MDnetSolutions Care Transition System | Page 2

Throughout this document you’ ll discover how CTS works, the research that supports our model, the ease of adoption and integration into any clinical setting and why this platform is so meaningful to patients and valuable to providers.
The Imperative for Intervention
Time and again, studies have shown that patients with complex care needs are at high risk when they transition from one care setting to another. Compared to typical patients, high-risk patients are less likely to comply with elements of their care plan, and more likely to require emergency care or be readmitted to the hospital. They also are more costly to treat.
On the other hand, patients who are engaged with their care team tend to have better outcomes. They follow their discharge plan more carefully and are more inclined to ask questions or report problems.
Caregivers who maintain a high level of engagement with their patients through the entire continuum of care are better equipped to identify when their patient is struggling or experiencing complications. Early intervention can reduce readmissions, control costs, prevent penalties – and save lives.
The Solution is Here, and It’ s Simple
Chances are, you’ re keenly aware of the need to engage high-risk patients following hospital discharge, but you’ ve had limited means to provide the type of frequent and thorough outreach necessary to make sure your patients are symptom-free and complying with their home care plans.
Now, CTS can monitor your patients for you. Not only does our IVR system check-in with patients 15 times during their first 30 days at home, it also identifies“ red flags” captured during the call and alerts the care team in real time.
Here’ s how it works:
1) When patients are discharged, they provide their home or mobile phone number and choose the time of day or night they prefer to be contacted.
2) Our CTS program calls patients at their chosen time and asks a series of tailored questions about their health and recovery. Patients respond by speaking or pressing the appropriate keys. Each call takes no more than four minutes.
3) The first five days following discharge, patients receive a daily check-in call. On days six through sixteen, they receive a call every other day. From day 17 to day 30, they are contacted every third day.
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