Transitions of care Helper

Address every hospital and ER discharge

Address every hospital
and ER discharge

Schedule Call

When patients leave the hospital or ER, the handoff back to primary care is often slow, manual, and error-prone.

HealthHelper’s Transitions of Care Helper streamlines outreach, triage, and follow-up so no patient slips through the cracks and your nurses stay focused on clinical care.

Why It Matters

Scalable support that lowers total cost of care

Lower readmission rates

driving higher shared savings

Capture TCM
billing

increasing revenue for your practice

Reduce ED bounce-backs

addressing care before it’s costly

save staff time
and cost

allowing top-of-license care

How it Works

HealthHelper connects to ADT feeds, routes patients to the right workflow, and handles care coordination

Admission or discharge detected via ADT feeds

Routed to condition-specific triage workflow

Coordinators conduct SMS and phone outreach with triaging

Visits and handoffs scheduled based on patient needs

Continuous check-ins to ensure patients stay on track

Activity documented back into the EHR for full visibility

Configurable based on your clinic’s setup and goals

What you Get

Seamless discharge coordination
frees up your nurse care managers

Scalable follow up to broaden coverage

Consistent first-line care coordination and triaging

Follow-up scheduling and
nurse handoffs

Frequently Asked Questions

How do you track ADT (admission, discharge, and transfer) events?

We connect directly to ADT feeds from your health information exchanges (HIEs), hospitals, or intermediaries such as Bamboo Health or your state HIE. If ADT feeds are already available, we’ll integrate with them. If not, we can help identify and establish connection options to ensure full visibility into patient transitions.

Which discharges do you cover?

We can cover all discharges, or focus on a targeted subset based on your needs. For example, we can segment by payer, contract type, risk profile, care management enrollment, or specific diagnoses and procedures. This flexibility allows you to align our work to your population health priorities and value-based care contracts.

Do you triage patients?

Yes. We define and configure triage questions and nurse handoff workflows with you.

Do you treat all discharges the same?

No. Our system segments discharges dynamically using both ADT and EHR data - such as diagnosis, admission type, length of stay, LACE score, and prior utilization. Each segment follows a tailored workflow, ensuring that low-risk patients receive efficient outreach while high-risk patients get escalated care.

Do you schedule follow-up appointments?

Yes, we schedule follow-up appointments for patients.