Like all healthcare providers, Hackensack University Medical Center is looking to expand its scope of services beyond the hospital walls.

Faced with a new emphasis on clinical outcomes, patient-centered care and the elimination of preventable readmissions, doctors want to keep in touch with their patients after the visit, to make sure advice is being followed and prescriptions are being taken.

To facilitate the process, Hackensack UMC is turning to EmmiTransition, a new solution from Chicago-based Emmi Solutions that pushes information out to patients after their hospital stay through a combination of phone calls, interactive voice response calls and online services.

"We've always tried to make at least one phone call upon discharge," said Louis E. Teichholz, Hackensack UMC's medical director of cardiac services. "Ideally, we'd like to make multiple phone calls, but the problem is in terms of resources. (EmmiTransition) gives us a better way of staying in touch."

The hospital – New Jersey's largest provider of inpatient and outpatient services – was one of four to test the solution, focusing on 100 discharged patients with congestive heart failure for 45 days after their release from the hospital. In the recently completed study hospital officials identified 313 "red flags," or conditions that could affect patient outcomes, satisfaction and risk, and acted on them immediately, saving more than 600 hours and countless thousands of dollars had those patients been readmitted.

The key point, say officials at the hospital and Emmi Solutions, is that communications with the patient can take place at any time at home, rather than when the patient returns a phone call or visits a doctor, and any red flags are transmitted to care providers via e-mail the minute they're recorded. In addition, information is sent to the patient so that he or she can consult it at any time.

“EmmiTransition allowed us to reach our patients more dependably (and) get comprehensive reports and freed precious time to respond to patients who learned when to call us with issues such as swelling and weight gain so we could help them address these,” said Michelle Browning, a discharge nurse at the hospital, in a press release.

Added Teichholz: “As we work to adjust from a volume- to value-based healthcare system, we know that interacting with our patients more often and more effectively – both in and outside of the hospital – is the key to better outcomes and reduced readmissions. Yet, with time and resources in short supply, providers are struggling with how to do this. EmmiTransition proved an effective solution that significantly benefited both our patients and our staff. It identified red flags that would have led to increased readmissions – if not worse in some instances.”

Some patients, Teichholz said, liked the interactive nature of the solution so much, they keep calling to talk with hospital staff.

"It's shared decision-making, " he said. "We're going from a passive system to an active one."

Devin Gross, Emmi Solutions' CEO, said the new solution expands the company's platform, which has always been focused on providing services outside the hospital visit. By creating a "circle of care" after the visit that includes the hospital, the patient, the primary doctor, specialists and family members and other caregivers, the process gives everyone a stake in the patient's follow-up care and ensures that actionable information is passed around.

Transition care is new to hospitals," he said. "They're just learning how to do it. And we're giving them something that can be delivered in ways that people can consume when and where they want. That's what keeps them motivated and engaged."

“We believe patients never really leave the care of their providers – they just move through different environments and have different care needs,” Gross said. “EmmiTransition is designed to be about much more than mitigating the risk of today’s readmission penalties. It addresses broader business challenges and opportunities by changing patient behavior through engagement, supporting better self-care and being active members of their healthcare team.”

While the initial tests focused on patients with CHF, Gross said EmmiTransition can eventually be used by hospitals for a broad range of patients.