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The Net.Orange Readmission Management Solution allows hospitals to minimize exposure to potential readmission penalties from CMS and commercial payors. It allows hospital staff to reduce readmissions cost-effectively by leveraging owned physicians to provide the necessary post-discharge care for high-risk patients. High-risk patients are identified prior to discharge using predictive risk stratification algorithms and other guidelines.
Once identified, the Net.Orange solution orchestrates the care coordination process for patients using a consistent longitudinal care plan and transition checklists. The Net.Orange solution leverages all owned physician EMR systems as well as Hospital systems such as ADT, patient access, HIS, Discharge etc.
Provide clinical coordinators with tools to communicate custom-tailored "longitudinal care plans" to high risk patient with an easy-to-follow summary of key action steps (medications, appointment regimens, dietary needs, etc.). Use ongoing reminders for action steps to patients and care team members via e-mail, SMS or through portals to ensure that this plan gets executed.
Use historical Claims, Admission Discharge and Transfer (ADT) data and real-time clinical EMR/HIS data to proactively identify high-risk patients for enrollment in your facility's readmissions program. The predictive model incorporates the two best known industry risk weighting methodologies - the LACE (Length of Stay, Acuity of Admission, Comorbidity of Patient, and Emergency Department Use) approach, and the Johns Hopkins Adjusted Clinical Groups (ACG) case mix system - to identify patients with the highest likelihood of readmissions
Monitor all clinical transactions to determine compliance with the patient's custom-tailored longitudinal care plan and generate "gaps in care" alerts such as failure to fill a prescription, or cancellation of a scheduled follow-up visit or out-of-range clinical indicators (blood pressure, for example).
Care coordination dashboards prospectively identify cases with the highest risk of readmission to allow ambulatory case management to target necessary care for the patients with the greatest needs.
Activate patients and non-clinical care givers to improve communication and remove impediments to access clinical caregivers. Enable campaigns for chronic illnesses, introduce education, new services, providers, current problem list against care plan, medications, appointments and responsible providers to improve outcomes via monitored hand offs.