Transition Planning

Reduce readmission rates by proactively identifying high risk patients and monitoring and promoting their preventive care compliance.

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.

Identify At Risk Patients

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.

Best Practice Planning

Transition Planning enables an organization to perform discharge planning according to best practices for high-risk patients. Transition plans span inpatient and post-acute care settings and are shared with all members of the multi-disciplinary care team to enable safe discharges and improve care coordination among care team members.
  • Offers easy-to-follow checklists and action steps to increase patient participation and compliance
  • Gives care team ease of patient education information dissemination
  • Delivers best practice processes for patient discharge task lists and post-acute care appointments
  • Automates referrals among providers within a shared network

Coordinate & Optimize Outcomes

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.

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Key Features

Monitors clinical transactions to determine compliance with the organization's care plans
Uses best practice risk weighting methodologies such as the LACE (Length of Stay, Acuity of Admission, Comorbidity of Patient, and Emergency Department Use) Score