The Challenge
Simplify the journey from hospital to home
The journey from hospital to home can be complex and often highly fragmented. With the right support in place, 80% of members sent to a post-acute facility could recover at home with the same or better outcomes.1 A simplified path home should include discharge plans that identify the right provider, address the whole person, including non-clinical support, effectively engage members, coordinate care services, and connect information back to providers.
Program Results
- $6 PMPM in annual savings3
- 25% reduction in total SNF days4
- 21 states with in-market clinical support teams3
Prefer receiving care in the home5
Our Approach
Our Site Optimization solution ensures that members who can safely go home after a hospital stay, do go home with the right services. For members who require a transition to a post-acute facility, we identify the right provider and proactively engage facilities to ensure optimal length of stay and recovery plan progress for the duration of their stay.
The journey home from the hospital begins with our HomeFirst Analytics and clinical in-market engagement teams. Alongside our analytics, clinical in-market engagement teams collaborate with providers and advocate for members from the time they’re admitted into the hospital through discharge. They work with the hospital to understand the member’s clinical and non-clinical needs and ensure the right home services are in place. By doing so, we set members up for success in meeting their care goals and reduce the number of unnecessary post-acute stays and unnecessary readmissions. We provide hospital and post-acute care discharge managers with recommendations for the optimal site-of-care and a transition plan for each member’s post-acute care.
For members appropriate to transition to a PAC facility, we engage on day one to ensure facility alignment with outcome goals and establish measurable milestones. By doing so, we can optimize the length of stay and ensure appropriate discharge home.
The CareCentrix Value
With the appropriate support, coordination, and real-time data, CareCentrix can reduce unnecessary PAC stays and increases positive outcomes for members who follow our discharge recommendations.
Our Site Optimization 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 teams to manage hospital discharge. Our platform seamlessly integrates with health plans’ systems and includes automated data feeds, clinical notes, and authorizations to manage care effectively.
CareCentrix has a robust implementation process that begins with a dedicated and experienced team, focused on flawless execution to get the Site Optimization program up and running.3