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Using automation to help mitigate post-surgical risk

As an increasing amount of reimbursement is tied to overall outcome quality, providers are taking on more risk – particularly in the weeks after surgery.

Evidence suggests that a combination of better risk profiling, patient engagement in self-management programs and targeted follow-up, can reduce readmissions and post-surgical complications. For example, Boston University Medical Center reduced readmission rates by 30% by providing clearer instructions to patients about how to take medicines and when to make follow-up appointments. [1]

The challenge with post-discharge monitoring is that it’s labor-intensive and difficult to coordinate across multiple care teams.

Lumeon Care Pathway Manager provides a central command center for monitoring real-time patient statuses and directing activities throughout the care continuum. It does this by pulling in data directly from patients, as well as integrating existing technology and care teams.

We enable providers to build their own post-discharge workflows that combine automation, digital patient interaction, risk profiling, as well as system-generated tasks. This provides a scalable, efficient way to keep patients on track, ensure compliance, and focus attention on the most at-risk individuals.



Automated risk-profiling to identify high priority patients

Care Pathway Manager can be used to automatically send patients custom e-forms (such as KOOS questionnaires). The system incrementally tracks and calculates risk-scores and can color-code dashboards or send alerts to physicians. This helps identify ‘at-risk’ patients before and after surgery.

Digital wellness plans and patient portals

Automatically send activities and resources relevant to the patient’s profile. This could include activity programs both prior to and after surgery (such as physical therapy or medication reminders). If patients forget to fill in data or tick off an activity, they can be automatically reminded to do this.

Personal goal tracking to increase patient collaboration

Providers can set clinical recovery goals for each individual based on their age or even track personal goals e.g. running a marathon. Progress can be tracked via personalized e-forms and even linked to particular automated programs of activities and helpful resources for patients.

Integrated virtual care solutions

Telemedicine is an increasingly popular means of following up with post-acute patients. Care Pathway Manager enables providers to integrate virtual consultations into their pathways and automatically prompt standard intervals of follow-up or send invitations to patients to book consultations.

Effective care coordination

Our APIs allow you to integrate data from EHRs, telehealth software and other third-party systems for centralized control of workflows. Our dashboards then allow you to present staff with exactly the relevant information required to make decisions, as well as gaining visibility of what’s coming next in the pathway.

Advanced analytics to identify best practice

Lumeon Analytics allows you to consolidate all outcomes data so you can see which sites or physicians have the highest readmission or goal achievement rate. You can also compare digital wellness programs or measure the effectiveness of new engagement strategies. All of this is achievable using near real-time data.