Care Transitions

The overarching goal of eQHealth Solutions' Care Transitions Program is better health outcomes for members and a reduction in 30-day readmissions post hospitalization. This is done by empowering members with the tools and resources needed to self-activate the healthcare system, self-manage their chronic health conditions and address barriers to care. Care Transitions works to assure that members adhere to the physician prescribed discharge plan, follow-up with their treating providers post-discharge, and have the tools for self-management through extensive education and coordination of needed services.

eQHealth Solutions' Care Transitions Program is member-centric and focuses on providing tools to members so that they are enlightened and empowered about their health conditions and physician prescribed treatment plan to make informed healthcare and treatment decisions.

Core Program Elements:

• Empower members so the member is viewed as the solution
• Medication reconciliation
• Educate members and teach the warning signs of complications
• Adherence to prescribed physician follow-up care
• Adherence to the physician prescribed discharge plan
• Condition self-management skill building
• Coordinating access to primary care and needed services

At-a-Glance: Care Transitions Program Overview

Referrals & Member Enrollment: Participants are referred to the program at the time of admission to a facility with a defined diagnosis that meets program inclusion criteria. The health coach then performs an in-person evaluation of the member.

Enrollment Timeframe: Members enrolled for 45 days post facility discharge.

Diagnoses Covered: Diabetes, heart failure, COPD, acute myocardial infarction, pneumonia, total joint replacements, and stroke.

Mode of Care Coordination: In-person and telephonic outreach.

Clinical Quality Measures: HEDIS standards of care related to covered diagnoses. 

Outcome Measures: Overall reduction in 30 day readmissions, both all-cause and diagnosis specific.

Why Adopting a Care Transition Program is Important for Your Organization?

Care transitions occur when a patient moves from one health care provider or setting to another.  Unfortunately, many of these transitions do not go as smoothly as planned and a patient’s health may deteriorate causing a return to the hospital for care. One in five Medicare patients discharged from a hospital are readmitted within 30 days which equates to a staggering 2.6 million seniors;  and costs for providing care for these readmissions cost over $26 billon dollars every year, according to the Center for Medicare and Medicaid Services. Additionally, one study from The Joint Commission states that 80% of serious medical errors involve miscommunication during the hand-off between medical providers.

With a patient’s health at stake and the substantial financial consequences of preventable hospital readmissions, effectively and carefully managing the transition of care is vital for improved patient outcomes, reducing costs and empowering patients to self-manage their conditions.

What Sets eQHealth Solutions' Care Transitions Solution Apart From the Rest?

Our service offering can be sold as a standalone solution or bundled with our Medical Management comprehensive offering, giving our clients exactly what they need to reach their organizational goals for quality outcomes and cost reductions. Additionally, eQHealth’s Care Transitions service is delivered not only telephonically, but also in person allowing for face to face personalized care for your patients/members. ​Additionally, as part of our solution, you have access to our innovative Population Health Management technology that is second to none in managing all points of transitions, planning, multi-disciplinary communication, support, compliance, and assessment as well as documenting and analyzing best practices in care measures. ​