Collaboration between care team members across the continuum was key to keeping him out of the hospital.
Hal’s COPD and heart disease had resulted in 8 ED encounters and 5 inpatient stays within a year. He’d been prescribed an inhaler, but his problems persisted.
With the Collective platform, Hal’s care manager was empowered to help. She was notified the next time he was in the emergency department with a flare-up and was able to intervene in real time, learning from the ED physician that Hal hadn’t obtained his prescribed inhaler because it was too expensive and wasn’t covered by his Medicare plan. She collaborated with Hal’s primary care physician and a clinical pharmacist to get an override through his plan and add insights about his needs to the platform.
Hal now has his inhaler, is well educated about his needs, and hasn’t required a trip to the hospital for his COPD since.
(Anonymized patient story)
Optimize Transitional Care Management with real-time notifications
Collective identifies specific discharges likely to qualify for TCM services based on settings of care, complexity of decision-making, and patient conditions. Providers can direct efforts toward providing care as soon as patients discharge to the community.
Succeed under BPCI Advanced through unhindered
Through Collective, patients who fall into a BPCI episode are flagged, and care histories are pushed to care managers, skilled nursing facilities, and specialists as patients move through the care continuum. These efforts smooth transitions of care, reducing avoidable readmissions and lengths of stay.
Collective helps you achieve improved patient outcomes at a lower cost.
Reduce avoidable hospital admissions and readmissions
Reduce overdoses and opioid prescriptions coming from the ED
Reduce number of ED encounters from frequent utilizers
Improve efficiency in post-discharge follow-up
Increase savings both at an organizational level and statewide
Improve satisfaction from both patients and providers
For ACOs and other organizations with an emphasis on accountability and value-based care, meeting regulations established by CMS and ONC is key to ensuring patients are receiving the best care possible while avoiding penalties. It can be difficult to know where to begin coordinating care with navigating several care teams and providers. This whitepaper provides a starting point for ACOs looking to help patients and lower costs.
Providence Health, a health system serving patients in Alaska, California, Montana, New Mexico, Oregon, Texas, and Washington launched Better Outcomes [thru] Bridges, or BOB, in its Oregon locations. This program focuses on involving key community members to better...
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