Each year 6.5 million patients with acute heart failure are hospitalized at a cost of $200 Billion. Of those, ~25% are readmitted within 30 days at a cost of $50 billion. Under the provisions of the Affordable Care Act, Medicare has levied $273 million dollars in fines from healthcare organizations for excess 30 day readmission rates. Preventable readmissions are primarily due to poor patient adherence, poor communication among the circle of care, and lack of an early signal detection system.

We leveraged the Salesforce platform to create the Tebia “PRM” (patient relationship management) system that connects all stakeholders (patients, providers, caregivers, payers) to help coordinate care post hospital discharge.

Tebia is

1) A simple, but effective low tech patient monitoring app with a high tech back end. Through automated SMS text messaging to newly discharged heart failure patients we are able to monitor for early warning signs of impending readmission. Using a clinically validated questionnaire and algorithm, changes in patient status are tracked over time and alerts sent to caregivers and healthcare practitioners in the event that medical attention is warranted.

2) A mobile link that connects each stakeholder with real time health information, helping to ensure no patient falls between the cracks. Case managers can see the status of all their patients and prioritize urgent cases for immediate attention.

Tebia’s innovative patient relations management system for heart failure patients reduces hospital readmissions for significant cost savings by improving post-discharge care coordination and early signal detection.

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