To health plans, hospitals, and accountable care organizations, ILS Care Transition Services dramatically reduces avoidable readmissions with “high-touch” interventions and access to community based support services coordinated through our unique technology platform which can be seamlessly integrated with existing medical management processes. ILS Care Transition Services provides critical support, effective coordination of services, and vital guidance immediately following an in-patient stay for a successful recovery at home to the elderly and at-risk populations.
ILS Care Transition Services offers support at the time when elderly, dual-eligible and special needs individuals are most vulnerable: the transition from an institutional setting back to the home and community. It is designed to optimize the ability of individuals in hospitals or nursing homes to return to their place of residence, improve their recovery, and avoid readmission.
The program goes beyond clinical care models and looks at lifestyle components that may impact readmission rates, such as poor nutrition or inability to fill prescriptions, to more fully address the unique needs of the member. The comprehensive program educates patients on healthy living, coordinates service delivery, and facilitates access to appropriate resources to ensure a successful transition. The program involves:
Individualized Counseling: Connects hospitalized members with coaches who meet with them in the hospital before discharge, follow up with a home visit within 72 hours, and maintain regular telephone contact for the duration of the transition (up to 60 days). The coach helps to follow the post-discharge plan and develops the personal health record.
Comprehensive Home Visit: Unique in the industry, the Care Transition program gets a true sense of a member’s needs and lifestyle through home visits, the cornerstone for a successful post-acute care transition program.
Specialized Technology: ILS’ differentiated process of identifying institutionalized members and its system of managing cases through a web-based portal are designed to seamlessly integrate into health plans’ existing medical management and operational processes. Also, ILS has partnered with BenefitsCheckUp in order to help our members find benefit programs that can help pay for medications, health care, food, utilities and more.
Streamlined Coordination Among Stakeholders: Care transition care plan developed by ILS Care Transition Services coaches enables strong integration and coordination of clinical and community-based support elements
In today’s fractured healthcare system, this holistic approach gives members the best chance at a successful recovery, significantly reducing readmissions, decreasing associated costs for payers, and providing increased peace of mind to members and their families.
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