Care Team Connect Reduces Preventable Readmissions
It is a startling fact: currently, 1 in 5 Medicare patients in the U.S. is readmitted to the hospital within 30 days of discharge. This costly drain on the healthcare system has prompted the Centers for Medicare and Medicaid Services (CMS) to generate $26 billion in cost savings over the next decade by cutting preventable readmission payments.
The news of potential cuts has prompted the healthcare industry to seek out solutions to reduce preventable readmissions.
As hospitals and care management organizations focus their teams on myriad efforts to help patients transition more effectively, they realize the need for creating care transition coaches and care network partners to help teach patients self-management skills and compensate for those unable to independently demonstrate self-efficacy. Unfortunately, with the creation of these new roles and teams comes new silos of care providers and documentation – often in unshared excel or soft charts – with no closed loop communication about completion of critical action items.
As these pilot programs achieve early success, they often set their sights on program growth. However, with paper-based models cross-coverage and scalability is sacrificed, as is leadership’s visibility into the effort required or the outcomes achieved.
Care Team Connect’s secure, web-based platform powers your readmission program to consistently deliver the right care to the right patient at the right time, resulting in a sophisticated and efficient care coordination network. Whether you have one transition coach or a nurse navigator, social workers and/or a pharmacist team, only Care Team Connect helps you close the identified gaps in a resource-efficient and scalable way.
By using Care Team Connect’s technology platform, the care teams involved are able to coordinate efforts to improve patient outcomes and reduce preventable readmissions. Our intuitive, scalable solution helps you manage targeted patient populations by risk, payer, diagnosis and care setting, generating individualized care plans that drive transparency and accountability across the care continuum.
Care mangers will have the workflow tools to turn data and protocols into coordinated care and executives will have reporting to determine program effectiveness and outcomes.
Power Your Care Network
Care Team Connect provides you with the power to deliver consistent and efficient care to reduce preventable readmissions. CTC will insure you create the appropriate program for optimal resource utilization while enabling a scalable model to address additional patients quickly as readmission penalties take effect.
With Care Team Connect, you will:
- Assess patient risk and apply an automatically generated care plan based on patient-specific information
- Identify patients appropriate for self-management coaching and understand key gaps to be addressed for patients
- Ensure medication fulfillment and compliance
- Communicate and/or facilitate post-discharge appointment requirements
- Educate patients on conditions, symptoms and medications
- Coordinate required community resources
- Gain visibility of post-acute provider compliance with post-discharge best practices
- Engage and activate the family support system