Getting the Patient Appropriate Care After Discharge

When patients arrive at a hospital or ER, HIE*Lite instantly matches them to their primary care provider, medical home, and ancillary care providers. Before leaving, patients are evaluated, appropriate follow-up care is booked, and the patient is provided with easy-to-understand documentation for timely post-discharge care. Follow up is verified, and obstacles to attendance can be resolved for improved outcomes and patient satisfaction.

HIE*Lite links hospitals with providers to bridge the communication and coordination gap. In its regional pilot, HIE*Lite increased patient satisfaction while reducing hospital and ER revisits from 18% to 5% among an urban safety-net population of 360,000.

A New Level of Real-Time Care Coordination

For patients in need of follow-up care, frequent flyers, those with chronic conditions, or high cost/high-risk patients, HIE*Lite provides specific workflows to support immediate needs identification so that the appropriate care can be scheduled and provided to minimize the chance of a revisit to the ER or acute care.

HIE*Lite can also direct patients without primary care providers to aligned providers in their area, thereby establishing appropriate primary care. HIE*Lite provides:

  • Easy workflow steps to schedule follow-up appointments and reschedule missed appointments.
  • Instructions in the patient's primary language for post-hospital care, including optional transport arrangements
  • An optional diversion to a primary care provider for non-emergency circumstances.
  • Follow-up reminders to verify that patients attended appointments, and if needed, reschedule.

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Hospital and Emergency Department Visit Alerting and Notification System for Providers

HIE*Lite can securely and immediately notify any associated providers that a patient has arrived at a hospital for care. These alerting messages may take several different forms and can be sent to primary care providers, specialists, community health centers, mental health professionals, insurers, managed care organizations, or external case management and social work staff. This allows rapid coordination and collaboration on patient care needs to prevent readmissions and financial readmission penalties.

A Deeper Level of Care Insight

The HIE*Lite enterprise patient master registry can also be used to identify patients' medical chronic conditions. HIE*Lite provides the information needed to ensure that proper care coordination can be achieved according to each unique patient situation. This deeper medical and clinical collaboration of current information on patients between provider participants across the continuum of care increases overall efficiency, improves the quality of care and helps manage chronic condition development, thereby reducing overall costs of care and increasing the patient's quality of life.

Directed, Prioritized Workflows for Increased Efficiency

From the moment a patient arrives in the ER or hospital, each step of the processes is directed by a sophisticated tasking system to keep everyone involved focused on scheduling and delivering the appropriate care. HIE*Lite further supports care coordinators by bringing all the contact information together with provider and service resource directories for such items as:

  • Associated primary care providers and medical home
  • Associated specialist providers
  • Contracted transportation services
  • Clinic care coordination liaisons
  • IPA, managed care, and insurance liaisons

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The Bottom Line:

Care coordination is a front-line approach to improving quality, reducing costs, and lowering readmission rates.

HIE*Lite helps pull together the people needed to make a difference in a patient's journey. With HIE*Lite, care coordinators can operate efficiently and effectively in assessing, communicating, arranging, and following up on downstream care needs. When applied over large groups of patients, it helps improve the health of populations while facilitating greater patient satisfaction.

Trans World Health Services Compass Screens