Care Transition Services

Current data indicates that 15-20% of individuals who are discharged from hospitals will be readmitted within 30 days or less*. Many of these readmissions are preventable. ILS Care Transition Services (CTS) has been proven to significantly reduce readmission rates. By working closely with our healthcare partners and individuals who have been recently discharged, we have been successful with transitioning individuals back home after a hospitalization and dramatically reduce avoidable readmissions through “high-touch” interventions and access to community based support services. ILS Care Transition Services provide critical support, effective coordination of services and vital guidance immediately following an in-patient stay to ensure a successful recovery at home.

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 health and avoid a readmission.

Our program goes beyond clinical care models and looks at lifestyle components that may impact readmission rates, such as nutrition and the ability to fill prescriptions. Our comprehensive program educates patients on healthy living, coordinates service delivery, and facilitates access to appropriate resources to ensure a successful transition. The Care Transition Program employs a multi-faceted approach consisting of the following:

Individualized Counseling: Transition Coaches meet with patients in the hospital or skilled nursing facility prior to discharge. They explain the discharge plan with clear instructions to follow at home. An in-home follow up visit is conducted within 72 hours post-discharge. Individuals are then monitored by the Coach and Transition Care Coordinators who maintain regular telephone contact for the duration of the transition period (up to 60 days), monitor progress and update the individual’s health record.

Comprehensive Home Visit: The Care Transition program provides expert coordinated transition planning, service delivery and monitoring through a Comprehensive Home Visit scheduled 48 –72 hours post discharge. This home visit provides the Transition Coach with a better sense of the individual’s needs and current lifestyle and what interventions may be required to ensure successful recovery at home. The home visit is the integral interaction for the post-acute Care Transition program.

Specialized Technology: ILS’ eCare Central integrated technology platform and data analytics capabilities enable prompt identification of members who are hospitalized and will be in need of discharge and transition planning. ILS’ web based portal enables ILS, health plans and providers the ability to view Individual Care Plans, details of the discharge and transition plan and monitor service delivery and health outcomes. ILS has partnered with BenefitsCheckUp in order to help our members find benefit programs that can provide financial assistance for medications, health care, food, utilities and more.

Streamlined Coordination Among Stakeholders: The development of a post-discharge plan includes both clinical and support service needs, a comprehensive home visit by a Transition Coach, regular telephonic outreach, the ongoing exchange of data and information on service delivery and health status are all critical components of our program. Our integrated technology platform supports streamlined coordination among caregivers further ensuring the individuals successful transition from hospital to home. In today’s fractured healthcare system, this holistic approach gives members the best chance at a successful recovery, reducing readmissions, decreasing associated costs for payers and providing increased peace of mind to members and their families.

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*Source of Data Http://www.chqpr.org/readmissions.html