Care Transitions

A set of rules, assessments, and workflows, the Care Transitions capabilities in Jiva help case and utilization managers:

  • Assess admission/readmission risk
  • Conduct pre- and post-discharge care transitions
  • Prevent unnecessary ER visits and assist in identifying avoidable hospital care

Assess admission/readmission risk

Proprietary predictive models combine with client-configurable rules to identify individuals at risk for admission or readmission. Using data in Jiva and from a variety of other sources, including behavioral and social determinants of health, statistical models generate a risk rank and index, stratifying individuals as high, medium, or low risk. The results inform pre-discharge planning, admission risk assessment, and 30-day readmission risk assessment, which then drives the appropriate transition of care plan based on the patient’s situation and needs.

Pre- and Post-discharge assessment

This assessment optimizes the discharge process before, during, and after discharge, thereby improving the care of patients as they transition from hospital to home and lowering preventable 30-day readmissions. The assessment provides care planning recommendations for safe discharge and acts as a comprehensive guide for pre-discharge planners to coordinate communications and care. It also includes a post-discharge review, administered at up to 30 days, designed to mitigate complications that could lead to readmission.

Prevent unnecessary ER visits

The ER Prevention ruleset identifies individuals who use the ER for conditions that are treatable through primary care and individuals whose care is now emergent but stemmed from a preventable or avoidable condition. It provides an outreach assessment and recommended care planning to modify patient behaviors to reduce unnecessary ER visits.