Readmission Manager
| Prospective management of readmission risk against all patient populations to ensure focused care is provided post hospitalization, promote communication amongst providers, patients and other care givers. Discharge instructions with acute focus on the importance of medication administration and post discharge orders to ensure proper care coordination and transitions management. |  |
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Real time integration between all disparate EMR's by eMPI, clinical repositories, ADT for all patients across your health system
Discharge orders are monitored and real time clinical alerts are engaged when necessary care is not completed
Prospectively measure process change, physicians and care teams engagement, high risk care misses, and resource consumption
Discharge orders are monitored and real time clinical alerts are engaged when necessary care is not completed
Prospectively measure process change, physicians and care teams engagement, high risk care misses, and resource consumption
Identify Risk
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.
Patient Engagement
Activate patients and non-clinical care givers to improve communication, remove impediments to access clinical care givers. 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.
Care Coordination
Care coordinator workflow and care plans are initiated to monitor the trajectory of the patients' condition and to prevent them from future readmissions.