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Discharge Optimization
Unlock the Power of Family Care to Reduce Readmissions

KareTeam effectively engages family in post-discharge, age-in-place care.  The result, lower readmission rates and better patient outcomes. All this is at no cost to your care facility.  Simply refer KareTeam as an available resource as part of the discharge process.  KareTeam is available at a modest subscription fee to families providing support for ongoing age-in-place care.

Why Family Matters

Readmissions and the role of the discharge process is an area of increasing focus.  Simply put, readmissions truly matter, and family engagement is crucial. Today's discharge staff operate with limited tools for effectively involving family members, especially when considering the numerous topics beyond standard discharge plans that significantly impact outcomes. These extend far beyond basic activities of daily living to encompass medication management, home safety modifications, meal planning, caregiver coordination, emotional support, and so much more—creating an overwhelming scope that no discharge planner could possibly cover comprehensively. KareTeam Age-in-Place bridges this critical gap, empowering families with the personalized guidance and continuous support needed to successfully keep aging loved ones at home.  

Readmissions  Matter

  • Medicare Penalties: Through the Hospital Readmissions Reduction Program (HRRP), CMS penalizes hospitals with excessive readmission rates by reducing reimbursements by up to 3% of total Medicare payments.  

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  • Value-Based Care Models: Many alternative payment models reward hospitals for reducing readmissions as part of total cost of care calculations

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  • Commercial Payer Contracts: Increasingly include readmission metrics in performance-based reimbursement structures

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  • Public Reporting: Readmission rates are publicly reported on CMS's Hospital Compare website, affecting hospital reputation

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  • Quality Rankings: Major rating systems like Leapfrog and U.S. News & World Report factor readmission rates into their hospital rankings

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  • Patient Satisfaction: Avoiding unnecessary hospitalizations improves patient experience and HCAHPS scores

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  • Capacity Management: Reducing avoidable readmissions frees up beds for new admissions and elective procedures, resulting in higher revenue per bed / day

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  • Resource Utilization: Allows more efficient allocation of limited hospital resources

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  • Continuity of Care: Focusing on readmission prevention improves care transitions and follow-up

Family Matters

  • Knowledge Transfer: Family members often become primary caregivers after discharge and need to understand treatment plans, medication regimens, and warning signs

 

  • Continuity of Care: Families provide critical continuity between hospital and home

 

  • Patient Advocacy: Engaged family members can better advocate for patients' needs with healthcare providers

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  • Emotional Support: Family support reduces patient stress and anxiety, which can otherwise exacerbate health conditions

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  • ​Caregiver Advise, Record, and Enable (CARE) Act: Adopted in over 40 U.S. states to formalize protocols for involving family caregivers in discharge planning and post-acute care

 

  • Studies show that patients with involved family members have up to 25% lower readmission rates. (Univ Pittsburgh Medical Center)

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  • Caregiver preparation is one of the strongest predictors of successful transitions from hospital to home

Everything Else

  • Discharge Plans typically focus on immediate medical needs and basic care instructions rather than comprehensive support for successful long-term recovery and aging in place.

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  • The list is long ... in no particular order!

    • Family caregiver coordination 

    • ADL support (Activities of Daily Living)

    • Home environment setup and modifications

    • Meal planning and shopping

    • Home maintenance (cleaning, pets, yard, etc)

    • Social engagement

    • Purpose and Meaning

    • Financial matters

    • Legal considerations

    • Medication management

    • Memory support

    • Transportation (medical and non-medical)

    • Physical activity

    • Fall prevention

    • Sleep hygiene

    • Spiritual and cultural needs

    • Caregiver services beyond what family can cover

    • And the list goes on!

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Anything on this list could be the cause of readmission!

KareTeam Promise

  • KareTeam is a natural compliment to discharge plans and processes

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  • KareTeam rallies family as an effective post-discharge caregiver team,
    improving compliance with discharge plans

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  • KareTeam's advanced technology helps families understand the topics and tasks beyond the discharge plan that are important for successful transition to home

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  • ​KareTeam is paid for by family as an affordable monthly subscription, no cost to care facility

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  • A simple referral to KareTeam is all that's needed!

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  • Referral Card with QR code provided by KareTeam, with c0-branding available to include in discharge package

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