Readmission Defense for High Risk Patients
Nurse Wellness Calls
Nurse wellness calls are conducted routinely to engage and assess if patient’s needs are being met and report recent vitals and changes in symptoms. Patients are asked specific questions based on their health history and recent wellness calls. These patient engagements are utilized by patients to express concerns with their care, issues with durable medical equipment, medication questions, and any other issues impeding their recovery. The TeleCare wellness nurses are trained to collect as much information from the patient, provide best practice level advice, and expedite all care issues to the appropriate care provider for the patient.
Vitals & Symptoms Tracking
The OverSightMD platform and TeleCare wellness nurse calls make receiving symptoms, vital signs, and other changes in condition easy to acquire from patients and analyze for clinical teams. All data is incorporated into the patient’s personal health record and becomes actionable in the patient population management dashboards. Clinical teams can act on alerts and prioritize responses to meet each patient’s needs and review and share health analytics on individuals and populations with referral sources and other care providers.
Alert Based Interventions
Nurse triage is a proactive care model that is based on stratifying risks at the patient level so care providers can intervene and reduce preventable readmissions. Changes in vitals and symptoms are the leading cause of alerts from the TeleCare team to providers, however, there are many other problems that cause preventable readmissions. These include unanswered care requests, questions with care plans, DME issues, concerns about a family caregiver, financial issues, medication questions, mental health issues, PCP coordination, transportation coordination, and other social determinants. Care providers can improve their workforces care utilization and stay laser-focused on the highest risk patients while TeleCare nurse triage steps in and addresses social determinants of health and expedites the most important cases.
Analytics for Providers
The OverSightMD platform delivers real-time analytics for care providers for their entire population. Providers have the ability to run reports on alerts by the individual patient, by facility or region, and by their entire population. Patient reports are easily shareable with referral sources and primary care physicians and other specialists so everyone is on the same page regarding recent changes in a patient’s health. With on-demand analytics about current patient’s care at home, providers now have a proactive readmission defense strategy.