Transitions
A poorly managed transition from an acute setting to home leads to poor quality of care, unnecessary costs, and re-admissions. The numbers are staggering:
• 20 percent of Medicare members are re-hospitalized within 30 days of discharge
• One-in-10 Medicaid members are re-admitted to the hospital within 30 days
• 14 percent of Medicaid members with three or more underlying health problems
are re-admitted within 30 days of their previous hospital stay
Inadequate communication and non-compliance of member follow-up account for many re-admissions.
Most of these re-admissions are the result of discharge timing, errors and oversights that occur
during the period between the acute care discharge and resumption of care by the primary care
physician.
Transitions Management Means Improved Continuity of Care.
INSPIRIS' Transitions program focuses on improving continuity of care during the critical
days post discharge from the acute setting to the home and community setting. It is designed
to reduce re-admission rates by identifying and addressing the needs of members prior to acute
discharge, immediately post-discharge and at routine intervals during the first four weeks
after hospital discharge. During this time, INSPIRIS helps ensure follow-up care is received,
appropriate self-care is followed and health deteriorations are recognized and treated early.
Focus Where it Counts!
INSPIRIS' Transitions program offers two levels of services based upon member risk. This
allows for a fully integrated approach that tackles the varying needs of any health plan or
state health system’s avoidable re-admission problems. While both levels of service deliver
intensive member contact for 30 or more days post-discharge, our unique process
for identification and stratification of members allows more targeted interventions based upon
member need.
INSPIRIS’ Transitions program works with a health plan to identify high-volume facilities for placement
of an INSPIRIS (or health plan) professional to conduct point-of-service stratification assessments.
Members are then placed into one of two risk levels. They receive:
• Unique interventions designed specifically for their risk level
• A wide range of services inherent to both levels
• 24/7 access to support via a state-of-the-art Clinical Communications Center
comprised of RN Care Managers and Care Management Assistants
Seamless Infrastructure Support
The INSPIRIS secure HIPAA-compliant electronic health record facilitates program
transparency and provides for online reporting and progress tracking.
Impressive Benefits
• Lowered re-admission rates and associated costs
• Elimination of gaps in care
• Improved outcomes for recently discharged
• Excellent return on investment
