Avery Readmission Avoidance Program (RAP)

• Chronic Care Management (CCM)
• Social Determinantes of Health (SDoH)
• Transitions of Care (TOC)
• Annual Wellness Visits (AWV)
• Behavioral Health Management (BHM)

The end users are patients, care team members, clinicians, organizations and consumers.

• Reduces readmissions with a comprehensive approach that includes RPM, patient education, and condition-specific clinical pathways.
• Integrates diagnosis-specific pathways into patient care plans for consistent application of best practices.
• Provides a guarenteed reduction in readmissions to ensure program effectiveness.
• Offers extensive, tailored patient education resources crucial for post-discharge engagement and compliance.
• Utilizes RPM to continuously monitor patients and dynamically adjust care plans, minimizing the need for in-person visits.
• Streamlines the reimbursement process, specifically addressing telehealth and RPM billing issues, reducing administrative burdens.
• Enhances HEDIS scores and Medicare Star Ratings by improving quality of care and patient outcomes.
• Coordinates actively with primary care and transition teams for smooth transitions and continuous care, enhancing patient outcomes.