Transitional Care Services

We are dedicated to promoting the safe and timely passage of patient care plan requests across all levels of health care. Through our unique platform, care coordination is automated for enhanced patient experience, compliance and profitability.

ACH’s Care Coordination Manager is a rules-driven, closed loop messaging platform that enables hospitals, or other at-risk entities, to share and assign care plan requests across a diverse provider community and receive structured replies. It’s a solution designed to help hospitals, health systems and provider-led health plans succeed with 30-to-90-day episode management, whether for ensuring bundled payment profitability, maximizing ACO savings, managing post-acute costs, or reducing re-admissions.

Spanning the care continuum, ACH’s Care Coordination Manager serves:

  • Hospitals
  • MD groups
  • Home health
  • SNFs/LTACs
  • Health plans
  • ACOs
  • Care management companies
  • Bundled payment conveners

how we do it

  • Based on the health care organization’s rules, Care Coordination Manager uses feedback received from MDs, SNFs, LTACs, HHAs and other network providers to adjust a patient’s care plan accordingly.
  • Updated the patient’s episode record
  • Triggers care manager intervention when needed
  • Using interoperability standards inherent in every certified electronic health record (EHR), the solution integrates with the EHR of the hospital/health system and those of community providers to streamline coordination and share clinical information required for effective care transitions.

What This Means For You

  • Full visibility into the compliance of a patient’s post-discharge care plan throughout the duration of the entire episode of care.
  • Certainty of care plan compliance, even 30-90 days after leaving the hospital.
  • Bundled payment profitability
  • Fewer avoidable re-admissions
  • Improved patient engagement
  • Incremental revenue from Transitional Care Management (TCM) visits
  • More efficient use of care managers