues that arise—big or small,” Kayla explains. “Most patients are hesitant to call the doctor’s office, and will either ignore the problem or overreact and escalate to emergency care. Deacon prevents a lot of late-night anxiety and stress."

Round-the-clock support helps patients stay calm, informed, and confident in their recovery.

Customization

No two patients are alike, and their care plans shouldn’t be either. Deacon collaborates with providers to develop individualized plans tailored to each patient’s medical history, support network, and recovery goals.

We identify what services each patient will need after discharge before they even enter the operating room. That means no delays, no scrambling to arrange post-op care, and no unnecessary SNF stays or readmissions.

This tailored approach ensures patients receive the right services, in the right setting, at the right time.

Deacon’s philosophy is simple: consistent, personalized, human-centered care helps patients recover faster, avoid complications, and feel more confident every step of the way. By offering education, continuity, and 24/7 support, we create a better care experience.

In Part 2 of this series, we’ll shift focus to the operational impact of Deacon’s model: how we help hospital teams work more efficiently, coordinate care across settings, and improve performance under TEAM.