CARE TRANSITIONS MANAGEMENT

Reduce readmissions | Improve patient experiences

Bridge care gaps with coordinated care transitions

Poor management of care transitions is a key driver behind readmissions and is estimated to generate over $45 billion in wasteful spend each year.

Managing patients post-discharge is currently a huge drain on hospital resource, with many patients still falling in-between the gaps because of failure to book timely follow-up appointments or difficulties passing information to PCPs/post-acute providers.

Lumeon’s Care Transitions Management solution allows emergency or inpatient departments to deliver consistent handovers by coordinating follow-up appointments and automatically transferring key information to post-acute providers.

For those ready to take things further, the platform can also risk-stratify and signpost patients at discharge. Low-risk cohorts can be managed by Lumeon autonomously, while it coordinates pathways for high risk patients by orchestrating both in-person and virtual checkpoints.

 

Key benefits:

a mobile phone screenshot showing a follow-up appointment reminder

 

An image showing the steps in the patient journey from hospital to home

Appointment coordination

Timely follow-up can have a significant impact on reducing readmissions. Lumeon ensures that this happens consistently and automatically, by reaching out to patients and post-acute providers to coordinate follow-up appointments.

In network 

Out of network 

Example follow-up message for patient
booking out of network.

Risk evaluation

Tackling readmissions starts before patients leave your hospital. Lumeon can generate risk scores at discharge and automatically assign patients to an appropriate pathway for post-discharge monitoring.

 

PCP notifications

Communication breakdown between providers is a key driver of readmissions. Lumeon ensures key information is automatically transferred to post-acute providers so that they can reconcile medications and reduce waiting times for appointments. No more waiting for discharge letters to be faxed.

Patient monitoring

Most hospitals don’t have the bandwidth to make discharge phone calls to every patient. Lumeon reduces workload by autonomously interacting with low-risk patients, while enabling nurses to maintain continuous contact with those most at risk.

 

Discharge instructions

 Patients often struggle to take in all the information communicated to them at discharge. In order to help them comply with key activities that need to be completed at home, Lumeon can automatically send patients standardized digital reminders, based on their discharge diagnosis.

Use case: Diabetes monitoring

A large health system has been using Lumeon’s automated SMS reminders to monitor diabetes patients with poor glycemic control who are at risk of readmission.

The program was devised so that diabetes nurses could keep a regular track of daily blood glucose levels, without having to take readings face-to-face or over the phone. Lumeon’s Care Pathway Management platform allows patients to receive automated SMS messages each day and text back their self-recorded glucose levels. This means patients on the program, often from low socio-economic backgrounds, don’t have to pay for travel into the hospital or take unpaid time off work.

Nurses have more accurate visibility of patient status, and are supported by automated detection of potential hypo/hyper glycemic episodes. The hospital can now successfully stabilize more patients on the program and safely transfer them to PCPs.


Results

a screenshot of an ipad showing a list of daily blood glucose levels from patients