Our Approach

Our Approach

Capture information in real time

Harness all available patient data to quickly and accurately identify patients upon arrival that are potentially at risk. The quality and timeliness of available data plays an important role in this. Data from electronic health record (EHR) systems and other in-house sources is used to achieve a complete and real-time (or near-real-time) picture of admitted patients, their diagnoses on admission and their current disease states.

Risk assessment

Assess patients by running real-time patient data through our proprietary risk modeling software. The software scores patients by level of risk, enabling staff to quickly allocate resources and attention appropriately and ultimately maximize positive patient outcomes and keep at-risk patients out of the hospital

Real-time monitoring

Continually track at-risk patients, from the hospital to the PCP and home care settings. Work lists integrating case management, discharge planning, and follow-up/monitoring procedures help reduce readmissions by ensuring each patient receives the proper care while in the hospital and while transitioning to a home or outpatient setting. Each care settings has an important, specialized role in keeping patients out of the hospital

Tailored procedure document

The objective is to equip clinical staff to educate patients about their disease, their risks, and what they can do to self-monitor their condition. For this, detailed post-discharge plans are created, shared with patients and outpatient staff, and monitored by care coordinators

Monitor performance improvement

Provide a real-time feedback loop through dashboards customized to the user’s role. Stakeholders across the chain-of-care would be able to view real-time data and analyses in a way that’s customized based on their responsibilities.