Inpatient Post-Discharge Patient Navigation

A health system is struggling to reduce inpatient readmissions which is negatively impacting their Star ratings. The system believes the readmissions are avoidable if discharged patients attended necessary follow-up and speciality appointments in a timely matter. However, with the data they have, it is difficult to segment their readmission issues by service line, discharge diagnosis, and facility/clinic. 

By leveraging Care Continuity's Inpatient Post-Discharge Patient Navigation services, the health system was not only able to reduce readmissions through better navigation tactics, but they also unlocked valuable insights into network performance. 

Medium to extra large health systems

Leading EHR functionality takes a very basic approach to patient navigation. When utilized, the EHR prioritization queue is binary, labeling every patient as urgent or non-urgent. Instead, Care Continuity not only expands the total number of evaluated data points needed to properly prioritize a patient, but Care Continuity also expands the priority listing to 10 levels, allowing for a more nuanced and tailored navigational experience. 

In addition, the EHR functionality requires the health system to staff a team of navigators. Unfortunately, this largely non-clinical function is staffed by clinical staff, severely hampering their ability to work at the top of their license. 

Care Continuity pairs their purpose-built software with a team of trained, non-clinical concierges who are experts in patient experience and proper navigation.