We help patients adhere to their discharge plan, reducing costly hospital readmits
Reduction in cost for readmits as well as post-discharge ED visits and the high costs and penalties that come with it.
Our combined TCM/CCM service provides a fully clinically integrated environment for hospitals and affiliated providers.
Our first step is to work with your Case Managers to identify Medicare patients who qualify for our TCM service. Our next step is to meet with each qualified patient while they are still in your hospital to educate them regarding the TCM program prior to discharge. We then obtain a copy of the discharge plan, and connect with the patient post-discharge to ensure they stay on-track. Once the TCM service is completed, we will normally enroll the patient into our CCM program through their primary care physician.
We work with your hospital to determine the percentage of patients that are served & connected with a provider as well as the population without a primary care physician. Certain patients that need a specialized level of care post discharge, such as a surgical patient, are also addressed during the population management exercise.
We work closely with your Case Managers to develop a seamless and well-coordinated action and interaction between us, the physician practice, and your hospital. This close interaction allows us to know what patients are in an inpatient setting at the hospital, when they are scheduled to be discharged, and to obtain copy of the proposed discharge plan in a timely manner.
Our team has harnessed the direct messaging infrastructure afforded by the creation of Health Information Exchanges (HIE). This allows us to establish a direct communication channel between your hospital and our software. By working inside your hospital system, we can send messages to ourselves relating to patient health information and discharge plans in a timely manner without requiring hospital staff to provide real time data messaging.
On a regularly scheduled monthly CCM call, a patient expressed her concern about an issue with her eyes but said that she had not looked for assistance. Renova Health then contacted the PCP and they wanted to see the patient immediately as this could be a symptom of something serious.