HOW IT WORKS
Our services begin when you assign a portion of your patients to us. After receiving the pertinent patient information from you and your risk assessment (this can be a formal risk number or your subjective prioritization), we will contact each of the patients within 24 hours of discharge. After introducing ourselves we will obtain detailed “social determinants of health (SDOH)” and fill in any missing medical information so that ONclick can maintain a comprehensive profile of each patient in our data base. We will endeavor to understand the primary care givers and sources of support within the home and the community. We will identify locally available resources such as meal services, transportation options, church and senior center numbers and locations, etc. We will instruct the patients that, barring any true emergencies that necessitate an ER visit, they should call ONclick and we will talk them through the next steps to ensure their well being and give them confidence that they will be taken care of.
The next stage of our process is regular outreach to the patients. Armed with the medications, next appointment information and our own prioritization model, we will call patients within a couple weeks of our introduction (or when an appointment is scheduled or a change in medication is imminent) and then call them on a recurring basis as needed. Much of the benefit of such calls is simply letting the patient know that they are not being forgotten and someone is looking out for them. But these calls will also provide valuable monitoring of the patient’s situation and help ensure the patient has the best chance to adhere to his or her health regimen.
ONclick will maintain its own EMR on each patient and will provide real time access to that EMR for hospital personnel, PCPs and other pertinent parties.
We believe our ONclick program can be highly effective in preventing unnecessary ER visits and hospital admissions. Many studies indicate that one third to one half of ER visits are for non-urgent care. The New England Health Institute estimates that 56% of ER visits are “totally avoidable.” Other studies show that up to 30% of hospital re-admissions can be avoided by a single call to patients after their initial discharge from a hospital. Reducing ER visits and hospital readmissions is probably the most effective tool you have for reducing your costs and improving your patient’s satisfaction and over-all condition. We can be a major contributor to this effort.