CUSTOMER STORY
How Regional One Health Identifies High-Risk Patients Sooner
At Regional One Health, a 350-bed hospital in Memphis, TN, the Transitions of Care (TOC) program plays a critical role in preventing readmissions and improving outcomes for vulnerable patients. But for Kristine Hoang, the program’s lead pharmacist, a key problem was slowing everything down: outdated, inaccurate diagnosis codes were being used to screen patients, and it wasn’t working.
“We were missing patients who should’ve been enrolled in our program, especially those on high-risk meds like anticoagulants,” said Hoang. “They wouldn’t show up in our screening reports because their diagnosis hadn’t been coded yet.”
That meant patients in danger of complications, like bleeding events or medication errors, were flying under the radar. And on top of that, Hoang and her team were wasting valuable time sifting through reports filled with patients who didn’t clinically qualify for TOC services.
”It saved me about 45 minutes a day. But it wasn’t just about time – it was about accuracy. We were able to stop chasing the wrong cases and start acting on the right ones.”
Kristine Hoang, Pharm.D.,Clinical Pharmacist, Transitions of Care
A Better Way to Screen and Scale
Hoang needed a smarter, faster, more accurate way to find the right patients. That’s where Inovalon’s Ambulatory Surveillance™ came in.
Working closely with Inovalon, she helped configure customer screening rules based on real-time data: labs, home and inpatient medication lists, and other high-risk criteria. The result was a fully tailored solution that aligned with how her team worked and was able to identify the patients that needed help most.
“It saved me about 45 minutes a day,” she said. “But it wasn’t just about time, it was about accuracy. We were able to stop chasing the wrong cases and start acting on the right ones.”
”I just said what I needed in an ideal world, and they helped make it happen.”
Kristine Hoang, Pharm.D.,Clinical Pharmacist, Transitions of Care
Faster Follow-Up. Better Outcomes. Fewer Readmissions.
Beyond screening improvements, Hoang uses Inovalon’s software to track outpatient follow-ups more effectively. That means fewer patients fall through the cracks after discharge, and pharmacists can maintain clinical oversight even after the initial transition period.
“I can easily see when a previously enrolled patient is coming back to the clinic next week,” she explained. “That lets me follow up, flag any new concerns, and make sure nothing gets missed.”
As the team prepares to expand the TOC program with additional pharmacist support, they’re already seeing exciting results. Emergency department visits and readmissions have dropped, and outcomes for chronic conditions like heart failure and diabetes have improved according to internal quality improvement studies.
“The solution helped us expand our reach, and that’s translated into better care for more patients,” Hoang said.
”We have lowered readmission rates, lowered ED visit rates, [and] improved outcomes for patients with diabetes and heart failure.”
Kristine Hoang, Pharm.D.,Clinical Pharmacist, Transitions of Care
Built With Clinician Feedback at Every Step
One of the biggest benefits? Flexibility. Hoang emphasized how responsive the Inovalon team has been to feedback and how invested they are in making the system work for her hospital’s unique needs.
“I just said what I needed in an ideal world, and they helped make it happen,” she noted.
That responsiveness is helping Hoang and her team explore broader applications – from reducing inappropriate COPD prescriptions to supporting medication safety enhancement initiatives across Regional One Health.
Looking ahead, Regional One Health’s vision is clear: equip its pharmacists with the tools to work at the top of their license, extend the Transitions of Care program, and deliver safer, more strategic patient handoffs without the administrative burden that slows care down.
”It’s been really exciting to see all of the changes they’ve made in response to our needs as clinicians.”
Kristine Hoang, Pharm.D.,Clinical Pharmacist, Transitions of Care
Transform Transitions of Care at Your Hospital
Ambulatory Surveillance gives you near real-time visibility, smarter screening, and customizable workflows that help your team catch risk sooner and act faster – just like Hoang’s team at Regional One Health.
