The FONEMED Integrated Care Transition Program

FONEMED’s standard Integrated Care Transition program consists of the following five components.  All services are customized to meet client requirements. 

1.  Patient Health Record

• Electronic transfer of data from hospital records to ICT Patient Record Templates for each Disease State.
• Optional:  Collection and entry of data.

2.  Care Plan

• ICT RN completes appropriate care plan for each disease state based on destination,  PHR and telephone interview .  The care plan includes:
  • Medications/ compliance
  • Automated reminders
  • HSR and IVR Queries
  • Health Coaching Sessions by phone
• Optional: Physical visit(s) by Community Based Organizations and /or Quality Improvement Organizations.

3.  Monitoring

• HSR and IVR Queries relayed to ICT for entry onto dashboard. If alert is triggered there is an automated response followed by Health Service Representative (HSR) intervention and escalation to a Registered Nurse when required.
• Optional:  Remote Monitoring devices and communications unit and customization of IVR.

4.  Health Coaching

• ICT RN and/or HSR scheduled telephone calls.
• Optional:  Patient initiated internet interaction with video and other coaching aide, Conferences with dieticians, doctors, specialists and Text and Email reminders and educational components.

5.  Documentation

• Integration of PHR, Care Plan, monitoring and coaching reports in summary record for trending and use by caregivers.