Post Acute Transitions
In-person visits are essential to reducing unnecessary hospital readmissions
Approximately 3.3 million adults are readmitted to a hospital within 30 days of discharge, contributing to $41.3 billion in hospital costs. Medicare beneficiaries account for the largest proportion of readmissions (55.9%) and an estimated 23% of readmissions are preventable. The Matrix Medical Network Post-Acute Transitions program enables health plans to deliver support directly to members to help them recover effectively and avoid unnecessary readmissions.
High-Touch Care Prevents Hospital Readmissions
An essential component of any readmission reduction program is an in-person visit to those members identified as high risk for complications and the potential for unneeded re-hospitalization.
By conducting in-person visits with those members at the highest risk, Matrix helps to improve the success of readmission reduction efforts.
High-Touch Care Prevents Hospital Readmissions
An essential component of any readmission reduction program is an in-person visit to those members identified as high risk for complications and the potential for unneeded re-hospitalization.
By conducting in-person visits with those members at the highest risk, Matrix helps to improve the success of readmission reduction efforts.
Personal Post-Discharge Support
Through this program, a Matrix clinician conducts a home visit and assessment shortly after care transition. These visits support the member:
- As they transition back home after a hospital stay resulting in higher member satisfaction
- By increasing member confidence to be an active participant in managing their recovery as they move from the hospital back to the home
Visits can be conveniently ordered, on-demand, by the health plan’s care management team via our web portal.
The Four Components of the Matrix Assessment
Ensuring Adherence to Post-Discharge Care and Recovery
Documentation
Medication Reconciliation/Personal Health Goal
Complete medication reconciliation and develop health goals and questions for physician as part of simple person-centered record
Coaching
Medication Self-management
Utilize medication self-management approach to improve knowledge and understanding of medication regimen
Follow-up
With PCP/Specialist
Confirm primary care and/or specialist follow-up appointment is scheduled
Education
Patient Knowledge of Red Flags
Address “red flags” and ensure that patient is knowledgeable about warning signs regarding change in condition and how to respond
Documentation
Medication Reconciliation/Personal Health Goal
Complete medication reconciliation and develop health goals and questions for physician as part of simple person-centered record
Coaching
Medication Self-management
Utilize medication self-management approach to improve knowledge and understanding of medication regimen
Follow-up
With PCP/Specialist
Confirm primary care and/or specialist follow-up appointment is scheduled
Education
Patient Knowledge of Red Flags
Address “red flags” and ensure that patient is knowledgeable about warning signs regarding change in condition and how to respond
The Matrix Difference
Matrix post-acute transitions program addresses the readmissions challenges that health plans face. Matrix helps to improve the success of readmission avoidance by conducting in-person visits with members that are identified as most at risk. The four elements of the Matrix assessment standardize and improve post-discharge care and recovery as members transition from the hospital back to the home.
Contact us today to see how we can help you close critical care gaps to improve the overall health of your members and help you meet your quality goals.
The Matrix Post-Acute Transitions Program enables health plans to execute their programs to reduce avoidable hospital readmissions.