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Support patients’ transitions from acute and post-acute care settings all the way home to increase shared savings. From identification within the acute setting to stabilization in the home, we track the patient's journey longitudinally and support recovery throughout the entire episode of care to drive appropriate utilization, reduce readmissions, and improve outcomes.
Stratify patients based on both episode and individual factors through a clinical model that addresses care needs, whether clinical or social. Our clinical and social care teams assess social determinants of health, follow up with treating physicians, educate patients on chronic conditions, and coordinate with local care teams.
Leverage our national network of providers and community-based services to prevent readmissions by giving patients continued support from our social care coordinators and, when appropriate, our nurses and nurse practitioners. Leveraging insights gained from managing $6.1B of BPCI-A spend in 2019, we develop comprehensive discharge and post-acute plans to improve savings and outcomes.
Focus on episodes and patients with the highest risk of rehospitalization to optimize patient recovery. We identify opportunities pre-discharge, then engage with patients within the first 72 hours at home. Registered nurse care coordinators are assigned to every episode, bringing in nurse practitioners, licensed pharmacists, or physicians as needed on high risk cases to collaborate with the patient’s primary care or specialty provider.
Get a better line of sight to operational, clinical, and patient experience metrics at both the patient and program level so you can implement swift interventions and/or recommend corrective actions.
Operational metrics include:
Clinical vs. social outreach rates
Completion rates for medication reviews
Percent of PCP follow-up visits scheduled
Outcomes reporting includes:
Readmission rate for transition to home and non-transition to home programs
Patient experience survey results