Using Predictive Analytics to “Nurture” Recently Discharged Patients

August 25, 2016

Cyndi_Rizzitello-1.jpgIndustry Challenge

Home health agencies work hard every day to ensure the patients they serve receive the appropriate care in order to recover, regain independence and become as self-sufficient as possible. But due to limitations in the home health benefit eligibility requirements, agencies often have to discharge patients who might not be fully ready or able to care for themselves. Or maybe they seem ready but wind up declining after discharge unexpectedly.

Any decline after discharge leaves patients, agencies and referral sources at risk, especially if it results in emergent or inpatient care. And further, if your agency is not aware of the decline, another agency may have the opportunity to take over the care of those patients, potentially affecting care continuity and/or permanently losing them as customers.

So we know there is a lot at stake but you’ve already got enough to manage taking care of the patients who are on census. How can you afford to keep an eye on discharged patients as well? I’d argue that you can’t afford NOT to keep those patients within your reach.

Some agencies have adopted post-discharge calling programs whereby in-office callers contact patients at pre-determined days post home health discharge. Reasons for establishing these programs are multifaceted–they are typically geared to:

  • Provide an opportunity to discuss patient satisfaction in advance of the HHCAHPS survey
  • Allow for decline monitoring so that additional care needs can be triaged
  • Provide the opportunity to stay connected with their entire patient population

It’s a great initiative but we all know how tight home health budgets are these days. How can agencies provide this level of post-care discharge without breaking the bank?


Well, the answer lies in leveraging the benefits of predictive analytics.

Let’s say you want to call discharged patients 14 days post-discharge to check in to see if they were satisfied with the services they received. Because you know a portion of your population may be in a more fragile health status than the rest, you might want to call the sickest patients first. You may rely on the discharging clinician to determine and convey risk but we all know that can be very subjective. And randomly calling won’t be the most effective way either.

Medalogix offers a better strategy. By tapping into the benefits of predictive analytics, Medalogix Nurture does the work for you. It will tell you which patients to call first.

This happens through the magic of data science, where OASIS and other EMR data is modeled. Then, based on past-patterns of patient acuity and readmissions, patients are ranked according to their risk. Your post-discharge calling team now knows which patients need to be called sooner than later, while still ensuring all patients, regardless of risk level, are eligible to be tracked and called.


Additionally, Nurture manages your entire calling program. It displays EMR data, highlighting important details from the last episode, houses call talking points that you can customize for callers to reference and a place to document details of the conversation. In addition, monitoring reports allow you to gain insights on call volume, caller productivity, generated referrals and converted admissions.



Nurture easily helps agencies gain efficiencies by eliminating paper processes and taking the guesswork out of deciding who to call and when. So stay connected with your patient population. They are just as important after discharge as they are when they are receiving care. Stay in touch. Your outreach can:

  • Provide a friendly voice that reminds your patients you care
  • Boost your patient satisfaction rating
  • Improve care quality
  • Avert a possible rehospitalization

When you continue to nurture your patients after they leave your census, your patients and referral sources will be grateful and loyal to your agency–not the one down the street.

Learn More About Medalogix Nurture Here 

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