Reducing Hospital Readmissions Part 2: Monitoring the Patient Care Transition Journey

Mark Bernstein
September 21, 2018

Monitoring the Patient Care Transition Journey

Reducing Hospital Readmissions Part 2:

Ed KirchmierMonitoring and managing the care provided to patients discharged from the hospital with a care transition system can help to reduce the potential harm, unnecessary expense and potential financial penalties associated with re-hospitalizing a patient. In our previous post, we shared how to use data the right way to easily and effectively reduce readmissions.

In this post, we’ll recap the information presented by Ed Kirchmier, VP of Global Delivery at AAJ Technologies, on a Care Transition System that AAJ Technologies developed.

Four Key Elements of the Patient Care Transition Journey

As an IT provider of solutions and working with our customers, one of the solutions that we created is a Care Transition System platform. So, along with several customers who provide care transition and coaching services, we created a web and mobile platform to guide and manage patients in their transition from one care setting to the next. This helps prevent a vast majority of hospital readmissions.

Our solution addressed four key care transition elements:

  1. PCP specialist follow-up
  2. Medication management
  3. Nutrition management
  4. Home and community-based services


Managing Transitions Between Patient Care Settings

With the Care Transition System in place, health care providers follow a specific set of guidelines with their patients to properly educate them on their upcoming transition process. Once this is complete, a series of appointments and tasks are entered into the system to ensure the entire follow-up process is executed and information is not lost between care givers.

The cadence of these appointments and calls is configurable to the needs of the care coordinator. For example, the cadence to include a coaching assessment session one to two days before discharge, a post-discharge home facility visit within 48 to 72 hours, and many follow-on calls on days 2, 7, 14, 2, 30, and 45 days after discharge. AAJ Technologies designed a simple user interface to ensure the Care Transition System is easy to use; while providing a complete transparency for all steps in the care transition process.

Workflows, Reminder, & Notifications Assist Patient Care Transition

A case is at the center of this system and that case is created to govern all of these activities for the care coordinators, their patient touch points and external orders for service. And there’s workflows, reminders and notifications to ensure these activities are followed. The Care Transition System platform will evolve to integrate with upstream systems like EMR’s, eligibility systems and downstream systems like practice management systems, pharmacy systems for prescriptions, and order management systems for those home and community services in order to fully automate the process.

Users begin by giving the patient an assessment of their health and information on their current care plan during the pre-discharge phase. Based on the answers to these questions, the platform triggers certain events or ‘red flags.’ These red flags are then transitioned through the workflow that’s designed to address the problems that were raised during the assessment. For example, if a patient who is about to be discharged from a hospital indicates they don’t have a future PCP appointment already scheduled, the system workflow triggers a series of actions. Those actions may include setting the appointment for the patient, scheduling alerts and reminders for both the patient and the care coordinator as the appointment becomes closer and ordering a prescription refill.

Reducing Readmissions by Monitoring the Patient Care Transition Journey

Reducing readmissions with BI and Analytics Webinar AAJ Technologies Care Transition Image 2With the implementation of the platform, care transition service providers have greatly reduced hospital readmissions because they monitor the appointments and home services for the patient along their journey to better health. Thanks to the system, care providers are using patient centered records and structured checklists for critical activities. This allows care providers to easily educate patients on self-management and maintenance to help reduce their chances of being readmitted to a hospital.

By implementing this platform, we now provide a consistent and reliable mechanism to track record and report each activity the patient undergoes during their care transition journey and allows all care providers full access to these records for higher quality care. Once this operational data is harnessed, the real analytics can begin to identify key trends in the process that can lead to fine-tuning the care coordination and coaching cadence which ultimately leads to less readmissions.

That’s just one example of a solution that that AAJ Technologies helped our customer build with the goal of eliminating or reducing readmissions.

More About Eliminating or Reducing Readmissions

Ed’s presentation during the “Reducing readmissions with BI & Analytics” webinar hosted by AAJ Technologies contained a lot of ideas and actionable information. In a future posts we’ll be sharing more about the ideas, information and insights shared by the other presenters. In the meantime, you can reach out to Murray Izenwasser, our Vice President of Digital Transformation to learn how AAJ Technologies can cost-effectively help your company leverage a sound Care Transition System to reduce unnecessary hospital readmissions.

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Mark Bernstein

ABOUT Mark Bernstein

Director of Marketing, Mark is a professional with over 20 years of experience and an outstanding track record of achievement in B2B and B2C marketing. At AAJ, Mark wears many hats and oversees the marketing department with a focus on digital marketing including events, email, websites, social media, and lead generation.

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