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What is Transitional Care?

Our Transitional Care team monitors patients who were recently discharged from an acute care facility who are at high risk for readmissions.

  • Manage conditions that influence post-acute recovery using remote patient monitoring to help prevent condition exacerbation
  • Decrease avoidable rehospitalizations and ER visits
  • Monitor goals and measures including follow-up visits and medication adherence
  • Reduce total cost of care through performance-based transitional care

RemoteCare makes Transitional Care easy for Home Care Agencies.

STEP 1

Identify Patients for Remote Patient Monitoring

  • Two Chronic Condition or more
  • Medicare Eligible – RF can do query!

Agency refers Patient to RF via JotForm or Patient Report

STEP 2

Agency or RF Contacts Patient

  • Education Patient /Aide on RPM
  • Get Patient Approval ( HIPAA)

STEP 3

RF Clinician Evaluates & Prescribes RPM

  • RF Clinician Creates CAREPLAN
  • RF Clinical staff defines the measurement ranges & assigns monitoring clinical pathways. ( 90+)

STEP 4

RF Delivers Device Directly to Patient

STEP 5

RF & Aide Assist Patient use of Device

STEP 6

Technology & Case Managers Monitor Patient

  • Monitor Patient
  • Automated Reminders/ Live Reminder Calls
  • Live Case Manager Coaching based on Care plan
  • Built in Alerts
  • Documented Communication
  • RF Provide Device Support

Why Consider Remote Focus as a Partner?

In an environment that is focusing more and more on clinical measurements and outcome, Remote focus is the perfect partner to help agencies address the new clinical requirements. RemoteFocus team grew inside the homecare market and understands the complexities of your agency to become a true partner.

Dive Into the Benefits of Remote Focus

  • Increases patient compliance with recommended preventative care measures, such as Medication Adherence, Lifestyle & Nutrition choices.
  • Increases ability to catch new health concerns and complications faster and sooner.
  • Increases Agency’s compliance with quality measures.
  • Increases patient compliance with recommended preventative care measures, such as Medication Adherence, Lifestyle & Nutrition choices.
  • Increases ability to catch new health concerns and complications faster and sooner.
  • Increases Agency’s compliance with quality measures.
  • Increases patient compliance with recommended preventative care measures, such as Medication Adherence, Lifestyle & Nutrition choices.
  • Increases ability to catch new health concerns and complications faster and sooner.
  • Increases Agency’s compliance with quality measures.

More Benefits Include:

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Deliver Better Clinical Outcomes

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Reduce hospitalization

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Increase Value based reimbursement

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Increase Patient retention (Transitional care)

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Increased Patient Satisfaction/feedback

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DME Allocation

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Referrals

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Ad hoc Prescriptions

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Clinical/Patient data - Medications/Diagnosis/Health Status

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Reduce Loneliness & identify depression

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Urgent Telehealth