Discharge Management

Putnam Health Advocates can help identify potential high-risk patients at admission, pre and post discharge.

There are several reasons why patients re-admit to facilities, many of which center around the understanding, implementation and management of pre/post discharge plans and, the resources needed to comply with them. Our Re-admission Management Strategy suite of services aptly called, READY! brings those resources together with leading edge technology to ensure successful outcomes.

With Medicare Reimbursement penalties of $41B for 2015, hospitals must find a better way to manage hi-risk readmissions.  READY! does just that.

Factors that affect high readmission rates:

• Premature discharge or inadequate post-discharge support
• Discharge to an enviornment that is not capable of meeting their needs
• Insufficient follow-up
• Therapeutic errors
• Failed hand-offs
• Poor information transfer from hospital based providers and PCP’s
• 12 – 34% of discharge summaries reach PCP by the time of first follow-up
• Adverse drug events and other medication related issues
• Complications following procedures
• Have limited post-discharge support and resources
• Re-admits through the healthcare continuum

How We Can Help

Utilizing Population Health Management software to identify current and future at-risk patients and, deploying “boots on the ground” Care Management teams with access to Tele-health and Wellness technology, READY!℠ is designed to close the inherent gaps that prevent patients from achieving optimal outcomes pre and post discharge.

We have brought all the elements together under one umbrella to ensure that the patient is ready at discharge and has access to the tools and resources they need for continued success, post-discharge. For hospitals, our reporting capabilities provide support of efforts at 30-60-90 days post-discharge; thereby, minimizing or eliminating reimbursement penalties from payers should the patient re-admit.

We will follow the patient for up to 90-days to ensure compliance with care plans; access needed resources; remove barriers to payment; coordinate and communicate with other providers and, provide bi-weekly reporting standards to the client facility.