A Unique Transitional Care Program Designed Specifically to Reduce Readmissions
Four Seasons Nursing and Rehabilitation Center, a 270-bed facility, has launched a Personal Concierge™ program to continue to support patients with their recuperation as they transition to home-based care. The goal of the Four Seasons Concierge Care program is to enhance patient recuperation, improve post-discharge health, and reduce the number of readmissions.
At discharge, patients (and their caregivers) who had been receiving inpatient treatment for chronic conditions will enroll in the Personal Concierge™ program, extending the condition-specific support they had been receiving as inpatients following discharge. The conditions focused on include diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic joint care (CJC), and chronic kidney disease (CKD),
As part of the initial enrollment, patients complete a health risk assessment (HRA) survey that confirms their condition, captures baseline health indicators and considers their self-admitted confidence level to follow their care plan post discharge, as well as circle of support. Leveraging GoMo Health’s sophisticated business rules engine, the feedback is scored, and each patient is assigned to an appropriate engagement track for the duration of the program. Throughout the course of the program, patients receive content, resources and reminders to help them and their caregivers effectively manage their conditions at home. At the end of the program, each participant completes a conclusion survey to assess program effectiveness and impact.
The Four Seasons Concierge Care program is designed to align with the new CMS Quality Strategy to improve care transitions and support as patients are discharged from a skilled nursing facility (SNF) to their home-based community of care. Providing innovative, timely education and reminders directly to patients and in support of their individual care plan, readmissions are reduced, and recuperation improves, especially for high risk and senior populations.
Our unique Personal Concierge™ Readmission Reduction program is designed to support transitional care, from the point of discharge up to 90 days post. The program is based upon GoMo Health’s proprietary emerging science, BehavioralRx™, the science of patient engagement.
Learn more about them and see examples of their messaging below.