Successful Transitions Home
Whether going home after a hospital stay, outpatient procedure, or emergency department visit, Smart-ER™ organizes the work flow for the callback staff in performing re-contact phone calls.
Checking on a patient's well being and compliance with medications and follow-up prevents readmissions, and supports BOOST (SHM), RED (AHRQ), and Care Transitions efforts. In fact, telephone follow-up reduced costs by 84% in CHF patients.
Accountable care organizations appeal to payers when they manage medically-fragile patients using a nurse coach model with diagnosis-specific risk indicators.