Cordata Transitional Care

Managing patients in transition can be the most difficult kind of care coordination - as these patients are so easily lost from the system. Patients are constantly transitioning from inpatient discharge to home, inpatient to skilled nursing, inpatient to home health, outpatient discharge and more. The patient experience doesn’t end at the hospital exit. Patients need consistent guidance and support at every step of their healthcare journey. The Transitional Care team must manage education, care team communication, transportation, patient satisfaction, community follow-up, outreach, medication adherence, monitoring to prevent re-admission or adverse events and tracking.

Why Cordata

Cordata Transitional Care solution helps transitional care teams coordinate & manage patients transitioning from one level of care to another...from the complexities of inpatient to SNF to the simple outpatient discharge pairing of a patient with a PCMH or primary care providers. The Cordata platform supports the beginning of care with a simple admission or a care plan kickoff, to deep disease-based care planning, through to discharge-focused care management and best-practice outcomes for value-based care reporting.

  • Simple-to-use assessment tools assist care coordinators with gathering distress and care benchmarks at discharge or other pivotal events.
  • A specialty-driven patient record includes all prior history and treatments as part of a longitudinal view that includes the current care plan and future events.
  • The cloud-based architecture makes information available to all clinicians on the care team, regardless of their local EMR.
  • For long term care management post-admission, Cordata's patient engagement solution offers continual omni-channel communication with patients to ensure high satisfaction, on compliance with ongoing medication adherence, management of symptoms, care plan communication, appointment reminders, ongoing education and much more.

Using Cordata Transitional Care, health care organizations can:

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  • 1

    Gain visibility into referrals, admission, discharges and patient flow

  • 2

    Coordinate activities of multi-disciplinary teams

  • 3

    Identify and manage complex issues for patients that affect compliance

  • 4

    Engage patients frequently to encourage achievement of treatment goals

  • 5

    Decrease readmissions or the need for over-utlization such as ED visits for primary care services

Product Features

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Referral Tracking

Track source of referrals for pain management and identify educational opportunities for community providers

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Care Plan

Track patients through a long-term treatment plan executed by primary care, pain management, behavioral health, or community addiction centers

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Patient Engagement

Educate and communicate with patients to influence behavioral changes

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Custom Intake

Identify those who have behavioral health issues that must be addressed in conjunction with medical treatment

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Coordination Reminders

Establish appropriate follow-up with patient and community providers to track compliance and resolve issues

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Outcome

Identify and monitor both preparation and rehabilitation activities that improve outcomes

Increase Patients. Decrease Costs. Increase Revenue.

Improve your business results and clinical outcomes today.

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