Managing patients’ needs across a continuum of care
Approach: Data and experience show us that proactive care driven by evidence-based medicine is the most effective way to keep people healthy, happy and out of the hospital. Call9’s evolutionary approach across the continuum of care seeks to understand which patients are at risk of becoming sicker.
+ Risk Assessment to Optimize Care Plans
Call9 works in partnership with our SNF partners to proactively identify clinically complex patients—particularly those who have been transferred repeatedly, required Call9’s services three or more times in a 60-day period or are new admissions to the facility—to establish a baseline understanding of their physical and mental health status and goals of care.
+ Goals of Care Discussions to Identify Patients’ Wishes
Providing patient-centered care begins with understanding patients’ wishes. Knowing what a patient’s goals are in light of their medical situation is imperative in delivering the right kind of medical care. Research has shown that advance care planning can increase patients’ quality of life, improve the experience of family members and decrease health care costs.
+ Predictive Analytics to Identify Most Vulnerable Patients
Call9 leverages historical data from external EMRs, health information exchange (HIE) and our own history of patient interactions to predict who is at the highest risk for hospital transfer. Using data analysis and machine learning techniques, we’re able to anticipate overall patient acuity across the service, as well as anticipate expected resource utilization, in order to ultimately provide better outcomes for patients.
+ Proactive Care to Prevent Hospitalizations
By proactively knowing patients, their goals of care and advance care plans, Call9’s on-site staff and remote provider team can immediately care for them in the comfort of their nursing home bed. As patients return to baseline, they move to follow-up status and are monitored to ensure clinical stability and foster a smooth continuum of care.
Regular communication with the patient and their family, primary care provider and the facility care team during every patient encounter is a cornerstone of providing high-quality, patient-centered and coordinated care.
Continuity of Care
Care doesn’t end once a patient has been treated for an acute event. Because the Call9 Clinical Care Specialist is present in the nursing home at all times, we are able to extend our service and continue observing patients for one to two days following initial Call9 treatment. This ability to monitor patients for changes in condition over time—particularly within 24 hours of an acute episode when patients are most vulnerable for hospitalization—is critical for patient safety in the care of complex, chronically ill, older adults.
Shared Decision Making
Call9 providers communicate updates to the patient’s primary care provider (PCP) and coordinate all care plans with the facility care team in order to provide seamless care delivery that is consistent with the patient’s goals of care. PCPs are notified of any significant change in status or unexpected decompensation, and care plans are shared with the facility care team and documented in the facility EMR.