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greenway blog July 30, 2018

Transition of care tips from CHCs

A patient moves from one care setting to another, but does he or she know what to do next? 

Transitions of care — also called patient handoffs — are an essential part of population health management, one that community health centers (CHCs) managed long before population health became a buzzword. 

Population Health Blue Green

CHCs have extensive experience meeting the requirements of value-based programs while serving disadvantaged communities. By managing transitions of care, they help patients obtain the best treatment possible. 

How do they do it? 

Get connected

Interoperability enables the electronic exchange of data and gives providers the most up-to-date information on their patients. Many CHCs use an interface to exchange information with providers when a patient is hospitalized. How and with whom you connect will depend on where your patients go for care outside your four walls.

Coordinate care

By forming relationships with trusted specialists, you can ensure your patients remain in good hands. CHCs often have teams dedicated to coordinating care for high-risk patients. Team members follow up on next steps, review overall progress, and solicit the patient’s input on their condition and treatment.

Plan for emergencies

If your patient visits the emergency department, schedule follow-up appointments as quickly as possible. Patients who have experienced an acute event often require changes to their care plan. They also may require medication reconciliations to avoid adverse reactions.

Commit to population health 

Many CHCs manage transitions of care while serving patients who need special attention due to language, literacy, or income barriers. It isn’t a simple process, but it can be done.

For more about population health management, and to find out if your practice is prepared, check out our quiz.

Related Solutions

Population Health

Tools that drive improved health outcomes of patient groups.

Learn More

Interoperability

Data connections that improve visibility across the range of care.

Learn More

Care Coordination Services

Engage and empower your patients between office visits.

Learn More

Additional Resources

Community Health Alt Blue Green
Quiz

Population health and your practice: Are you prepared?

Read More
Small practice managed efficiently thanks to Greenway solutions. Illustration.
Greenway Blog

Making value-based care work for the small practice

Read More
Chronic Care Management_Lime
Past Webinar

Grow your practice with chronic care management

Read More
Population Health_Mint
E-book

Population Health: Your guide to proactive patient care

Read More

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