Patient Outreach

Care Coordination & Engagement

Caradigm solutions enable the care team collaboration and increased patient adherence that drive improved outcomes for patient populations.


Patient engagement is a key component in managing the health and wellness of populations. Engagement programs can address the influence of patient lifestyle and behaviors on health outcomes, which have five times the influence of the efforts of providers or health plans. Your organization needs to engage patients for smoother recovery from health episodes, encourage informed patients to select appropriate treatment options and promote ongoing self-management.


Caradigm Patient Outreach provides opportunities for you to engage patients outside of the care setting to help trigger health related behavior change. These opportunities include:

  •    Patients within the episode of care–making patients part of the care team, engaging with them early in the episode    and in the hospital, preventing readmissions and providing them with tools for self-care
  •    Patients with chronic conditions–addressing the segments of the population that generate the highest cost, yet are    often motivated and open to patient engagement, by providing the tools for ongoing care management in the    home
  •    Healthy patients–engaging them around wellness and health maintenance and promoting fitness and positive    behaviors to prevent health episodes and cost

The integration of outreach capability into Caradigm’s platform helps you create more patient centric outreach campaigns. Data ingested into Caradigm’s platform becomes the source of how you are able to personalize each patient’s engagement. Once a patient is engaged, the built-in identification of barriers to behavior allows the seamless delivery of content designed to overcome each specific barrier. Patients can then be offered the chance to immediately schedule the behavior during the engagement.

Examples of campaigns include:

  •    Patient Onboarding
  •    Assessments
  •    Readmissions Reduction
  •    Quality Gap Closures
  •    Reminders
  •    Condition Monitoring.


How it works



Key Features


Patient Onboarding and Health Risk Assessment

  •    Personal welcome to the provider network/plan
  •    Capture of patient information:
    •   Patient-reported primary care physician – or the need for one
    •   Information and needs identification for care team follow-up
    •   Email and cell/SMS contact information and opt-in for future outreaches
  •    Generation of baseline view of patient’s overall health status, functional status and activities of daily living, home    support, home medical aids, fall risk, tobacco use and mental health/depression.
  •    Elicitation of patient-satisfaction ratings for outreach call


Transitions of Care

  •    Patient communication at 48 hours, 5 days and 14 days post-discharge
  •    Multiple follow-up options to the care team
  •    Identification of risks to trigger follow-up calls by patient care teams.
  •    Provision of condition-specific warning signs and symptoms to patients admitted or discharged with Medicare-    tracked readmission conditions: AMI, asthma/COPD, CABG, CHF, THA/TKA, or pneumonia
  •    Elicitation of patient satisfaction ratings for the outreach calls and net promoter ratings of the provider network


Gaps in Care

  •    Information and education to patients about gaps
  •    Documentation of gaps that have been closed by the patient
  •    Assessment of the patient’s intent to close gap
  •    Integration to Caradigm Quality Improvement through patient enrollment to address gaps in care


Key Benefits

  •    Supports patients through critical progressions between care settings
  •    Helps reduce preventable readmissions and supports improved performance in CMS readmissions regulatory    programs
  •    Proactively identifies and offers real-time intervention and support for common readmission causes–lack of    support at home or self-care confidence, failure to receive or understand discharge instructions, failure to schedule    follow-up PCP appointments, questions about new medications and refills, and uncertain home health services    status
  •    Identifies and overcomes barriers to gap closure
  •    Gains patient commitment to gap closure
  •    Can increase reach by up to 2x increase versus live-agent HRA attempts.
  •    Can increase the completion rate of a 35-question HRA–as much as an increase from 10% to over 80%.
  •    Can reduce readmissions to the hospital by up to 13% through education and coordination of care.
  •    Can reduce ER visits within 30 days of discharge by an average of 22%.
  •    Reduces the nurses’ administrative burden.
  •    Delivers additional Insights. For example, an assessment of patients just discharged for a heart event found that    48% were not prescribed beta blocker, and of those who did get a prescription, only 85% had it filled.
  •    Can increase flu-shot rates by up to 34%.
  •    Can increase the cervical cancer screening rate by up to 53% increase, and increases mammogram rate by up to    45%–compared to a control group that received no intervention–through combined women’s health outreach
  •    Can increase pap test rates by over 20% in over a control group that received no intervention
  •    Can increase number of completed and returned home-testing colorectal cancer kits within six months by 41%–    compared to patients who didn’t receive the outreach
  •    Can increase member refill rates in a targeted population within 6 months by 40%
  •    Can increase the Net Promoter Score by 85%