Enhancing Transitional Care Management with Virtual Care

Role of Transitional Care Management

Unfortunately, high risk patients may find returning home post-discharge to be overwhelming and these patients may be at-risk for rehospitalization. Transitional care management (TCM) services help patients transition from inpatient care to the community setting by bridging the gap with extra support to help patients:

  • Adjust to their new medication and treatment routine
  • Address barriers to adherence and self-care
  • Acclimate to any change in their functional status

The objective is to support the patient’s needs while minimizing deterioration and reducing potentially preventable medical errors and rehospitalizations during the initial 30 days following discharge from an acute or skilled stay.  The initial few days and few weeks are critical to reducing high-cost utilization of EDs and hospitals.

Role of Virtual Care in Enhancing TCM Services

Traditional TCM programs may prove ineffective in engaging at-risk patients – and rising-risk patients – in the critical 30 day period post-discharge.  TCM succeeds when a provider can efficiently and effectively coordinate and champion support for all medical conditions, psychosocial needs and ADL requirements.

Virtual care enables post-acute care organizations to streamline communications between the care setting, the primary care physician (or other specialists), additional services (such as DME and home infusion) and the patient – while helping the patient safely transition to care at home.  Synzi’s HIPAA-compliant virtual care platform helps clinicians:

  • Conduct a face-to-face virtual visit prior to the patient’s discharge from the acute care setting. This initial call can set expectations with the patient.  Remote family members and a medically certified interpreter can be included in the video call to drive understanding and alignment on next steps. Discharge information can be reviewed along with the need for and/or follow up on pending tests or treatments. Initial education can be provided to patient and family caregivers to help support the patient’s role in self-care and return to ADL.
  • Check-in with a patient over video to assess the patient’s condition and answer questions in real-time. Medication reconciliation and management can be conducted during these virtual visits with the prescribing physician and pharmacist included in the call.  Additional members of the broader care team can review the need for any follow-up diagnostic tests or treatment and also discuss referrals and community resources needed for the patient’s regaining activities of daily living.
  • Schedule and send a cadence of ongoing messages to help promote patient understanding of one’s condition(s) and the importance of medication adherence. The messaging can be tailored to reflect the patient’s multiple conditions and translated into the patient’s primary or preferred language.
  • Conduct assessments in between in-person and video visits to gauge the patient’s health. Clinicians can gain insight into the patient’s progress in between visits and explore if the plan of care may need to be changed or if the patient’s change in condition necessitates a more immediate intervention.
  • Monitor and manage the patient on key vital sign with remote patient monitoring technology. With Synzi’s RPM feature, post-acute care organizations can leverage patients’ everyday devices (such as smartphones, tablets, and PCs) while easily and securely obtaining patient data on key measures.  Patients can easily share vital signs from their smartphone, tablet, or PC and Bluetooth-enabled devices.   The solution monitors a wide range of health data such as weight, blood pressure, blood sugar, blood oxygen levels, heart rate, etc.  The platform provides real time patient health data directly to an organization’s dashboard and triggers alerts when patient data is out of normal range, helping teams better monitor patients’ condition(s) and identify compliant and non-compliant patients.

Multi-channel communications and increased touchpoints have resulted in better outcomes for the high-risk and rising-risk patient populations.  Patients are more likely to stay in a virtual TCM programs.  No-show’s to scheduled visits and virtual visits have decreased. Adherence to medicine and treatment plans have increased.

Virtual interactions are even more critical amid the COVID-19 pandemic as patients (and their family caregivers) may be restricting in-person visits for fear of infection and/or transmission. Patients are better managed from a frequency and personalized perspective, leading to better clinical outcomes for the patient and better financial outcomes for payors, referral sources, and home health providers.

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