Use Case: Transition of Care (TOC) Work Queue

Challenge

Managing patient transitions from hospital to home can be complex and time-consuming. Our client needed a way to quickly identify and manage patients who had recent hospital admissions, discharges, or emergency room visits to improve continuity of care, reduce readmissions, and capture appropriate reimbursement.

Solution

Our client deployed S4CH’s Transition of Care (TOC) Work Queue within our Analytics Platform (powered by Spotfire) to provide real-time visibility into hospital ADT (Admission, Discharge, Transfer) messages.

• Integrated Data Feeds: We configured an interface between multiple RHIOs to receive and consume ADT alerts daily for the attributed population. Hundreds of alerts are imported and accessible each week.

• Actionable Work Queue: TOC nurses can sort, filter, and prioritize patients by region, payer, hospital, diagnosis, risk score, language, or record type. They can input call outcomes, enabling oversight and performance monitoring of the TOC team.

• Patient 360 View: Each record displays a consolidated summary of demographics, health center activity, medications, risk scores, risk-contract claim history, and HEDIS measures.

• Integrated EHR Alerts: ADT alerts feed directly into the client’s EHR, triggering auto-loading of TOC templates based on days since discharge (1-7 days or 8-14 days). This ensures timely coding and consistent follow-up visits.

Results

The TOC Work Queue and automated workflows transformed the client’s care coordination:

By consolidating disparate ADT messages into a single actionable dashboard, S4CH helped this client create a scalable, measurable, and revenue-generating TOC program. This use case demonstrates how analytics-driven work queues can improve care quality, compliance, and financial performance simultaneously.