Post-Care Follow-up and Readmission Reduction

Re-Engineered Discharge Improves Outcomes, Reduces Cost and Penalties

The EcoSoft Health Post-Care Follow-up solution enables you to re-engineer your discharge follow-up by automatically scheduling remote or on-site post-care assessments specific to the patient’s condition at pre-defined intervals throughout the recovery period. Our assessments evaluate environmental, social and behavioral as well as clinical factors in real-time with pre-configured or customized assessments and surveys. It alerts appropriate care team members if potential recovery problems are detected. Early notification allows the care team time to address issues in the care setting. Content appropriate to the patient’s condition can be delivered as audio, video and text-based content delivered for patient education.

Dramatically scale-up your post-care patient follow-up and provide your Care Managers with the tools they need to actively manage, coordinate and track patient progress after care. EcoSoft Health software tools help your team proactively engage in the patient recovery process. This engagement improves care quality and patient satisfaction. It helps reduce post-care complications that can result in readmission. Accountable Care Organizations now have a tool to actively manage care transitions and adapt to new reimbursement models.

Benefits Of Our Solution

Post-Discharge Follow-up

Post Discharge Follow-up
Assessment System Proactively Identifies Complications
The system assesses patients after care as well as on a periodic basis. Real-time evaluations reveal patients whose status may be worsening due to chronic disease or a medical complication. The solution provides objective measures of patient health status, readmission risk, and care progress.

Alert Appropriate Care Team Members Immediately After Complications Are Suspected
The assessment engine can generate an immediate alert to any or all members of the patient care team if results exceed set thresholds or detect worrisome trends. Alerts can identify an urgent intervention need or care-plan change that may avoid unnecessary hospital readmissions. Results indicating less urgent responses are queued for review at the appropriate medical staff level. This alert capability gives the care team more time to focus their efforts on providing care to those who need it most.

Optimize Efficiency Through The Use Of Appropriate Medical Skill Levels Assessments can be delivered by a medical assistant at point-of-care or over the phone, operating on either a desktop or mobile device. Staff members are empowered to perform the assessment. Patient responses are immediately evaluated by the assessment engine and risk level determined.

Use Automated Workflows To Schedule Followups
Receipt of a discharge notification, which may be from an automated integration with a hospital medical record/patient registration system, triggers a structured workflow appropriate to the discharge type or chronic condition. The workflow engine combines automated assessments, followup notifications, and other patient and care-team communications. Communication workflows can be configured to deliver any of these communications at specific intervals following the care event. At the designated times, the system reaches out to the designated contact by predefined email or text message, providing for response through a link to a questionnaire, survey, or scheduling request.

Reduce Readmissions
Government at both federal and state level is acting to improve healthcare outcomes with penalties for excessive readmissions and incentive payments for excellent performance. Hospitals often lack the infrastructure to manage patients post-discharge and mitigate the risk of penalties. Our solution equips the care team with tools to actively manage, track and coordinate patients post-care. Readmissions are reduced both through the assessment function (to detect and allow intervention for medical complications or non-adhering patients) and the wellness-nurturing function (to remind and encourage patients).

Dashboards For Followup
Dashboards track patient responses to assessments and questionnaires. Follow-up dashboards provide queues for the medical staff to administer assessments to patients. Dashboards of completed assessments, prioritized by readmission risk, provide access for review of the assessment results. Assessments can be marked as having been reviewed directly from this dashboard or from the generated notification. Assessment results and review status are recorded and stored permanently in the database. Results for a specific patient are available for review and analysis on multiple levels.

Dashboards For Patient Trending Analysis
Assessment results are analyzed in dynamic real-time dashboards. Key indicators help evaluate the patient's readmission risk and can identify worrisome trends to inform patient counselling. On a higher level, assessment results can be used to visualize population health and for predictive analytics. Comparisons on key performance metrics are provided across locations/practices and even for individual members of the care team. Once a baseline is established, it can be used to measure the effect of any changes in treatments and protocols. Questionnaire results can be exported for detailed analytics, either in full or summarized to remove patient identifying information.

Integration With Other Systems
The EcoSoft Health solution is designed to operate either on its own or fully integrated with a facility’s existing systems. It readily integrates with the facility’s medical record/registration technology for bi-directional data exchange. Our preferred integration method is through standardized integration data protocols, preferably Health Level 7 (HL7 FHIR). Our solution can also integrate with a provider’s proprietary intervention alert technology, if one is in use.

Benefits to the Provider

Systematic active patient contact using less staff time

Early and efficient means of identifying post-care complications

Tracks performance, collects patient satisfaction and outcome survey data

Immediate access to KPI/CQM data and Analytics Dashboards

Identify KPI/CQM by sites of care and care pathway

Identify problem areas early, avoid potential penalties

Easier compliance reporting

Improved outcomes

Benefits to Care Manager and Care Team Members

Extend patient engagement reach with systematic follow-up

Greater patient contact using less staff time

Early and efficient means of identifying post-care complications

Focus time on patients in need of acute care

Greater patient contact using less staff time

Remote access to information for patients in need of acute care

Improved outcomes

Benefits to the Patient

Greater understanding of their condition and care follow-up

Improved outcomes

Improved care experience

Improved overall health

Want More Information?

Thank you for your interest in EcoSoft Health. Please fill out the form below and we will contact you shortly.

First Name:*
Last Name:*
Title:*
Company:*
Phone:*
E-mail:*
Area of interest (optional):
Scored out leads:
Import Form:

*Indicates a Required Field