University Hospitals Health System’s Population Health department encompasses a large ACO that provides both transitions of care and longitudinal care management, and a Transitional Care Management pool for UH’s Primary Care Institute. These care management teams outreach to patients who have discharged from a hospital or skilled nursing facility, and follow patients for 30-90 days after the discharge to support a smooth transition of care and reduce readmissions.
UH sought a solution that provided frequent touch points and a greater awareness of patients with additional needs. UH partnered with Amwell to develop several automated chatbot programs to support the work of their care managers. This partnership helps identify patients with a higher level of need and allows care managers to prioritize those follow-ups.