PerformNext™ Care Continuity

Reduce avoidable patient readmissions

With the CMS Hospital Readmissions Reduction Program in effect this year, you need a solution to help you manage patient transitions. T-System Care Continuity goes beyond information storage and makes information actionable.

How is it unique?

  • ED focused: As the area that touches more than 83 percent of all patients that visit your hospital and treats the highest risk patients, focusing on transitions from the ED is the most effective way to reduce readmissions and improve patient outcomes.
  • Actively manages workflow: Web-based technology keeps all care team members informed of next steps with alerts and team-based workflow queues.
  • Proactively identifies high-risk patients: Customizable filters allow you to automatically flag patients with repeat visits, specific conditions, PCP status and more to help you manage high-risk patients and reach your goals.

How does T-System Care Continuity work?


(Click on image to enlarge)

1. Identifies patients at risk for readmission Identifies patients at risk for readmission. Based on customizable criteria, T-System Care Continuity will screen each patient for readmission risk and allow you to manage those patients proactively.

2. Set up notifications for high-risk patients Set up notifications for high-risk patients. T-System Care Continuity will automatically alert your case management team by email or text when a high-risk patient arrives in your ED based on your customizable criteria.

3. Use actionable data to improve patient care Use actionable data to improve patient care. The system provides proactive information sharing between the hospital and community care facilities with real-time notifications, secure access to patient records and team communication capabilities with care notes.

4. Match unaffiliated patients with a primary care provider Match unaffiliated patients with a primary care provider. T-System Care Continuity can generate a list of all ED patients who do not have a medical home and track the patient's transition from your medical staff to a successful match with a community provider for ongoing clinical care.

5. Close the loop Close the loop. T-System 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.

6. Engage community resources Engage community resources. T-System Care Continuity will automate transitions to those settings that can provide outpatient care for selected patient populations.
Identifies patients at risk for readmission Set up notifications for high-risk patients Use actionable data to improve patient care Match unaffiliated patients with a primary care provider Close the loop Engage community resources
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