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New program supports patients at risk for readmission

Care Support Resources (CSR) recently launched a new care management program—called Transitions of Care—that provides hands-on support for at-risk patients following discharge from a Legacy hospital. An R.N. case manager works with patients for 30 days following discharge from the hospital to aid in their recovery and reduce the risk for readmission. Transitions of Care supports the broader Care Support Resources effort to deliver care and improve outcomes for at-risk populations.

Legacy identifies patients to participate in Transitions of Care using a predictive model that incorporates data from historical medical and pharmacy claims, clinical data and self-reported data. Patient eligibility for these services is based on their insurance coverage. Current participating payors include the Legacy Employee Health Plan and CareOregon. We anticipate additional payors in the future.

Key components of the Transitions of Care program

  • R.N. case managers collaborate with care management staff and/or bedside nurses on discharge plans for patients participating in Transitions of Care.
  • Participants receive a home visit within 48-72 hours of discharge, during which an R.N. case manager evaluates whether they have the resources and support needed to follow their discharge plans.
  • R.N. case managers continue to check in with participants during the 30-day post-discharge window, monitoring their progress and providing support when needed. 
  • After 30 days, the patient, RN case manager, and primary care provider will determine if it is appropriate to enroll the patient into Legacy’s Care Support Resource’s Complex Care or Condition Care programs for ongoing support.

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