Care Transitions


According to Healthcare Cost and Utilization Project (HCUP) data, Medicare patients have a 25% higher readmission rate than those covered by other payers. Isn’t it time to engage these patients and ensure they have better outcomes?

The Healthy Every Day Care Transitions (30-Day) program focuses on preventing avoidable admissions, specifically for patients suffering from:

  • Heart Failure
  • COPD
  • Pneumonia
  • Asthma
  • Hypertension
  • AMI
  • Diabetes
  • Others as identified or needed

Patients are enrolled promptly at discharge, then engaged in daily surveys for 30 days. Care managers receive alerts when a patient’s survey indicates a problem complying with care protocols, allowing early intervention with the patient before a major health event occurs.

Care Transitions (30-Day) Program Features

  • Daily health survey accessible by phone or Internet connection
  • Survey questions tailored to assess the clinical status, self-care activities and social determinants of health
  • Care coordination worklists and alerts through the Navitas platform

Sara AldworthCare Transitions