At-risk patient identified during hospital stay.
Patient receives focused communication prompts and follow-up messages based on their specific diagnosis and risk factors.
Real-time responses are monitored and used to determine need for further follow-up and clinical intervention.
An Intervention Center RN initiates follow-up within four hours of discharge.
Telehealth platform allows patient or caregiver to easily provide response.
Modeled after national best practices and incorporating tele-health technology, our Transitional Outcomes Program (TOPs) Tele-Clinical Intervention Center delivers a patient-centered service designed to increase patient safety after discharge and reduce readmission rates to acute care facilities.
This program helps our patients move between practitioners, settings, and home as their conditions and care needs change. We use a collaborative, interdisciplinary approach to provide early identification of at-risk patients and assistance with transitional needs for specific patient populations.
Using an interactive tele-health platform, we can engage at-risk patients and their caregivers in order to provide continued education, follow-up, and empowerment during the transition to home.
Our hospital’s interdisciplinary team will identify patients who may benefit from post-discharge follow- up services with the TOPs Tele-Clinical Intervention Center. When a patient is identified for participation, we’ll work together with them and their caregivers to review the program and what they can expect. Within four hours of the patient returning home, an advanced practice RN will begin follow-up communication using telehealth technology. We’ll continue to follow patients for a minimum of 30 days after discharge.
We place each patient on a specific post-discharge clinical pathway that aligns with their diagnosis and associated conditions. These specific pathways allow us to ensure patients receive targeted prompts that are pertinent to their condition, along with appropriate follow-up messages. The patient or their caregiver can respond through a user-friendly messaging system. Responses are monitored in real-time by our telehealth team. If a concerning response is received, a team member will engage with the participant to carry out any necessary intervention. Throughout the process, patients can expect traditional phone call check-ins as well, and our RN clinical intervention team is available to patients by phone 24/7.
- Early and ongoing intervention during the first 30 days after discharge
- Education for patient and caregivers on safety and risk factors for readmission
- Convenient communication and real-time feedback using telehealth technology
- Intervention Center RN coverage
- Additional support provided on fall prevention, dehydration prevention, nutrition, stress management, medication compliance, and supply and food security
- Reduces unnecessary readmissions by supporting patient’s transition to home for 30 days post-discharge
- Minimizes lost revenue from Medicare readmissions
- Increases access to follow-up care from in-network providers
- Improves the patient experience
- Increases quality and decreases cost, demonstrating value to care continuum
- Improves star ratings
Frequently Asked Questions
Why should I respond to these text messages?
Our goal is to keep your health on track between visits to the hospital. We will send important information and ask how you are doing. We may also contact you by telephone if it looks like you could use additional help.
Can a family member receive messages too?
Yes, designated family members or caregivers can also receive and respond to messages. Just ask your care team to add them to your profile.
How much does it cost?
You do not have to pay us for this service. But if your phone service provider charges you for text messages, those fees may apply. You can opt out from receiving messages at any time by replying STOP to the text message.
How do I see my messages?
You will receive a notification that you have a new message. All you have to do is click on the link to open the message.
Are my messages with my care team secure?
Yes, all messages meet healthcare security and privacy standards.
What if I have questions?
If you have questions about your treatment plan, problem logging in, or questions about using our secure messaging feature, contact our hospital directly.