TransitionCare™

Providing patients the tools needed to successfully stay home.

Providing facilities the support needed to increase quality metrics.

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Discharging Patients Home is Complex and Plagued with Challenges

Assessing Patient Help

Organizing Home Services

Discharge Planning, Summary, and Checklist

Providers need to make sure that the patient and their care giver can perform self care activities, eat an appropriate diet, follow up with designated providers, and obtain and self-administer medications.

Visiting nurses, personal care, infusion providers, and other in home services need to be referred to and post-pandemic in home care cases can take up to a week to be successfully opened.

Patients need to be discharged at an appropriate time, with the appropriate services, and signed off from the appropriate providers all while receiving a thorough and easy-to-understand summary of stay.

Patient Instructions

Teachbacks

Medication Reconciliation

Discharge education needs to explain: "Why was I in the hospital?" "How so I manage at home?" "What should I do if I run into problems?" "Why is in important for me to do this?"

Discharge teams verify patient and care giver knowledge multiple times by asking questions about a discharge summary and patient instructions: "What is your understanding of your heart problem?"

Teams need to make sure that the patient's biggest responsibility of their own - taking their medications properly - is explained, understood, and that the prescriptions they are leaving with are accurate.

Centennial reduces discharge planner's burden and better supports patients at home

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Medications provided at discharge and hand-delivered to patients to their home setting

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Medication reconciliation and safety review

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24/7 on-call support

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Seamlessly integrates into facility workflow

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Medication adherence tools and solutions

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Clinical pharmacist follow-up

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Quality metric analysis, closure assistance, and goal setting

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Home-based team follow up and support

The Data is Clear

8.9%

30-Day Readmission Rate, compared to 21.3% control group

98%

Medication Adherence - Including 98% PDC in cholesterol and diabetic measures

23%

Reduction in ER-Visits

97%

Of Patients Continued to use Centennial for 90-days or more 

Implement TransitionCare into Your Facility

Type of Facility

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Centennial's collaborative approach has let me focus on patient care. Centennial works with us to provide medicines to patients and medication reviews for our charts. They are an asset to our team, every day.

John W. (Primary Care Provider)