The Informer Monthly
6 Tips and Tricks for Reducing Readmissions with Care Continuity

Don Beisert, Product Management Analyst By Don Beisert
Product Management Analyst

Ensuring that patients transition safely from the hospital to the next setting of care is a major step in providing coordinated care that reduces unnecessary readmissions. Below are a few tips and tricks for using T-System Care Continuity solution to support this process.

  1. Identify patients at risk for readmission. Use T-System Care Continuity to identify patients who are a high risk for readmission. Based upon the criteria you develop, Care Continuity will screen each patient who arrives in your ED for readmission risk and allow you to manage those patients proactively. Knowing where to focus your care coordination efforts is vital to successfully reducing readmissions.

    List of high risk patients

  2. Set up staff notifications for high-risk patients. Use T-System Care Continuity to automatically alert your case management team by email or text when a high-risk patient arrives in your ED. When Care Continuity identifies a patient who meets your criteria, notifications are sent to the designated team so your care coordination protocols can be started quickly.

    Text message alerting new patient referral

  3. Use actionable data to improve patient care. Proactive information sharing between the hospital and community care facilities is critical to managing readmission risk. Use T-System Care Continuity's real-time notifications when patients are admitted or discharged from the hospital to promote care collaboration. Secure access to patient records gives team members at all points of care the information they need to treat patients in the community. Team members can communicate within the system using care notes functionality.

    Care coordination case notes

  4. Match unaffiliated patients with a primary care provider. Patients who do not receive follow-up care for chronic conditions are at high risk for readmission. T-System Care Continuity can generate a list of all ED patients who do not have a medical home. Care Continuity's web-based interface can be used to track the patient's transition from your medical staff to a successful match with a community provider for ongoing clinical care.

    List of patients without primary care physician

  5. Close the loop. Care Continuity can monitor patient transitions by alerting your care team when a physician practice accepts a patient assignment. If the practice is unable to accept a new patient due to schedule conflicts, Care Continuity will help identify another practice that can meet the patient's needs. Closing the loop by making sure that all patients receive follow-up care is an essential part of reducing readmission risk.

    Schedule conflict notification for ED patient referral

  6. Engage community resources. Good working relationships between the hospital and the community ensure that patient care is provided in clinically appropriate and cost-effective settings. Identify resources that can provide outpatient care for selected patient populations, and take advantage of T-System Care Continuity's ability to automate transitions to those settings. This process efficiently ensures that patients receive appropriate follow up care.

    Clinic list of flagged high-risk patients

If you have questions or comments about this article, please contact Don Beisert at

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