Transitions of Care Solution 

Transitions of Care is a post-discharge follow-up service that is customized to compliment your health system’s transition of care strategy.

Envera Health’s Transitions of Care Solution helps you proactively reach more patients after discharge from acute care or ambulatory settings so you can focus your resources and time on the patients who need help.

Nearly 80% of serious medical errors involve miscommunication during patient transfers and transition of care.
Patients who report satisfaction with their care experience are 39% less likely to be readmitted.
Nearly 20% of elderly patients discharged from inpatient care are re-hospitalized within 30 days.

Transitions of Care: A New Journey with Envera Health

Attempting to avoid preventable readmissions and reduce their risk of penalties, health systems are turning to their already limited care management resources to contact patients after discharge — an inefficient approach at the expense of clinical priorities.

Through a brief assessment, we review the patient’s experience and transitions of care needs. Based on their responses, some calls are escalated to our clinical team to review discharge instructions and coordinate follow-up care to support the recovery process.

Transitions of Care Services

Our Transitions of Care Partners

We become part of your overall population health program.

With light and efficient multi-channel touches, we help you proactively reach more patients after discharge from acute care or ambulatory settings while you focus on the patients that need you most.

  • Reviewing Discharge Instructions

  • Evaluating Urgent Needs and Concerns

  • Scheduling Follow-Ups

  • Offering Community Resources

  • Education

Envera Health Center Agents understand the unpredictability of life. We work diligently with each patient to ensure their needs are met.

Working with Envera our 7 day post discharge office visits and home health visits increased remarkably, our 7 day readmit went down. More of the population was being touched, controlled and coordinated.

I think some of the reasons why patients were coming back was a surprise. There were things we did not expect, patients were reporting that after their inpatient admission they were not feeling better after coming home or their symptoms did not improve.

When patients are sent home from the hospital, they might not know what to expect. So, when they get home that’s a great time
for a care coordination representative to reach out and help resolve their problems at a time when they are ready to listen.

The day we make our first call, we’re starting to build a holistic view of the patient. We can look across the spectrum to see the other programs, appointments, and alerts they have within system. We work with our health system partners on care management and community resources to deliver the most comprehensive care for each patient.

Everything is linked together, so while our team is managing transitions of care cases, they can see all interactions with the patient and the system.

Ingrid Kaiser, Envera Health

How Bon Secours Mercy Health is Creating a New Discharge Experience

Webinar | Redesigning Transitions of Care

When Bon Secours Mercy Health asked how they could prevent readmissions and reduce their risk of penalties, their clinical team knew what they needed: a new approach to transitions of care
– one that would free up their higher clinical team to focus on their care management priorities while still enabling the system to tackle reducing readmissions as a top priority.

Watch the Full Webinar Today!

Preview of a live webinar hosted with Bon Secours Mercy Health

A New Approach to Transitions of Care

Download Your Transitions of Care Guide Today

There is a direct connection between your transitions of care process and how likely a patient is to return to the emergency department. Our New Approach to Transitions of Care Guide can help you understand those connections and share insights into improving the care transition process for your patients and providers.

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