Connecting Patients to Proactive Care
Care Navigator Calls
Patients unable to self report through our wellness tracking app can update their care navigator 24/7. Care navigators are available between 9AM and 6PM PST Monday through Friday to assist patients. Patients are asked specific questions based on their health history and recent updates. The TeleCare tracking system leverages trained professionals to speak directly with patients to improve adoption by patients of all capabilities and improve the value of alerts shared with care providers. TeleCare care teams are trained to collect as much information from the patient and expedite all care issues to the appropriate care provider for the patient.
Vitals & Symptoms Tracking
TeleCare vitals and symptoms tracking delivers analytics for clinical teams. All data collected from the care navigator calls and web app self-reported information is incorporated into the patient’s personal health record. This data becomes actionable in the patient population management dashboards with real-time patient risk stratification. 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
Patient Wellness Tracking is a proactive care model based on real-time updates from patients 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 tracks issues, addresses social determinants of health, and expedites the most important cases.
Analytics for Providers
The OverSightMD platform delivers real-time on demand 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 ondemand analytics about current patient’s care at home, providers now have a proactive readmission defense strategy.