Care ContinuityTM | Patient Transition Management


Automated provider notifications.
Aggregate patient data in an
easy-to-read central online location.


The ER touches more than 83 percent of all patients that visit your hospital and treats the highest risk patients. Care Continuity™ actively manages patient transitions with a focus on the highest impact area for improved patient outcomes.


Effectively reduce avoidable readmissions

In 2013, approximately half of all hospitals in the U.S. lost a combined total of $300 million in Medicare payments for penalties associated with patients diagnosed with acute myocardial infarction, heart failure or pneumonia being readmitted within 30 days. Care Continuity™ allows you to automatically flag and track those patients to ensure they receive follow-up care.

Enable continuity of care

Many systems only aggregate data and allow access to anyone that looks for it. This Web-based solution goes beyond information capture – it provides actionable work queues and alerts to keep all care team members informed of next steps.

Improve physician alignment & prepare for bundled payments

Engaging community providers is critical for improving referrals and effectively coordinating care. Physician referrals constitute a significant source of hospitals revenue; care coordination will set you up for the future as healthcare moves further down the path of bundled payments.
(Click images to enlarge)
Provides PCP notifications and anywhere chart access

Provides PCP notifications and anywhere chart access


Automatically notifies the patient’s PCP or care givers at key intervals throughout the ED and inpatient encounter who can then view aggregated clinical records for that patient through a web portal.

Manages patients at high-risk for readmission

Manages patients at high-risk for readmission


Based on customizable criteria, Care Continuity™ will automatically alert your case management team by email or text when a high-risk patient arrives in your ED and flag those patients at discharge so you can ensure they receive the needed follow-up.
Automates referral management

Automates referral management


Generates 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.

Closes the loop

Closes the loop


Monitors 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 identify another practice that can meet the patient's needs.
Coordinates care planning

Coordinates care planning


Track calls, treatments and care plans with an easy-to-use patient care management platform for the entire care team.


Notifies patient’s PCP or care givers at key intervals throughout the encounter who can then view aggregated clinical records. Case management team is alerted when high-risk patients arrive in ED and flags them at discharge to ensure needed follow-up. Tracks transition of ED patients without a medical home from your medical staff to a community provider for ongoing care. Monitors patient transitions by alerting your care team when a physician practice accepts a patient assignment or identifies another practice that can meet patient’s needs. Track calls, treatments and care plans with an easy-to-use patient care management platform for the entire care team.
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Download white paper Cutting avoidable readmissions starts in the ED

Strategies for reducing
ED overuse
Strategies for reducing ED overuse on AMN Healthcare
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