Acute Care Outreach Team

In May 2022, VHAN established a new acute care outreach team for Connected Care of Middle Tennessee Medicare ACO patients. The outreach team helps increase communication between acute care teams and ambulatory care providers and care management teams. The focus is on readmission reduction and leveraging post-acute care services to help meet patient goals.

The program supports hospital-based teams regarding utilization patterns on a patient-by-patient basis. The outreach team screens patients for potential inclusion in skilled nursing facility (SNF) waivers, communicates eligibility to hospital-based teams and supports patient notification and referral processes. The program also helps move patients with emerging needs into care management programs.

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