Transitional Care

A Hospital Readmission Solution

Guardian Healthcare provides a framework for an improved transitional care model to help reduce preventable hospital readmissions and avoidable emergency department visits.

The Guardian Healthcare Transitional Care Model

Identify Through multiple predictive modeling systems and in-home patient assessments, Guardian Healthcare clinicians are able to identify patients at high risk for preventable readmissions and emergency department visits	Collaborate Transitional Care Coordinators help facilitate the coordination of care and collaborate with the patient and caregiver, physician, hospital, health plan, and other healthcare facilities	Integrate Evidence-based clinical pathways are integrated into patient-specific care plans, leading to improved outcomes and increased patient and caregiver satisfaction	Educate Comprehensive patient and caregiver education, including signs and symptom awareness, medication management and reconciliation to encourage patient engagement	Follow Up Ensure timely follow up physician appointments occur post-discharge, coupled with Guardian Healthcare telehealth services to complement in-home patient visits	Report Real-time hospital and health plan-specific outcome reporting. Patient readmission notification reporting within 24 hours
			Transitional Care Model of Success

Did You Know?

Guardian Healthcare has a 7% readmission rate for patients readmitted to an acute care setting within 30 days of start of care with a diagnosis of Heart Failure, Pneumonia, or Myocardial Infarction (with the same readmitting diagnosis).

Why Patients Go Back to the Hospital*

Patients may not completely understand what is wrong with them
Patients may be confused about what medicines they should take and when they should take them, and they may not take the right medication at the right time
Hospital staff may not communicate important information to patients’ primary care providers
Patients may not schedule needed follow-up appointments with their primary care providers or specialists
Hospital staff may not inform patients or their primary care providers of test results that could affect their care
Family members may not know how to help provide care at home

Dartmouth Atlas of Health Care, Care About Your Care, September 2011

Our vision is to transform the delivery of care to create a better healthcare experience.

Our mission is to continuously improve the value of healthcare - across the continuum and for all stakeholders - through innovation, collaboration and excellence.

Transitional Care

A Hospital Readmission Solution

The Guardian Healthcare Transitional Care Model

Identify

Collaborate

Integrate

Educate

Follow Up

Report

Did You Know?

Why Patients Go Back to the Hospital*