Develop Better Care Practices with Better Patient Engagement

Use Cortex to Monitor Patient Trends, Improve Care Practices, and Reduce Readmissions for Better Outcomes

Home Health Agencies face an entire different set of problems when it comes to patient care. As a part of the critical care continuum, home health agencies are important to a post-acute patient’s care at hospitals and skilled nursing facilities. Unlike hospitals and skilled nursing facilities, monitoring a patient’s care regimen, such as health status and medicine adherence can be far more challenging for Home Health Agencies

Even with the best of intentions, it’s difficult for agencies to know if their operations are yielding positive outcomes. Without proper and timely feedback from patient engagement, your agency and its referral partners may be subject to costly and unexpected hospital readmissions, and even worse, your patient suffers care setbacks.

OneCare Home Health & Hospice tackles this head-on

As a part of Healthy Living Network, OneCare Home Health & Hospice have strived to reduce readmission rates for their patients. Tyler Hunsaker, Executive Director at OneCare, has used CheckUp™ Calls from Cortex to improve their patient care process. According to Tyler, “one of the questions I absolutely love is related to our medications, and if our team has reviewed that and taught the patient according to those medications. And we’ve been able to initiate some good practices based on that data, and it’s a great trend for us because we can see if people are actually implementing what we’ve done as far as medication education and reconciliations based on the answers that we get.”


As the patient care process improves, OneCare was also able to significantly reduce readmission rates. And when a patient does get admitted to a hospital, “there are opportunities also to recapture patients that we’ve had on service before, just based on us knowing that hey, they’ve had a hospital stay” by using Hospital Alerts from Cortex.

“Honestly, Cortex has been a great tool, and one that we’re going to continue to use. As we grow as an agency we’ll find better ways to use it, to our advantage” says Tyler.

See the full interview with Tyler here:

Cortex Solutions

With Check-up Calls and Hospital Alerts, OneCare Home Health & Hospice was able to reduce costly hospital readmissions, improve their patient care process, and increase patient engagement and satisfaction.

Check-Up Calls™ provide a way to monitor and intervene when patients struggle. In addition, follow up calls evaluate patient satisfaction as well as specific scores via scripted calls made by our Registered Nurses. Powerful dashboards from Cortex provide real-time data and opportunities for improvement.

With Check-up calls, “we can see if people are actually implementing what we’ve done as far as medication education and reconciliations based on the answers that we get. So if we get a whole bunch of red, we know our team’s not doing what we’ve encouraged them to do. But as we see more green, we recognize that this has really helped us with our quality assurance program” says Tyler.

Hospital Alerts notifies you the moment Cortex identifies a patient is at high risk for readmission or has been readmitted to the hospital. Through the use of state’s Health Information Exchange (HIE) systems, Cortex integrates data from hospitals and post-acute providers across the continuum. 

For Tyler and OneCare, “It’s no longer ‘word of mouth’ or ‘yeah we’ve got a great agency, try using us.’ We can now say ‘hey we’ve got a great agency, and these numbers PROVE IT.’ I think a single platform for all of this service is just a cool idea, and has been really useful for us.”

"The reason it’s helped us is because we’re able to evaluate our processes, and see why it is that patients went back to the hospital, what we could have done differently, you know, doing some of those ‘root cause’ analysis I think are very informative to our agency and help us to figure out where it is we’re lacking."

–Tyler Hunsaker, Executive Director
OneCare Home Health & Hospice

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