Increase Revenue and Results
with a Post-Discharge Call Program
through return to center and in network referrals to your team
Decrease VBP Penalties
by reducing the readmission rate from home
Help Avoid Litigation
with real-time complaint alert and documented patient feedback
with managed care groups with readmission intervention data
Improve Online Reviews
through request and follow-ups, with appreciative patients
Improve Patient Satisfaction
by addressing issues and extending care after they discharge home
Benefits for Skilled Nursing Facilities
Ensures a Smooth
Transition to Home
Nexus Health care coordinators confirm timely receipt of post-discharge services and medications by coordinating directly with other service providers. We also assist with scheduling and confirming attendance with follow-up appointments.
Identifies and Escalates
Changes in Condition
Through Nexus Health Call Center we educate the patient on disease-specific yellow and red flag symptoms and the specific activities to stay healthy. If changes in clinical condition occur, we immediately escalate concerns to a designated member of your clinical team.
Supports Quality and
We will incorporate your patient-specific satisfaction and experience questions into our call to help your organization identify areas for improvement. Our care coordinators take an active role in referring patients to other services within your care network.
Nexus Health Call Center Program
- Schedules PCP follow-up appointments and secures transportation when necessary
- Ensures prescriptions have been filled and all medication questions have been answered
- Confirms the home health provider has contacted the patient and there are no concerns regarding visits
- Confirms DME equipment has arrived and helps with troubleshooting if/when there are delivery issues
- Asks patient satisfaction and experience questions
- Reviews disease-specific yellow and red flag symptoms
- Identifies changes in clinical condition and escalates concerns to a designated clinical team member
- Asks questions unique to your facility and customized by you
- Delivers automated calls that allow the patient to connect with a member of the Nexus Call Center team
“ By bridging that gap between skilled nursing facility and home, Nexus Health Resources allowed us to capture more referrals to our TheraCare Home Health network. This not only improved the patient experience and quality of care, but it provided a return on investment for Cantex Continuing Care.”
Lara Cline, NP,Director of Care CoordinationCantex Continuing Care Network
Some of Our Success Stories
Condition(s): Hip Replacement
During a routine 48-hour discharge call it was discovered that the patient had not received the prescribed Durable Medical Equipment (DME). A Nexus Health transitional care coordinator initiated a three-way phone call with the DME company to determine why the equipment was not delivered. The issue was resolved and delivery was scheduled for later that day, which allowed the patient to ambulate and work toward recovery.
During a 1-week interval discharge call the patient shared that he was having difficulty with bathing. Nexus Health assisted in securing a handicap shower stool and having it delivered to the house.
At two weeks post discharge, Nexus Health transitional care coordinator phoned Chuck to see how things were progressing and asked if he had been weighing himself daily as directed; he admitted he had not weighed himself in a few days. When asked to weigh himself during the call, Chuck reported a 4-pound weight gain. Nexus Health initiated a three-way phone call with Chuck’s primary care physician and the care plan was updated to include a diuretic. Additionally, Nexus Health reinforced the discharge instructions, including a review of Chuck’s low-sodium diet requirements. The quick intervention on weight gain helped to avoid a readmission.
Condition(s): CHF, Diabetes
Nexus Health contacted Bruce one week after being discharged with a pneumonia diagnosis. During the call, the patient reported that his blood glucose levels were high. Nexus Health assisted Bruce with securing a same-day appointment with his primary care physician.
When following up with Betty 24 hours after discharge, it was discovered that her local pharmacy was out the prescribed antibiotic and she was waiting to hear back. Knowing that without the medication the patient was likely to readmit, Nexus Health transitional care coordinator initiated a three-way call with the pharmacy and Betty to secure the antibiotic. The pharmacist was able to secure the antibiotic from a sister location, thereby reducing the risk of readmission.
Condition(s): Knee Replacement
Nexus Health followed up with Anthony 24 hours after discharge from a knee replacement procedure. It was discovered that Anthony had not made an appointment with his primary care doctor because he was unable to drive and didn’t have access to transportation. Nexus Health assisted with securing an appointment with his primary care physician as well as transportation to and from the appointment through a local church volunteer group.