High-touch, High-capacity Patient Outreach
Registered Nurses personally reach out to all patients or the patient’s authorized representative within 24 hours of discharge to review and coach patients on their discharge instructions and care plan.
Personalized Co-Morbid Health Assessment
RNs create customized care paths incorporating ALL of a patient’s co-morbidities and key psycho-social health determinants.
Persistent Patient Engagement
Multiple methods of patient contact over 30 – 60 days regularly “check in” on patients, utilizing a patient’s customized care path.
Listen to a sampling of CareMaestro’s automated patient engagement function. Patient responses trigger health alerts based on established thresholds for specific care paths.
Efficient and Effective Alert Management
Health alerts validated and triaged by RNs identify patients at risk and the 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.