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Care coordination:
clinical & social

Managing holistic care across
home, community, and post-acute settings

 

Signify Health coordinates and delivers clinical, social, and behavioral health services during every point of the patient journey. From helping post-discharge patients safely transition to the next site of care, to supporting their whole-health needs once they’ve arrived at home, we enable services to be delivered quickly, reliably, and in coordination with all interventions.

Transition to home

 

Signify Health leverages our vast network of field-based clinicians and community-based services to help patients transition home from hospital or acute-care facilities. Used as a standalone offering, or to amplify your existing episodes-of-care program, we enable communication and collaboration across all members participating in a patient’s care.

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Smooth and informed discharge

Ensures the hospital discharge process is smooth and the patient is compliant with discharge instructions.

 

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Complete plan of care

Coordinates and secures a complete plan of care that includes clinical, social, and behavioral health interventions.

 

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Non-medical health needs

Uncovers and addresses social determinants of health that can increase readmission risk.

 

Social care coordination

 

Social determinants of health (SDOH) put outcomes at risk—and they can’t be solved with a simple referral. At Signify Health, our integrated SDOH solution breaks down the traditional barriers between clinical and community care, allowing healthcare and social service agencies to work collaboratively within a privacy-enabled model. Finally, you can connect upstream social interventions to patient outcomes and plan performance goals.

 
Segmentation & risk scores

Identifies social risk with predictive SDOH analytics, HRE data, and assessments.

 
Coordinated social care networks

Combines our nationwide network of community- and faith-based organizations with a specialized team of social care coordinators.

 
Privacy-enabled collaboration

Facilitates the safe and compliant exchange of information across mission-driven organizations and the healthcare ecosystem.

 
Longitudinal records

Documents clinical and social information on real-time longitudinal records for a complete picture of each person’s health status.

 
Proven outcomes

Only Signify Health’s privacy-enabled framework connect upstream social interventions to patient outcomes and plan performance goals.

Complex care management

 

We comprehensively manage the clinical and social needs of patients with chronic conditions—replacing fragmented care with a multi-disciplinary approach. We provide care wherever it’s most convenient for patients and their families: from resident and palliative care facilities to their homes.

Real time patient Identification

Patient segmentation

Identifies and stratifies members by risk

Personalized Care

Personalized care

Enables providers to sit face-to-face with member for an enhanced experience

Education as Prevention

Education as prevention

Focuses on follow-up behavior and education as preventative care

Social Determinants

Non-medical health needs

Uncovers social determinants of health such as spousal support or food insecurity

Medication

Medication review

Works with members to review medications and increase adherence

Health Outcomes

21%

Reduction in readmissions per 1,000

 

Operational Efficiency

31%

Reduction in ER visits per 1,000

 

Financial Performance

26%

Improvement in Medical cost excluding SNF PMPM*

Health Outcomes

30%

Reduction in readmissions for safety net population

 

Financial Performance

46%

Reduction in post-acute care spend for high-utilizers

 

Operational Efficiency

2.5x

Increase in productivity from outsourcing social care plans

Want to explore how we can
drive better outcomes together?

Schedule a call or demo today to learn more.

Contact Us