Transition Risk

Management

Continue Care. Reduce Rebound.

Focus your scarce resources on the patients most vulnerable for readmission and revisit. Get risk stratification, features and analysis of the individuals being managed in and immediately after an acute or emergency encounter for 30-day readmission or 30-day revisit risk.

Components of Spotlight Transition Risk Management include:

 

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Unplanned readmissions are costing the US healthcare system upwards of $20B annually.

The 30-Day Inpatient risk module provides a focused view of patients in an active or recently discharged inpatient encounter. Every patient is assigned a risk score for readmission, along with reasons for increased risk to enable personalized discharge planning activities to mitigate the risks associated with transitions in care

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8.2% of patients revisit an ED within 3 days and in some cases cost 118% of the index visit

The 30-Day ED Revisit risk module provides a focused view of patients in an active or recently discharged emergency encounter. Every patient is assigned a risk score for revisit, along with reasons for increased risk to allow for personalized follow up activities to mitigate the risks associated transitions in care.

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Early palliative care can save money and improve quality of life in many patients.

The 1-year risk of mortality score helps inform clinician discharge decisions and provides caregivers with insight to help them guide patients and families to options when end of life is near.

 

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Payers are requiring more and more accountability beyond the episode

Track, trend and improve quality and performance around length of stay, ED revisits and inpatient readmissions, including key episodes types like coronary artery bypass graft (CABG), acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia and total knee arthroplasty (TPA)/total hip arthroplasty (THA)

Key Features

Check White 400Outreach List

Select active or recent encounters in highly customizable outreach lists

Check White 400Customizable Filters

Filter on any standard or custom attribute for maximum flexibility.

Check White 400Risk Distributions

Encounters stratified by risk probabilities for quick and easy visualization and focus

Check White 400Risk-Adjusted Targets

Benchmark performance on risk adjusted targets for more meaningful comparisons

Check White 400Transparent Risk Features

Target interventions based on specific risk drivers using individual risk probabilities and weighted risk features for each event, cost or condition.

Check White 400Workflow Integration

Worklists can be integrated with care management systems or EHRs and data can trigger workflows or rules in host systems.

Check White 400Social Determinants of Health

Individual health risks associated with social determinants are exposed for discussion and non-medical interventions.

Solutions Proven in Research and Practice

Our proven risk management and analytics models give healthcare organizations the power to act on real-time insights to improve health at a lower cost.

Solutions Proven in Research and Practice

Our proven risk management and analytics models give healthcare organizations the power to act on real-time insights to improve health at a lower cost.