Transitional Care Software Post Acute


Transitional Care Software

NexusConnexions® enables skilled nursing facilities to avoid unnecessary expenses and penalties by addressing the needs of patients that are currently living outside of direct medical care. The patent-pending technology automatically assembles an agenda for each patient interaction that is specific to their diagnosis, chronic conditions, payer, and referral hospital. For each communication activity, NexusConnexions provides dialogue suggestions and condition-specific objectives, which help the user apply proven tactics to positively influence patient outcomes and care plan adherence.


NexusConnexions Features

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Patient-Specific Transitional Care Follow-Up Assignments

Automate the assignment of customized transitional care follow-up calls from over 100 disease-specific care plans. Follow-up call assignments can also be customized by the patient’s referral hospital, payer, or readmission risk level.

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Customizable Condition-Specific Scripts

Apply consistency across your team on every communication with scripts that educate the patient on recognizing changes in their condition, responding to those changes, and improving adherence to their plan of care.

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Include Automated Calls between Live Calls

Optimize the efficiency of your team by giving them the option to send automated call reminders that give the patient a one-click option to connect directly with your team.

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Alerts Shared Across the Team

Keep your transitional care coordinators and clinical managers informed About changes in patient status through email alerts and a dashboard menu.

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Demonstrate Post-Discharge Readmission Preventions

Show your referral partners and payers the value.

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Provide Details on Patient Reach and Engagement

Provide your payers and internal team with details regarding your successful track record of reaching their patients as well as summarized reports of all the data collected from each patient encounter.

Benefits of NexusConnexions® for Hospitals and Health Systems

Cost Savings

  • Increase revenue by reducing value-based purchasing (VBP) program penalties
  • Reduce payroll expenses by effectively tasking non-clinical team members with performing and tracking post-discharge follow-up calls
  • Optimize reimbursement by supporting at-risk patients and ensuring care plan adherence during the critical post-discharge period

Organizational Benefits

  • Improve patient outcomes post-discharge
  • Gain insight into transitional care team performance
  • Improve patient feedback and quality measures
  • Protect referral partner and payer relationships by demonstrating transitional care successes