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Every Discharge Reached Within 48 Hours: How On Belay Books Follow-Up Care for 78% of Patients
A national Medicare ACO made Transitions Helper its first line of post-discharge outreach: 88% patient engagement, with care managers freed for high-risk clinical work.
Client Snapshot
Organization
On Belay Health Solutions, a national Medicare Accountable Care Organization (ACO) partnering with primary care practices to deliver value-based care for Medicare beneficiaries
Data Feeds
ADT (admission, discharge, and transfer) notifications via Bamboo Health and PointClickCare
Solution
Transitions Helper: post-discharge patient engagement, scheduling, and triage
Care Team
Coordination with practices, On Belay care managers, social workers, and RNs, documented in the EHR
The Challenge
Every morning, the practices in On Belay’s network wake up to a queue of ADT alerts no staffing plan can absorb. Each one is a patient just discharged from a hospital or emergency department, and every day that passes without follow-up raises the odds they come back through the same doors.
On Belay wanted to lower unnecessary readmission rates, and neither its practices nor its care managers had the resources to consistently and effectively engage patients after discharge. Without a reliable first line of outreach, patients slipped through the cracks: follow-up appointments went unscheduled, worsening symptoms went unreported, and care managers spent scarce time on outreach attempts instead of high-value clinical work.
Every day that passes without follow-up raises the odds a patient comes back through the same doors.
By the Numbers
100%
of qualifying patients reached within 48 business hours of discharge
88%
patient engagement rate
78%
of managed discharges resulted in a scheduled follow-up appointment
~70%
of qualifying patients completed a transition-of-care assessment
The Solution
HealthHelper’s Transitions Helper took over the first line of outreach. Intercepting ADT feeds from Bamboo Health and PointClickCare, HealthHelper segments discharge notifications, engages patients by text message and phone call, and guides each patient through the recommended transition-of-care workflow: scheduling the follow-up primary care appointment, conducting triage assessments, and connecting patients who screen positive to an RN.
How it works, from the patient’s side: discharge detected via ADT feed → patient texted or called within 48 business hours → follow-up appointment booked and triage assessment completed → positive screens warm-transferred to an RN → everything documented back in the EHR.
Patient Engagement
Multiple outreach attempts by text message and phone call within the first 48 business hours after discharge.
Scheduling & Assessments
Follow-up primary care appointments scheduled directly, with triage assessments completed during outreach.
Care Team Coordination
Results
Since go-live:
100% of qualifying patients are reached with multiple outreach attempts by text and phone within the first 48 business hours after discharge.
88% of patients engage with the outreach.
78% of managed discharges result in a scheduled follow-up appointment.
Nearly 70% of qualifying patients complete a transition-of-care assessment.
On Belay care managers and practice staff are freed from first-line outreach to focus on the highest-risk patients.
“Transitions Helper has become a true extension of our care team. The outreach is timely and convenient for patients, and our care managers can focus their time on the patients who need them most.”
Dr. Bob Lonigro, SVP of Clinical Affairs, On Belay Health Solutions
What’s Next
With Transitions Helper as its first line of outreach, On Belay turned transition-of-care management from a capacity problem into a reliable, measurable operation, reducing readmission risk and keeping patients connected to primary care.
Get a transitions-of-care coverage analysis: how many of your discharges receive outreach within 48 hours today? Get in touch.
