What We Do

Our solutions bridge the challenging gaps for managing in-home post-acute and sub-acute patient care (transitional care) and longer-term care (chronic care), specifically with respect to patient risk stratification, resource constraints, effective intervention and actionable information for improving care.

Patient Risk Stratification

• Are all high-risk patients contacted?
• Which patients should be prioritized?
• Are co-morbidities considered?

Resource Constraints

• Can all patients be engaged within 24 hours of referral?
• Can all patients be contacted for continuous and consistent follow-up?

Effective Intervention

• When is the right time to intervene?
• What is the most appropriate intervention?

Lack of Actionable Data

• Is there enough actionable data to enhance and support process improvements?
• Does the data provide meaningful information to improve patient outcomes?
A suite of patient centered care programs is tailored to integrate with and support your existing patient outreach. We cost effectively extend your reach into patients’ homes, coach patients through their care plans and alert the appropriate care provider to health concerns that often drive more expensive care including emergent care visits and hospital admissions or readmissions.
• Reducing avoidable readmissions
• Increasing patient satisfaction and loyalty
• Improving patient outcomes
• Optimizing staff efficiency and effectiveness
• Facilitating CMS regulation compliance
• Improving CMS episode of care outcomes
• Increasing Star ratings
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 unified health status assessment for ongoing patient engagement.

Transitional Care

Our patient engagement solutions are designed to substantially enhance your existing care transition services with industry-leading efficiency and effectiveness. We help hospitals and post-acute care providers fill their gaps in transitional care, specifically with respect to staffing constraints, patient risk stratification, effective intervention and actionable data. We improve care transitions utilizing our five key solution elements.

Chronic Care

Our chronic care management solution helps people stay healthier at home. It is designed to cost effectively engage patients in their homes with continuous and consistent follow up. We help Health Plans and Physician Medical Groups improve outcomes and reduce costs utilizing our five key solution elements.