This program is designed for completing and documenting tasks related to post-discharge under CMS’ Transitional Care Management initiative. Clinicians are able to work from a real-time updated Worklist of discharged patients. Post-Discharge Pathways are auto-triggered and patient Check-Ins are queued-up for a 30-day patient follow-up.
Programs contain proprietary clinical content, rules, and configuration settings that leverage the features of the RoundingWell platform.
RoundingWell Pathways facilitate efficient patient management. Whether it’s disease management, or physical or emotional health needs, evidence-based protocols guide clinicians through every step in a protocol.
Backed by clinical literature, programs include pathways that extend evidence-based guidelines and best practices throughout the care continuum.
Customers can further modify a program’s pathways to suit their organization’s needs. Also, customers can convert their own protocols and policies into our actionable pathway format.
As clinicians assign tasks, complete tasks, capture task notes and communicate with other clinicians, care management documentation is being timestamped and logged for automatic export back to the patient’s chart in the EHR.
Whether a patient is managing a chronic condition or they’ve been recently discharged, RoundingWell is effective at connecting with patients between visits through lightweight digital touches called Check-Ins.
Questions are automatically sent to patients or an approved caregiver to assess their current health status and to screen for specific needs. Education content tailored to the patient informs them about their disease, condition, and treatment plan.
By syncing to the patient’s current setting and treatment phase, RoundingWell Check-Ins help anticipate patient needs. Check-Ins incorporate notifications, screenings, and direct messages. Any potential patient-reported complications will trigger risk alerts.
Risk Alerts can be auto-triggered from rule-based EMR data or from patient-generated data from Check-Ins. Actionable alerts enable clinicians to practice exception-based care.
Once a risk is identified, RoundingWell automatically triggers a pathway if one exists. Also, customers have control over what alerts are identified, and clinicians are able to sort and filter their alerts.
Bi-directional integration streamlines workflows through automation and improves the efficiency of your clinician teams as they manage patients.
Segmenting your population is helpful in tracking care programs, assigning patients to a clinician or team, comparing patient groups, tracking and comparing performance, etc.
If the clinical data is available, RoundingWell can automatically trigger risk alerts and pathways based on EHR data.
Activity captured in RoundingWell is timestamped and logged for automatic export back to the patient chart in the EHR (via ORU messages).
Capture electronic assessments and screenings, such as PHQ-9, GAD-7, TICS, and PAM. Assessments are scored, which can then trigger risk alerts or prompt other actions in a workflow.
Patients automatically appear on a worklist when they match the inclusion rule(s) for that list. Reports uncover clinician and team adherence to standardized protocols.
Get in touch for a demo of our platform and to see care programs in action.