transitions-of-care

“The CoCENTRIX Coordinated Care Platform facilitates best practices for safe and accountable Transitions of Care”

CoCENTRIX facilitates positive transitions of care for:

  • Psychiatric Hospitals
  • Intellectual Disability Programs
  • Developmental Disability Programs
  • Corrections
  • State Agencies
  • Community Providers
  • Residential + Long Term Care

Background

As the delivery of behavioral health services becomes increasingly more complex and fragmented, the emphasis on positive and accountable transitions of care is critical to long-term quality outcomes and preventable readmission (and in some instances, preventable incarceration).

Today, individuals receiving health care — particularly those with comorbid behavioral and physical health conditions — are treated in multiple care settings including hospitals, outpatient clinics, inpatient residential, Intellectual Disability and Developmental Disability Programs, Corrections, and those offered by community providers.

Unfortunately, the combination of fragmented care delivery and underfunded services present real barriers for successful transitions of care.  All too often, transitioning individuals fall through the cracks and become part of a revolving door cycle that is unsafe and costly.

However, with regulatory drivers such as the Affordable Care Act and state Olmstead Planning, positive care transitions are at the forefront of organizations providing accountable care.  The enforcement of the integration mandate in conjunction with new funding streams for front-end services provide a compelling case for best practices in transitions of care.


Solution
“With over 32 years of behavioral health and case management domain authority, CoCENTRIX technologies provide the coordination essential for consumer-centered, positive transitions of care.”

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Five Key Areas CoCENTRIX facilitates Positive Transitions of Care

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Connecting the Individual and Empowering his/her Circle of Support and Accountability

As individuals transition from one care setting or level to the next, vulnerabilities such as physical ailments and illness, confusion, insufficient housing and transportation, etc. can impede on their care. It is paramount to the success of the transition for care providers to identify and involve the individual’s friends and family (or surrogate support) –also know as his/her circle of support and accountability.

The CoCENTRIXccp offers CARETILES — mobile, consumer applications for the individual and his/her circle of support and accountability — enabling them to be active participants in the care plan throughout the entire transition of care.

Learn more about CARETILES and how your organization can monitor and engage the consumer with mobile applications.


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Safe and Accountable Discharge Planning

Discharge planning, a type of care transition, actually begins the moment a patient enters a healthcare program or facility regardless of the service or attention initially requested or required.

The CoCENTRIXccp empowers your organization to create, coordinate and monitor a patient-centered discharge plan from intake through numerous transitions, levels, or locations of care including the patient’s home and, in some cases, for their entire life.

Learn more about our Discharge Planning solution.


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Medication Management

As the individual transitions from one setting to the next, medication management becomes more complex, particularly for individuals with more severe behavioral and/or physical conditions.

The CoCENTRIXccp provides a 360 degree view of the individual’s care plan including a comprehensive view of the individual’s medication list. Providers can easily reconcile, instruct and review medications as well as ePrescribe from a single interface. Additionally, our platform provides tools to increase prescription adherence and reduce the financial burden with coupon offerings.


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Collaborative Case Management

A core tenet of care transitions is comprehensive and collaborative case management. The CoCENTRIXccp offers enterprise-level, consumer-centered case management where case managers, clinicians, and other knowledge workers can collaborate on assessments, aftercare linking and referrals, treatment plans, follow-up and reminders, and ultimately ensure the individual is receiving the right services by the right providers at the right time during and after the transition.

Learn more about the CoCENTRIXccp’s Collaborative Case Management for Transitions of Care.


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Ongoing Communication and Monitoring

Without proper communication, one organization providing care to an individual or family may capture- but fail to share with other organizations involved in that care – such critical information as high-risk predictors, care plans initiated, or changes in health status.

As with any case management, it is vital for providers involved in the transition to be able to continuously communicate, monitor and assess the care plan. Along with CARETILES, the CoCENTRIXccp provides organizations along the consumer’s continuum of care with the ability to communicate, monitor, and verify each transition to ensure treatment adherence. Additionally, CoCENTRIX offers an integrated Personal Health Record for the individual to share with providers.


Position your organization to provide safe and accountable transitions of care.