Turn High‑risk Conditions Into Safer Recoveries.
Guideway tailors its post‑discharge activation program to each of the Hospital Readmission Reduction Program conditions – acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective hip/knee replacements. Within days of discharge, our Activation Care Guides connect with patients via phone and SMS, gather feedback on their stay, and proactively address the barriers that cause readmissions in these high‑profile cohorts. By combining Guideway’s Motivational Patient Guidance (MPG) framework with AI‑powered GPS tasking, we ensure that patients receive personalized support during the critical 30‑day window.
What We Do
- Conduct condition‑specific teaching and reinforcement on triggers, medication regimens and lifestyle changes.
- Identify early clinical warning signs (e.g., chest pain, shortness of breath) and ensure prompt escalation.
- Confirm follow‑up visits with cardiologists, pulmonologists, surgeons, or primary care providers.
- Address SDOH barriers such as transportation, affordability and access to rehabilitation services.
- Monitor adherence to discharge instructions and coordinate care across the continuum.
Benefits
- Lower unplanned readmissions across all HRRP conditions.
- Reduction in HRRP penalty exposure.
- Improved adherence to condition‑specific care plans.
- Early detection of clinical deterioration.
- Greater patient confidence and satisfaction.
- Increased downstream specialty referrals within your network.
- Enhanced market share through better care transitions.
