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.
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.
Gain visibility into referrals, admission, discharges and patient flow
Coordinate activities of multi-disciplinary teams
Identify and manage complex issues for patients that affect compliance
Engage patients frequently to encourage achievement of treatment goals
Decrease readmissions or the need for over-utlization such as ED visits for primary care services
Track source of referrals for pain management and identify educational opportunities for community providers
Track patients through a long-term treatment plan executed by primary care, pain management, behavioral health, or community addiction centers
Educate and communicate with patients to influence behavioral changes
Identify those who have behavioral health issues that must be addressed in conjunction with medical treatment
Establish appropriate follow-up with patient and community providers to track compliance and resolve issues
Identify and monitor both preparation and rehabilitation activities that improve outcomes