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Care Transition

A Patient Just Got Out Of The Hospital. Let’s Keep It That Way.

Transition Care Services = Safe Uneventful Recovery At Home = Reduced hospital readmission's.
Care Transition

Our Care Transition Program is structured to provide clinical support to patients after discharge from the hospital and thereby reduce readmission risk and overall healthcare costs. Active Wellness Care Transition Program is available as a stand-alone solution or as an extension of a provider’s care. Join the Managed Care solution to have an integrated healing experience. Our Transitions Care service covers outbound live contact of Active Wellness staff, with patients, provide a 24/7 in-bound nurse call line, coupled with consultations, electronic messaging, and proactive responses to alerts generated through remote biometric monitoring devices and integration of patient data. Scheduled follow-up calls and collaborative clinical assessments ensure compliance with care plans and modifications that may be desirable. We engage, enable and empower patients to become actively involved in and participate in their personal health-care decisions.

Key features cover ensuring patient understanding of their disease process and projected outcomes, medication reconciliation, virtual and physical scheduling physician follow-up appointments and educating patients on symptoms of concern.

What Our Care Transitions Program Includes?

Best of Both Worlds: A plan of care based upon the discharging institution and use of our best practices for remote care.

Engaged Patient: Ensuring the patient understands plan of care

Medication Therapy Management: Medication reconciliation and management and effectiveness and efficiency analysis.

Round the Clock Care: 24/7 nurse triage services available for any symptomatic patient calls outside dedicated case management coverage hours

Interactive & Intelligent: Proactive Real time alerts, escalations of gaps in care and early warning signs to the care team. Educational messages and special task reminders.

Virtual Home Visits: Talk to your care team via Audio calls. Have your Care team visit you through video calls.

Flexible Care Team Connect: Connect with the care team via IMs, Emails. Message your care team, fix follow up appointments from the comfort of your home. Have Health Service Specialists help you achieve your health goals.

Care Escalation: Physician escalation 24/7 (optional).

Encounter Documentation: Encounter documentation builds a continuum of care record for Care Team physician review and for specialist review. This forms a part of the PHR of the patient.

Biometric Monitoring: Remote biometric monitoring, including alert management services (optional: Active Wellness can support/supply procurement and management services of medical monitoring devices through its partners)

Proven Results

The home care program involving daily interaction with patients and reduces the cost associated with home visits. Care Transitions Programs have shown consistently that a reduction of readmission rates can be achieved for conditions like congestive heart failure, pneumonia and heart attacks by at least 10%-20%. Our proactive engagement and follow-up programs provide for the post-discharge follow-up call and physician visit. Active Wellness nurse support programs have been calculated to show an ROI of more than 200%.

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