For Hospitals
Improve Care Transitions & Reduce Readmissions
The residentialist team at Housecall Doctors Medical Group is an essential resource to avoid unnecessary skilled nursing facility referrals and reduce readmissions.
The Problem
- Close to 50% of patients readmitted within 30 days of discharge have not had a clinician visit between the original admission and subsequent readmission
- Post-acute care transition are often fragmented, and poorly executed
- Timely visits to primary care and specialists is often delayed
- In the current environment of readmission penalties and bundled payments, reductions in SNF referrals and avoidable readmission are mission-critical
The Solution
- Identification of patients at high risk for readmission and effective discharge planning
- Improved handoffs to post-acute providers with timely sharing of clinical information
- An effective post-acute clinical team in place to provide timely, high-quality care that focuses on the whole patient – both clinical and social issues
- Effective care coordination among the other field-based providers including home-health, pharmacy, case management and social work
- Effective return of the patient to the ambulatory care track when readmission risk has decreased
How We Help You
Quick Response
We quickly go out and see patient after discharge. First visits are scheduled within 24 hours after referral is received.
Communication
We communicate as frequently as necessary with you to provide updates on patient care and how they are responding to in-home visits.
Medical Prescriptions
We monitor and refill meds, in addition to updating the patient care plan as recovery/post discharge issues decrease over time.
Cooperation With PCP
The primary care physician does not need to be replaced; we can hand oversight of care back to the PCP after each episode of care is completed.