|1.||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. 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. 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. 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. 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. T-System Care Continuity will automate transitions to those settings that can provide outpatient care for selected patient populations.|
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