Improving Outcomes for Underserved Populations with Proactive Outreach

Patient follow up is a critical aspect of improving patient care after an acute episode. By proactively following up with patients, healthcare organizations can ensure patients have the resources and support they need to recover as quickly as possible. A common obstacle to patient follow up is finding the right resources and workflows to ensure all patients receive a timely intervention. For Federally Qualified Health Centers (FQHCs), it can be especially challenging to follow up as they may not have the data to know when their patients have been discharged from a nearby facility.

Choptank Community Health, a Maryland-based FQHC, sought to address this challenge and ensure their patients received timely follow up. Choptank serves over 25,000 patient annually, many being Medicaid recipients. To tackle the data obstacle and help their primary care patients throughout their entire care journey, Choptank partnered with CipherHealth to perform automated post-discharge follow up for patients who have recently been discharged from a hospital.

By following up with patients and providing assistance on behalf of their primary care doctors, Choptank was able to engage more than 70% of patients called to reduce both 30-day readmissions and 7-day emergency department returns. As healthcare providers across the continuum are tasked with delivering value, uncovering processes that create efficiencies to meet goals will be a key to success.

“It’s exciting to see Choptank leverage CipherOutreach successfully to dedicate more time for care coordination, improve access to care, and better meet the needs of their patients when they need it most. No matter where their patients are in their care journey, this team proactively engages patients in their care by connecting them to various providers and community resources,” says Lorraine Limpahan, Customer Success Manager at CipherHealth.

As providers and payers seek to engage patients and members to improve outcomes and loyalty, programs such as these will help differentiate the experience that is being provided. With automated outreach, engagement programs can be scaled to help reduce avoidable utilization, lower the total cost of care, and help address the root cause of potential issues, even those that are impacted by social determinants of health.

Learn more about this program by reading the full case study.

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