Care program: Care Transitions

What is the Care Transitions digital care program?

Wellframe’s Care Transitions digital care program bundle is a collection of 10 unique digital care programs:

  • Medical Care Transitions
  • Surgical Care Transitions
  • Behavioral Health Care Transitions
  • Coronary Artery Disease
  • Percutaneous Coronary Intervention
  • Myocardial Infarction
  • Cardiac Rehab
  • Heart Failure
  • Chronic Obstructive Pulmonary Disorder
  • Total Knee Arthroplasty

Each program spans 29 to 43 days. Three of these digital care programs are date-dependent: Behavioral Health Care Transitions, Care Transitions: Surgical, and Care Transitions: Medical. When clinicians add members to one of these three care programs, the member must enter the procedure or hospital release date. This makes it easier to inform members about what to expect and be cautious of at specific points in their care journeys.  

How does Wellframe’s Care Transitions care program empower care teams?

Earning members’ trust and encouraging them to play an active role in their care management is vital to improving care outcomes. By leveraging the Care Transitions digital care programs, care managers can ensure their populations are receiving relevant health information at the right time in their journey. 

Care teams can see how often members engage with their care program, and identify which resources they’re using. This kind of information can make it easier for clinicians to spot gaps in care, and give them clear intervention points.

In a study published in the Journal of Medical Economics, Wellframe’s Care Transitions digital care program reduced readmissions by 33% for patients with multimorbidities. Senior members benefited the most from using the Care Transitions program, demonstrating a 29% reduction in ER usage.

Surveys and assessments surface key insights

As part of the Care Transitions digital care programs, members receive digital surveys and assessments that can alert care teams to potential health issues or barriers to healthcare access. Care managers can also leverage validated screening tools within the digital care programs, including:

  • PROMIS Global Mental/Global Physical
  • PROMIS Emotional Support
  • PROMIS CAT Depression
  • PROMIS Pain Interference
  • PROMIS Anxiety
  • PROMIS Physical Function
  • PROMIS Sleep Disturbance
  • PROMIS Emotional Support
  • Stanford Physical Activity Instrument
  • CAGE Alcohol Abuse Risk

With Wellframe’s digital care programs, clinicians receive dashboard alerts when member responses indicate a care gap or unmet health need. These notifications make it easier for care teams to prioritize high-risk members for additional outreach and support.

What types of information do Care Transitions program participants receive?

Care Transitions digital care programs include educational articles, surveys and assessments, and regular automated encouragements. Program participants are given a daily checklist with health- and diagnosis-related tasks to complete. 

Daily checklists encourage members to take action to improve their health and wellness. These actions include medication reminders, tracking blood sugar, logging physical activity, and reading relevant articles about their diagnosis and benefits. A few of the articles recommended as part of the Care Transitions program offerings are:

  • Signs to Watch For
  • Getting Ready for Surgery
  • Warning Signs & Symptoms
  • Self-Care After a Cath Procedure
  • Returning to Activity After a Heart Attack
  • Depression & Heart Disease
  • What Causes CHF?
  • COPD: Following Up
  • Eating to Recover

Digital care programs like those in Wellframe’s Care Transitions digital care programs can help care teams build trust with members and uncover the information they need to improve outreach and care outcomes.