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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