High-touch, High-capacity Patient Outreach
Registered Nurses personally reach out to the patient or the patient’s authorized representative within 24 hours of referral.
Personalized Co-Morbid Health Assessment
RNs create a customized care path incorporating ALL of a patient’s co-morbidities and key psycho-social health determinants. A personalized care plan is established from our initial assessment and review of patient history.
Persistent Patient Engagement
Friendly, automated calls are conducted to efficiently “check in” and listen for new or worsening symptoms, tracking leading indicators for intervention or recommendations for increased levels of care.
Efficient and Effective Alert Management
Health alerts validated and triaged by RNs identify patients at risk and the family or healthcare provider is notified by phone, email or text for timely and appropriate intervention.
Data Analysis and Reporting
Data collected from patient engagement generates actionable analytics and reports for transitional care improvements.