TAVHealth captures and integrates patient lifestyle and motivation information with conventional electronic medical records, supporting the best possible outcome for every patient, every time.
Our custom network of local community resources and support services is updated every quarter to ensure the resources are current. Knowing what patients are up against is the first step; having quick access to resources is the second. Improved outcomes, lower costs and a better patient experience are all achieved with the Triple Aim of TAVHealth.
Traditional fee-for-service workflows have created unintentional results – readmissions and poor care coordination post-discharge. As hospitals are pressed to improve patient outcomes to maximize payments, we can support your care delivery models.
TAVHealth’s proprietary patient engagement tool, TAVConnect, was used by a Southeastern regional hospital’s cardiology group to ensure that all patients consistently received the same high level of care and achieved outstanding results.
Post-Discharge Patient Follow-Up. 98.3 percent of patients received attempted follow up calls within 48 hours of discharge.
Successful Post-Discharge Patient Contact. 83.4 percent of patients were successfully contacted from follow up calls within 48 hours of discharge.
Timely Physician Notifications. 86 percent of physicians were promptly notified of their patients’ hospital stays, driving better patient care.
Reduced 30-Day Readmissions. Over four years, the cardiology group was recognized by CMS for reducing 30-day readmissions more than 50 percent, from 17.8 percent to 8.2 percent.
The oncology care model is part of CMS’ effort to improve care quality and coordination and reduce the cost of specialty care. The five-year model started in spring 2016 includes payment arrangements based on financial and performance accountability for episodes of care surrounding chemotherapy administration to cancer patients.
TAVHealth’s proprietary patient engagement tool, TAVConnect, was used by a team of oncology nurse navigators, with notable results.
Increased Navigator Capacity. A three-fold increase in the number of patients managed by nurse navigators. Improved efficiency and better patient care.
Increased Physician Referral. Targeted communication and education ensured that physicians referred patients to oncology navigators. Before TAVHealth, nearly 60 percent of physicians declined to do this.
Decreased Emergency Department Visits. Before TAVHealth, 25 percent of oncology patients visited emergency departments for pain management. Education and process changes reduced that number to fewer than 5 percent.
Our customers rely on our rich experience working with the orthopedics population to provide best practices to track and complete requirements to support the service line.
Configured for the population and their needs, TAVHealth supports teams with the required and critical tasks for each patient. Starting with monitoring patient admission and discharge, identifying high-risk and very high-risk patients, users can easily document inpatient chart review, record program assessment appointments and set up care conferences. It also provides a forum for handling high-touch tasks like pre-surgery education and a warm hand-off.
Orthopedic Customer Success – One-Year Outcomes
Improved Patient Experience. Length of stay now just 1.2 days
Care Continuity. 98 percent of patients were called and 83.4 percent were reached within 48 hours of discharge
Risk Mitigation. Readmission rates all-cause fell by 33 percent
Collaboration for Cost Savings. Cost of care during the 30-day bundle period fell by 40 percent
Decisions Based on Real-Time Reporting. Cost of care after the 30-day bundle period fell
Financial Success. First-year net payment reconciliation
TAVConnect helps Clinically Integrated Networks (CINs) by connecting patients and families with the resources they need.
TAVConnect helps CINs by helping identify gaps in care and social needs when they happen. Care quality, the focus on positive patient outcomes and satisfaction improves health by caring for the whole person and their needs.
Personal Conversations Drive Insights. Using TAVConnect, care providers are prompted to record information about patient lifestyles, health goals, support networks and potential barriers to care.
Conventional Data Integration. Data collected through HL7 and ETL systems integration combined with relationship-based insights provides the insights needed for the best possible patient outcomes, every time.
Tracking EMR Discharge Transitions. With TAVConnect, notifications are sent to health care providers when a person reenters the ED. Before TAVConnect, the only way nurses and health care workers would learn that their discharged patients ended up in the ER was from a phone call from the patient or their family. Hospital staff have access to data and metrics to understand the reasons why their patients are readmitting. More information leads to decreased ER visits, better care and patient satisfaction, and reduced costs for patients and hospitals.
Health coaching can have direct impact on reducing admissions and improving patients’ quality of life, by taking a personalized approach to patient care. Going beyond data outcomes with population health strategies works.
The creation of a true continuum of care to support population health strategies, diving deep to understand each patient’s core motivation and drivers for improving their health status allow everyone to establish tactics to achieve goals.
An ACO’s Success
Reducing admissions and improving the quality of life for a patient population of 65,908 with hypertension was the goal for one ACO.
Health Coaches. Hired 100 health coaches who work face to face with patients in physician offices on goal setting and tactics
Blood Pressure Reductions. 74 percent of patients in program reduced blood pressure to 140/90 or less, considerably better than national averages
Reduce Readmissions. Readmit rates dropped for 151.64 per 1,000 patients to 129.02 per 1,000 over a five-year period
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