Inpatient Navigation Program
Rather than taking a one-size-fits-all approach to inpatient discharge follow-up, the Care Continuity program supports a smarter approach to prioritizing patient outreach and understanding the drivers of readmission risk.
Care Continuity Solution Framework
The Care Continuity Inpatient Navigation program combines AI prioritization models with expert navigation services and granular analytics to tackle the challenge of Inpatient Readmissions. We work closely with our health system partners to understand their current care transition team and design a program that layers in Care Continuity services to focus on specific patient populations. Using machine learning models, we better prioritize inpatient discharges and optimize the follow-up protocol and cadence for each risk segment. We outreach to these patients and engage them to understand potential risk factors, and escalate these problematic patients before they end up back in the hospital. Finally we create granular reports to highlight process challenges and opportunities to improve the program.
Technology Platform and Segmentation Models
Let's start with how the Care Continuity platform ingests data and uses our predictive models to prioritize patient outreach. We pull in clinical records for every inpatient discharge every day, and create a risk score that stratifies patients based on their likelihood and predicted timing of readmission. We then establish a follow-up protocol for each patient segment, with a different cadence or timeline for outreach and engagement. For certain DRGs and risk profiles we may contact the patient at 48 hours, 3 days and 10 days, while for another segment the cadence might be 72 hours, 5 days and 7 days. Rather than take a one-size-fits-all approach to navigation, the Care Continuity solution relies on a customized outreach timeline for each patient.
Patient Outreach and Navigation Services
In addition to our technology platform, the Care Continuity program also includes expert navigation staff to communicate with patients, schedule follow-up appointments, and monitor readmission risk factors. Our team of non-clinical concierges provides a white-glove service for key patient populations to improve post-discharge care plan compliance. This team focuses on 5 key questions related to readmission risk - including medication adherence, home health follow-up, DME concerns, follow-up appointments, and worsening symptoms. Based on this patient-reported information, the Care Continuity navigators escalate potential issues before they result in a return inpatient visit.
Virtual Screener and Digital Engagement
The Care Continuity team also uses digital tools to connect with patients and gather readmission risk concerns. We can send a text-based screener to collect information virtually, in a way that is more convenient for some patients. The content of this digital screener is tailored for each patient, and the information gathered is used for immediate escalation and prioritization of intervention strategies.
