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Study Reveals Significant Inconsistencies in Care Transitions

Digital Health Engagement Drives Better Care Management and Clinical Outcomes

A recent JAMA study revealed real inconsistencies in care transitions for patients. A full 20% of patients reported that social determinants of health (SDOH) stood in the way of achieving a healthy outcome. The point: Each patient is different and SDOH can impact their clinical outcomes.  

For example, challenges associated with transportation decreased the odds that a patient would complete their follow-up appointments by a whopping 70%. In addition, African American patients were less likely to have engaged in follow-up visits within two weeks of their hospital discharge.   

The study coauthors have three insights to share with healthcare leaders. These include:   

  1. Care transitions are variable
  2. Patients have significant SDOH issues
  3. Potential racial disparities occur during post-discharge follow-up with patients  

The reality is, the industry is aware that health inequity and lack of health literacy translate to poor clinical outcomes for patients and higher costs for payers and providers. Now, there is technology that can do something about it. Care Angel can help.   


Meet Angel: Award Winning A. I. Voice Nurse Assistant 

Our digital health assistant, supports payers and providers with care transition engagement by attempting to contact 100% of eligible patients discharged from hospital or clinical setting to home. Traditional nurse call centers will manage an average of about 10% of the clinical capacity - at a much higher cost. Our commitment is to apply proven machine learning logic and workflow that ensures, after a single attempt, the patient doesn’t go to the bottom of the list. Our scheduler is set to reattempt contact at a frequency defined by the client - extending reach without adding to labor costs. 

And of course, Angel adheres to Telephone Consumer Protection Act (TCPA) regulations and compliance. That typically means we commit to contacting a patient up to three times post-discharge. After a third unsuccessful phone attempt, over a set time-frame, we can send a text, voice mail or email to the patient inviting them to opt in to communications to manage their care journey.  

We help support care transitions in three pivotal ways:   

  1. Angel is a proven care extension. By optimizing and extending scarce clinical resources, Angel is highly efficient, effective, scalable, and delivers a sustainable case management model.    
  1. Angel supports a proactive, preventative care model. Through enabling outreach to more than 90% of members and patients, we help you mitigate risk. That translates to proven clinical impact and closed care gaps.   
  1. Angel relies on a data-driven algorithm. Intuitively, Angel suggests the next best actions for large patient and member populations after discharge. That means personalized pathways for each individual and more personalized attention to health equity.  

Angel’s innovative capabilities support healthcare payers’ and providers’ care coordination efforts by ensuring that clinicians receive notifications about any episodes that impact downside risk. We also empower members and patients to easily and proactively report and navigate the following tasks:   

  • Medication reconciliation  
  • New or worsening symptoms  
  • Transportation, food and other needs  
  • Scheduling follow-up care and appointments  
  • Medical supply needs 
  • Connection with the patient’s pharmacist 
  • Automatic transfer to nurse line if needed
  • And more  

Payers and providers have a vested interest in managing downside risk. That’s a goal you share with Care Angel. We automatically filter your populations by risk. The benefit to your members and patients: Access to care teams--in the moment with actionable information. That’s how you reduce churn and help patients stay healthy, reducing readmissions.

As you continue to embark on your value-based care journey, Care Angel will continue to add value.   

The end result: Fully optimized care transitions with the ability to proactively identify and close health equity and clinical gaps.

Want to Learn More?

Contact Care Angel Today! To learn more about Angel, contact us today by calling (800) 825-3227 or filling out our online form. We look forward to working with you and providing you with the healthcare management tools you need!