Rely Health Modern Geriatric Care Navigation

Problem

Care coordination and patient navigation are essential components within modern healthcare systems, particularly for older adults with co-morbidities and longitudinal chronic care management needs. These systems often lack integration, making it challenging for elderly patients to receive the right care at the right time. The need for a proactive, technology-supported approach to streamline care navigation for this population is evident.

Rely Solution

Virtual Back Office: Our virtual patient care navigators proactively engage with geriatric patients post-discharge, fostering strong patient relationships and improving overall satisfaction. Research shows that the quality of care navigation is often dependent on the determination and organizational skills of the patient; our navigators mitigate this by taking on the proactive role of managing patient interactions and follow-ups. The virtual navigation team operates as an extension of the hospital’s existing services, ensuring that every geriatric patient receives continuous, personalized care, which is crucial for maintaining high levels of patient satisfaction and compliance.

Warm Hand-Off: An integral part of our solution is the seamless handoff from existing case management teams, particularly those already operating within the Emergency Department (ED), to our virtual patient care navigation team. This process is designed to ensure continuity of care without overwhelming the patient or their caregivers. Case management teams provide a comprehensive overview of the patient’s current care needs, which is then seamlessly transferred to the virtual team. This approach is particularly beneficial for elderly patients, who often rely on multiple caregivers and services. By saving the virtual patient care navigation team’s contact information directly on the patient or family member’s phone, we ensure that patients have a direct line to ongoing support, reducing the burden on both the patient and their informal care network

1. Care Navigation Training: We offer comprehensive training materials specifically tailored to navigate the needs of the geriatric population. Our Patient Relationship Manager (PRM) works alongside the EHR to deploy and manage new workflows that address the specific challenges faced by older adults with multimorbidity. These training materials are designed to ensure that navigators can effectively manage complex care needs, standardize processes, and scale operations without compromising the quality of care. By automating low-acuity tasks, the PRM system allows human resources to focus on more complex care needs, ensuring that each patient receives the attention they require. By continuously engaging patients, we help prevent gaps in care that can lead to deteriorating health and increased hospital readmissions.
2. Longitudinal Follow-up: Our infrastructure supports the development and adaptation of workflows that automatically engage patients well after their initial visit. This hybrid model combines AI and live patient care navigators to ensure long-term sustainability and adaptability to the hospital's evolving needs. The importance of longitudinal follow-up is highlighted in the research, where continuity of care is seen as critical to improving outcomes for elderly patients with multiple LTCs
3. Enhanced Reporting & Demographics Tracking: Our web-based PRM, integrated with your EHR, automates demographic data collection and generates customized reports for administrative purposes. This integration improves data accuracy and provides valuable real-time insights for better decision-making and compliance. The research underscores the importance of accurate and comprehensive data collection in managing complex care needs, particularly in identifying and addressing the social determinants of health that can impact patient outcomes
4. No-Lift Coverage: We manage the patient populations after discharge, requiring no additional work from health systems, and scale our operations to cover every member of your daily census. Our virtual team engages with patients via their preferred contact methods, ensuring comprehensive coverage and patient retention. The research emphasizes the need for equitable care, ensuring that all patients, regardless of their personal circumstances, receive the same high level of support and follow-up.
5. Personalized Workflows: Each patient receives personalized communication, including SMS, email journeys, and phone calls, tailored to their specific healthcare needs. This approach emphasizes patient retention and appropriate placement in the care continuum. Personalization is key in managing the complex and varied needs of geriatric patients, ensuring that care plans are relevant and effective for each individual.

Program Benefits

Implementing the Rely Health Navigation Hub optimizes patient interactions by freeing up your care management and transitional care teams, allowing them to focus more on high-acuity patients and expanding longitudinal care pathways. Our virtual program ensures comprehensive follow-up for all patients, driving new patient acquisition and retention. Additionally, it improves hospital utilization rates by directing patients to appropriate primary care physicians, outpatient services, or community resources. The program is particularly beneficial in reducing the burden on informal caregivers, who often play a critical role in managing day-to-day support for geriatric patients

• Turn-Key Service: No overhead performance management or technology lift required. We design, deploy, and iterate until you reach your navigation goals.
• Dashboards & Analytics: Monthly charts for leadership demonstrating real-time health metrics.
• AI-Driven Scale: We achieve 10-15x more scale than in-house resources, ensuring comprehensive follow-up and engagement for every patient.

Summary

Rely Health’s innovative approach to geriatric care navigation redefines how healthcare systems manage and support elderly patients, particularly those with multiple long-term conditions. By integrating cutting-edge technology with personalized, proactive care, we ensure that every patient receives continuous, high-quality support tailored to their unique needs. Our virtual back-office model, combined with seamless handoffs from existing case management teams, enables healthcare organizations to optimize their resources, improve patient outcomes, and achieve significant scalability.

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