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Transition Planning empowers healthcare organizations to reduce preventable readmissions by helping to identify at-risk patients, enhance the management of discharge processing, and effectively transition the patient to non-acute care settings.
Health systems stand to significantly reduce the likelihood of readmissions if there are early outreach and intervention programs for chronic, high risk patient groups - but first those individuals must be identified out of whole population groups. Transition Planning uses historical data and Admission Discharge and Transfer (ADT) data to score and classify patients with the highest probability of readmission.
Transition planning dovetails into the Care Management activities that need to be performed for high risk patients in multiple post-acute care settings. The transition plans and post-acute care plans are accessible to each stakeholder along the care continuum via a standards-based technology platform that connects relevant clinical and operational data from both hospital and post-acute care settings. The creation of a virtually integrated delivery network helps anyone engaged in the patient's care to track progress and share statuses to minimize the financial risk of chronic patient readmission.