Reducing Readmission with Follow Up Care

Written by Innovation Care Partners | Jan 7, 2025 3:56:53 PM

Reducing Readmission with Follow Up Care
Mapping out follow-up care for patients while they’re still in hospital, Innovation Care Partners (ICP) and HonorHealth’s Collaborative Care model can help improve a patient’s recovery safely outside of it.

A Connected Ecosystem of Care
As a clinically integrated network and accountable care organization (ACO), ICP has built a large Care Management program with Transitional Care Managers (TCM) and Care Coordinators (CC) supporting patients – from the PCP office to hospitals and skilled nursing facilities and home.

Working Together for Better Outcomes
ICP’s affiliation with HonorHealth Hospitals allows ICP TCMs to work closely with HonorHealth case managers, patients and family members to plan care after discharge. TCMs talk with PCPs and specialists to bring information about the patient’s health and care history to help case managers make recommendations patients are more likely to follow.

Creating a Recovery Roadmap

Whether patients are discharged to a post-acute facility or home, ICP TCMs create a detailed transition plan covering:

• Follow-up visits with primary care physicians and specialists within days of release.

• Warm hand-offs to ICP Care Coordinators embedded at PCP offices for follow-up with prescriptions, appointments, and services.

• In-home services for DME and physical or occupational therapy.

• Patient and family education about their conditions and offer at-home care options.

• Potential social needs and coordination of services from a network of providers.

The primary goal of the Collaborative Care model is to keep patients safe and on the path to successful recovery.

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