Our AfterCare Tracking service is designed to provide oversight of the care continuum for discharging patients from hospitals and skilled nursing facilities.
Our team completes a comprehensive risk assessment on every patient that is receiving oversight. We analyze all vitals and nursing notes to build baselines for every patient to evaluate changes during aftercare. Our risk profile is unique in its focus on social determinants and any special circumstances making following the care plan at home away from care providers difficult. The aftercare success or failure is often determined by all of the existential factors that can contribute to readmissions. We are experts in identifying the environmental, social, and personal characteristics and making sense of these social determinants and how they impact some patients to be at a higher risk for readmission.
Aftercare Supervised by OverSightMD Team
Many patients going home still face serious complex health issues that only a highly experienced and connected team can support. All patients receive diligent reviews by their physician team through regularly scheduled wellness assessments from the OverSightMD support care team. OverSightMD interprets all assessments and directs our care team representatives to identify acute related concerns early and verify that the appropriate care plans are in place for the patient by their Primary Care Physician and ancillary care providers.
Primary Care Physician & Care Team Updates
Positive health outcomes combined with high patient satisfaction require every care provider to be on the same page so patients focus on healing not navigating the healthcare system. Our care teams and platform keep all providers connected so no one is left out of the loop as the patients condition changes or care plans evolve. We will inform all care providers and stakeholders with actionable hand-offs inside our platform and provide real-time updates and analysis to maintain open and transparent communication.
Care Coordination and Advocacy Support
We take patient satisfaction seriously. Our care team representatives make sure that no patient is left to fend for themselves trying to get medical appointments or care providers to take a health concern seriously. We have trained professionals that are available to comfort patients in their time of need and directly assist them with navigating the healthcare system during the critical at-home recovery period. If a care provider is not able to accommodate the needs of a high-risk patient, then we will advocate for the patient to obtain the care that is needed.
Transparent communication across the entire care continuum is our focus. We have extensive data sharing capabilities to easily collect patient information from any source to provide continuous oversight support. We can train any caregiver or care provider within 15 minutes on how to report patient symptoms, vitals, and notes back to OverSightMD in real-time, while at the point of care. This real-time exchange of information about a patients’ status is unprecedented and allows our team to be virtually in the room with the home healthcare nurse or caregiver to provide decision support and expedite primary care physician involvement if needed. In addition, all patient activities are documented and shared with all providers and stakeholders in real-time which eliminates the long delays in information being shared.
Clinical Decision Support
The success of a patients’ aftercare recovery is dependent on the quality of the hand-off at the time of discharge from acute or post-acute care. We have extensive protocols in place to start aftercare preparations and coordination at the time of admission to a post-acute facility or at the time of hospital discharge for a patient going directly home. Risk stratification, patient vitals analytics, nursing notes, and observation reviews allow us to develop a clear plan of action. Our care team and licensed clinicians continue to closely track each patient and aggregate all critical information that is made easily available and communicated to ancillary care providers during the discharge planning process, the transition of care, and for the remaining time of the bundle period.
Care Plan Oversight & Management
We are dedicated to ensuring quality of care for all patients. When patients, family members, and caregivers execute the care plan that has been designed by their primary care physician, successful outcomes are achievable and readmissions are avoidable. We engage with patients and caregivers on a regular basis to complete a wellness assessment to determine if the patient is recovering on schedule or additional support is needed. If our assessment uncovers an early sign of an acute problem with a patient, we notify the patients’ primary care physician or home healthcare provider to quickly address the issue. We continue to engage with the patient to verify that a clear care plan is in motion and responsive care is being provided. We will continue to coordinate care for the patient until the acute issue is resolved and the patient is stable.