How a Transitions of Care Pharmacist at Regional One Health Finds At-Risk Patients Faster

At Regional One Health, a 350-bed hospital in Memphis, Tennessee, the Transitions of Care (TOC) program plays a critical role in keeping high-risk patients safe after discharge. But for Kristine Hoang, Pharm.D., Clinical Pharmacist and TOC program lead, outdated diagnosis codes were making that harder than it should have been.

Patients on high-risk medications like anticoagulants often weren’t being flagged in time, simply because their diagnoses hadn’t been coded yet. “We were missing patients who should’ve been enrolled in our program,” Hoang said. “They wouldn’t show up in our screening reports because their diagnosis hadn’t been coded yet.”

That left her team spending time on patients who didn’t clinically qualify, while some high-risk cases went undetected.

How the Transitions of Care pharmacist moved to real-time screening

To better target the right patients, Regional One Health implemented Inovalon’s VigiLanz Pharmacy Surveillance Pro™. The solution helped automate the screening process by using near real-time clinical data – including lab values, home and inpatient medication lists, and other risk factors – to flag patients who truly needed TOC services.

Hoang worked with Inovalon to tailor the screening rules to reflect the team’s workflow. The result was a more accurate and efficient system.

“It saved me about 45 minutes a day,” Hoang 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.”

Supporting follow-up care and improving outcomes

In addition to screening improvements, Hoang and her team use the software to monitor upcoming outpatient visits. That extra visibility helps them maintain clinical oversight beyond the initial transition period.

“I can easily see when a previously enrolled patient is coming back to the clinic next week,” she said. “That lets me follow up, flag any new concerns, and make sure nothing gets missed.”

With plans to expand the TOC program, the team is already seeing measurable results. According to internal quality improvement studies, emergency department visits and readmissions have gone down, while outcomes for patients with heart failure and diabetes have improved.

“The solution helped us expand our reach, and that’s translated into better care for more patients,” said Hoang. “We have lowered readmission rates, lowered ED visit rates, [and] improved outcomes for patients with diabetes and heart failure.”

Built with clinician feedback in mind

Hoang also emphasized how responsive Inovalon’s team was throughout the process of configuring the software to meet her hospital’s unique needs.

“I just said what I needed in an ideal world, and they helped make it happen,” she said. “It’s been really exciting to see all of the changes they’ve made in response to our needs as clinicians.”

Now, the team is looking ahead to more use cases, including reducing inappropriate COPD prescriptions and expanding safety-focused medication initiatives across the hospital.

Catch risk sooner, act faster, and improve patient outcomes

With near real-time visibility, smarter screening, and customizable workflows, your team can identify high-risk patients faster and focus on what matters most – better care.

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