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.
Up to 45% of Medicare Advantage hospital readmissions are avoidable with post-acute care interventions.1
Program Results
- 95% of medication reconciliations completed were within 30 days of discharge2
- 92% of members followed up with their Primary Care Provider within 30 days post-discharge2
- Up to 20% annual savings on readmissions spend2
Our Approach
CareCentrix provides the 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 and care plan which anticipates the services required to close gaps in care. Our Care Transition Team, including physicians, nurses, and member advocates, supports members’ transition home by:
- Reviewing the personalized care plans
- Addressing questions and education on follow-up care
- Monitoring the recovery progress
- Coordinating community support needs, such as meals, transportation, emotional or psychological support
The CareCentrix Value
CareCentrix helps ensure a successful transition to the home and addresses gaps in care to reduce unnecessary hospital readmissions and costs for health plans.
Our Readmissions Management solution leverages HomeBridge®, our proprietary care coordination platform, which provides a single platform to document and access information offering complete transparency for providers and the care team. Our platform seamlessly integrates with health plans’ systems and includes automated data feeds, clinical notes, and authorizations to manage care effectively.
An independent study conducted by Avalere Health evaluated the impact of the CareCentrix post-acute care program for Medicare Advantage populations and reported:
- Up to 20% savings on readmissions spend2