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Success Stories: Safely transitioning patients from Hospital-to-Home

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We sat down with one of our hospital case managers to better understand how enTouch helps him on a day-to-day basis. What was the biggest thing he said? Communication...it’s a hot topic in healthcare and, in an industry that relies heavily on fax machines, it’s not always easy. Here’s a quick patient story that clearly outlines how increased, real-time communication can have a direct impact on patient care and outcomes. 


Tell us how you use enTouch

We’ve been using enTouch with a portion of our partners for about a year. My job is to be the advocate for patients throughout the continuum of care, so enTouch helps me communicate clearly and quickly with care teams and optimize care transitions to either Skilled Nursing Facilities (SNFs) or directly home.

Can you give us an example?

We recently had a patient discharged directly home after knee replacement surgery with continued care from a home health agency starting the next day. After the initial visit, the home health case manager let me know via enTouch that the patient did not have a good transition home and was not acclimating well to being home directly after the hospitalization. The patient’s family felt it necessary to go to the emergency room, however the immediate action from the care team allowed me to follow up with the patient and discuss alternate options such as admission to a SNF. I invited one of our partner SNF providers to enTouch and gave them a brief update on the patient’s status, including current concerns for the ability to care for himself at home. With this quick update and access to our EMR system to review the recent records, the SNF was able to accept admission within an hour.

What worked?

While discharging home had seemed to be the best option, situations can change quickly. The increased and expedited communication helped us to avoid a costly readmission. More importantly, we were able to get the patient an appropriate level of care where he felt safer and better supported. 

Meet David

David is a BPCI Case Manager at Centegra Health System in Illinois. Centegra Health System brings innovative, compassionate medical treatment to the people of McHenry and Kane counties. The health system includes hospitals in McHenry, Huntley and Woodstock, immediate care centers, multiple Centegra Physician Care locations throughout the region, Centegra Sage Cancer Center, Centegra Health Bridge Fitness Centers in Huntley and Crystal Lake, and Centegra Gavers Breast Center in Crystal Lake.

To learn more about how Centegra has drastically reduced their costs using enTouch, contact us here.  

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Posted on Nov 7, 2017 11:01:52 AM by Prepared Health in Home Health, in readmissions, in HHC, in entouch, in care coordination, in Hospitals, in Health Plans, in Case Management

Prepared Health

Written by Prepared Health

The Prepared Health mobile care coordination platform creates a virtual experience for the entire healthcare team so they can communicate with each other--and help patients and families stay connected--even though they may not physically be under the same roof. The platform helps professional and family caregivers capture rich and timely data from the home, and includes DINA, an AI technology that acts as a virtual care coordinator by identifying unmet needs and recommending clinical assessments. Today, Prepared Health is connected to 750 sites across the U.S. with demonstrated outcomes that dramatically decrease avoidable readmission rates, reduce unnecessary ER visits, and boost caregiver productivity. Based in Chicago, the award-winning platform has been recognized for its easy-to-use, innovative user experience. For more information, visit www.preparedhealth.com.