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Background & Problem Summary

Today’s focus on value-based care delivery demands that providers continually monitor their patients across the care community. Just waiting for when the patient comes in for an appointment is no longer enough. A study published in 2009 highlighted the need for improvement in care transitions by shining the light on preventable readmissions. One fifth of the Medicare beneficiaries studied returned to a hospital within 30 days.1 There was one striking feature – 50% of the readmitted patients had no follow-up outpatient visit post-discharge.

Event-based notifications are valuable for alerting providers to care events, such as admissions or discharges, that happen to their patients in other care settings. Management of chronic diseases and at-risk patients is improved, time to intervention is decreased, and communications between providers and patients is enhanced.

Notify makes it simple for providers to monitor activities for their patients across the care community, enabling proactive responses that support improved outcomes, higher reimbursements and lower overall costs.

1 S. F. Jencks, M. V. Williams, and E. A. Coleman, “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program,” NEJM, April 2, 2009 360(14):1418–28

Application Overview

Empower clinicians with timely event-based notifications, so they can effectively monitor and proactively care for their patients across the care community.

Notify is a platform designed to curate the stream of health care data as it flows through communities. It searches out significant events and delivers that information in a timely manner to help drive actionable results. Notify provides notification subscription based real-time events to care team members when there has been a significant event with one of their patients.

The robust Notify subscription functionality allows users to customize their notification subscriptions based on various criteria so they only receive notifications about the events and patients that are relevant to them. For example, the patient list functionality allows users to subscribe to event notifications for a specific set of patients, and the provider role functionality allows users to subscribe to event notifications based on a provider’s role. With Notify, keeping providers informed of care events such as a hospital discharge or readmission is easy.

Benefits and Features

Stay apprised of patient activity across the care continuum

Receive real-time alerts when your patients have a significant care event such as an admission, discharge, or readmission, in any care setting across the community.

Enhance care coordination

Augment care management programs with real-time, actionable information so care team members can proactively collaborate about patient care.

Customize notifications to meet your workflow

Subscription wizard allows users to customize their notification based on various criteria, so users only receive alerts about events and patients that are relevant to them, in their desired delivery modality (email, SMS, Direct message or Notify portal).

Reduce costs treating high-risk, high-cost patients

Event-based notifications provide real-time, actionable patient information so providers can effectively intervene with the most appropriate care for a patient, ultimately improving outcomes and reducing costs.

Improve reimbursements and qualify for incentives

Facilitate prompt follow-up by notifying primary care physicians of discharge events immediately so they can qualify for Transitional Care Management (TCM) reimbursement.

Use Cases

  • High-risk patient presents to the Emergency Department, and the care manager immediately receives a notification and intervenes with more appropriate care for the patient, ultimately improving the patient’s outcomes and reducing costs.
  • Patient is discharged from the hospital, and primary care physician is notified, so they can proactively schedule the patient’s follow-up appointment, and engage with the patient on post-discharge care.
  • Patient is readmitted to the hospital in less than 30 days, and all care team members are notified so they can collaborate and redirect the patient to a more appropriate care setting.
  • Home health providers are alerted in real-time about hospital admission, readmissions and deaths for their patients, enabling proactive planning and management of staff scheduling.
  • Emergency department case managers are able to identify patients who chronically utilize the ED for non-urgent care, allowing them to intervene and redirect patients to more appropriate levels of care.
  • Patient is admitted to the hospital, and the payer case manager is notified of the admission in a timely manner.