Azara Transitions of Care Module enables practices to receive real-time admission and discharge alerts from emergency departments and inpatient facilities, providing critical patient information to support timely follow-up care and reduce hospital readmissions.

Key Features

Real-Time Admission and Discharge Alerts Automated notification system for patient transitions

• Daily interface with Health Information Exchanges (HIE) or regional hospitals to receive patient admission and discharge information
• Automatic alerts integrated into Pre-Visit Planning (PVP) reports for immediate care team notification
• Critical details including admission date and time, location, diagnosis, and discharge disposition
• Support for both inpatient (IP) and emergency department (ED) stay alerts
• Timely access to comprehensive patient transition information not typically available in EHR systems

Transitions of Care Registry Reports Comprehensive tracking and management of patient episodes

• Daily registry reports to gather admissions and discharges within specific timeframes
• Filter and organize IP and ED events by date range and facility
• Identify "frequent utilizers" for targeted care management interventions
• Track readmission rates for cost management and performance monitoring
• Manage and monitor transition of care processes with relevant TOC quality measures through DRVS Dashboards

Care Management Passport In-depth patient episode review and coordination

• Comprehensive view of patient's inpatient or ED history and outcomes
• Synthesized longitudinal record combining data from multiple sources
• Support for medication reconciliation and discharge summary documentation
• Detailed patient information to support informed follow-up conversations
• Lower readmissions through comprehensive episode understanding

Discharge Follow-Up Support Streamlined post-discharge care coordination

• Improve patient follow-up by contacting IP/ED facilities to receive discharge summaries
• Access medication reconciliation documentation for safe transitions
• Enable care teams to recognize issues with medications or treatment plans
• Provide patient education and appropriately schedule follow-up care
• Support efficient and timely patient contact

Quality Measure Tracking Performance monitoring and compliance reporting

• Monitor transition of care quality measures through DRVS Dashboards
• Track performance metrics related to post-discharge follow-up
• Support NCQA PCMH requirements for population health management
• Enable data-driven insights for care improvement initiatives

Integration with DRVS Platform Seamless connectivity across population health management tools

• Integration with Pre-Visit Planning (PVP) for alert-based workflows
• Access to Care Management Passport for detailed patient review
• Connection with DRVS Dashboards for performance monitoring
• Coordination with other DRVS modules including Risk Stratification, Referral Management, and EHR Plug-In

Benefits

Reduced Hospital Readmissions Improved post-discharge outcomes through proactive care coordination

• Timely identification of recently discharged patients enables rapid follow-up
• Care teams can contact patients before complications develop
• Medication reconciliation and education reduce medication-related readmissions
• Frequent utilizer identification enables targeted interventions
• Project UTILIZE demonstrated remarkable reduction in readmissions across 20 Indiana community health centers

Improved Patient Engagement Enhanced communication and care coordination

• Automated alerts enable more timely patient contact
• Care teams can provide informed follow-up conversations with complete discharge information
• Better understanding of patient needs supports personalized care planning
• Improved patient experience through coordinated, seamless transitions

Enhanced Care Team Efficiency Streamlined workflows and reduced administrative burden

• Automated alerts eliminate manual tracking of admissions and discharges
• Pre-visit planning integration surfaces transition information automatically
• Care managers can prioritize high-risk patients and frequent utilizers
• Reduced time spent searching for discharge information across multiple systems
• RNs and PCPs appreciate improved timeliness of follow-up and scheduling

Better Clinical Decision-Making Comprehensive patient information supports informed care

• Complete view of recent hospitalizations and ED visits
• Understanding of diagnoses, medications, and treatment plans
• Identification of comorbidities and risk factors
• Support for evidence-based follow-up interventions

Value-Based Care Support Data-driven insights for population health management

• Readmission rate tracking for cost management
• Identification of high-utilizer populations for targeted programs
• Support for conversations with payers and funders regarding patient risk
• Leverage transition data to drive value-based care initiatives