Readmissions Management
receive necessary follow-up care—both clinical and non-clinical—to help
reduce unnecessary hospital readmissions.
The Challenge
Identify and close gaps in care that occur during transitions
The transition of care from in-patient facility to home is a critical point in the patient journey, and failure to address gaps in care can lead to unnecessary post-acute care stays and/or unnecessary hospital readmissions. It is estimated that up to 45% of Medicare Advantage hospital readmissions are avoidable with post acute care interventions.1
Successfully managing the transition of care for members requires the ability to assess risks and address clinical and non-clinical needs with continuous engagement and monitoring to follow through on care plans and recovery.
Discover how optimizing the transition of care home can improve savings.
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Program Results
- 97% of medication reconciliations completed were within 30 days of discharge3
- 92% of members followed up with their Primary Care Provider within 30 days post-discharge2
- Up to 10% annual savings on readmissions spend3
Our Approach
CareCentrix provides analytics, member engagement, and care coordination to close gaps in care that may occur during transitions of care.
Through HomeFirst Analytics, each member receives a personalized risk assessment that anticipates the services required to close gaps in care. Our interdisciplinary Care Transition Team, including physicians, nurses, and member advocates, supports members’ transition home by:
- Reviewing the personalized risk assessments
- Addressing questions and education on follow-up care
- Monitoring the recovery progress
- Coordinating community support needs, such as meals, transportation, emotional or psychological support
