Transitional Care

Services Overview

Our patient engagement solutions are designed to substantially enhance your existing care transition services with industry-leading efficiency and effectiveness. We extend your reach into patients’ homes, coach patients through their care plans and alert the right care provider to health concerns that often drive emergent care visits and hospital re-admissions.
We partner with hospitals and post-acute care providers to fill their gaps in transitional care, specifically with respect to staffing constraints, patient risk stratification, effective intervention and actionable data.
Our patent pending solution addresses the individual care complexities of each patient by incorporating their disease states, chronic co-morbidities, psycho-social and other risk factors into a single assessment tool utilizing our five key solution elements.

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.