Ensuring a smooth transition post-discharge while reducing readmissions
FountainView Care Center is a premier skilled nursing and rehabilitation center dedicated to providing superior care and quicker recovery to patients. FountainView and GoMo Health partnered to design a readmission reduction program that helps their patients take care of themselves post-discharge.
Create a smooth transition plan from inpatient to outpatient.
Provide a better understanding of daily healthcare issues.
Empower patients for better self-care management.
Reduce unnecessary readmissions.
GoMo Health leveraged its proprietary emerging science, BehavioralRx, the science of precision health, to build the program and determine the engagement strategy, approach and content delivered.
The following behavioral and cognitive techniques were applied:
Anchoring Technology / Cognitively connecting the desired action with an existing everyday activity.
Tailoring Technology / Persuasion through customization.
Nurturing Technology / Guided persuasion
Conditioning Technology / Reinforcing target behavior.
A readmission reduction program
designed for multiple conditions
In 2017, FountainView Care Center, a New Jersey Skilled Nursing Facility and GoMo Health launched the first of its kind 30-60-90 day readmission reduction program upon discharge for chronic conditions including diabetes, COPD, congestive heart failure (CHF), chronic joint care (CJC), chronic kidney disease (CKD) and sepsis.
Enrollment stratification by condition, risk factor, and communication preference
The system includes a custom-designed Health Risk Assessment (HRA) onboarding survey that identifies the patients’ procedure(s) or condition(s), and captures data (i.e. weight), to stratify and place them in an appropriate engagement track.
Support delivered to patients, family, and caregivers
GoMo Health’s Concierge Care® program, enables patients, caregivers, and family members to be included in post-discharge communications, health education and crucial reminders. This inclusive approach is designed to improve communications between everyone in the patient’s community of care, providing a better understanding of daily issues and relevant topics for patient-caregiver-family member discussions.
A cost-effective approach to reducing unnecessary readmissions
Following enrollment by a discharge administrator, nurse, or case manager as part of the discharge process, patients, caregivers, and family members receive three personalized Care Messages per week for up to three months, based on the select plan of care. Concierge Care® provides a unique and cost-effective approach to reduce readmissions and improve communications for high-risk populations.