Development of a Patient-Centric Care Transition Management Platform for Post-Acute Care Providers

The organization faces difficulties in tracking patient movements and managing care efficiently as patients transition across various care facilities within a post-acute episode. Existing scalable solutions are inadequate, and the organization lacks in-house software development expertise tailored to their specific clinical workflows, leading to suboptimal patient outcomes and operational inefficiencies.

A mid to large-sized healthcare organization specializing in post-acute patient care, aiming to improve care coordination across multiple facilities and reduce readmission rates.

• Create an integrated, automated platform supporting complex patient care workflows across multiple providers.
• Enhance patient tracking through seamless data capture and real-time updates during care transitions.
• Reduce hospital readmissions and length of stay in care facilities by improving care coordination.
• Support compliance with relevant healthcare programs such as Medicare post-acute care initiatives.
• Develop a customizable solution tailored to the organization’s operational and clinical processes for improved patient outcomes.

• Workflow automation based on organizational clinical protocols
• Real-time patient tracking and care transition updates
• Integration with existing health information systems and external data sources
• Customizable user interfaces for care coordinators and providers
• Automated alerts and notifications for critical care events
• Care plan management and documentation support
• Analytics dashboard for population health management and program compliance

• Electronic Health Records (EHR) systems
• Health information exchanges (HIE)
• Care facility management systems
• Patient engagement and communication tools
• Billing and insurance systems

• High scalability to support increasing patient volume and data load
• Real-time data processing and updates with minimal latency
• Robust security measures compliant with healthcare data regulations
• System availability and uptime of 99.9%
• User-friendly interfaces for diverse clinical staff roles

The implementation of this integrated, automated care transition management platform is expected to significantly improve patient outcomes by reducing readmissions and length of stay, enhancing care coordination efficiency. It aims to support compliance with healthcare programs, increase operational transparency, and enable proactive population health management, resulting in improved quality of care and potential cost savings.