Patients with chronic health issues often find themselves in and out of care facilities, which is a strain on them and on the systems supporting them. Studies have shown readmissions are often due to poor coordination of care and inefficient use of healthcare resources.


Blaze Advisors helps create and guide transitional care teams with protocols, outcome tracking, program support, and oversight to help establish the right building blocks for a successful care program.


In our view, there are four primary building blocks to create a successful transitional care program:

  1. Patient stratification
    Blaze developed the Care Optimization Index, which assesses risk based on clinical picture as well as challenges related to social determinants of health. 

    1. Tiers patient based on risk

    2. Provides decision support workflows to direct care

    3. Stratifies patients

    4. Continued use of standardized triage and assessment tools to promote early detection of needs, alignment of support to match need, and establishment of medical necessity for service delivery. 

  2. Electronic referral system and patient registry
    Blaze provides a secure electronic referral platform allowing the call center to track, trend and share referral information, along with clinical decision support pathways based on patient risk, guiding therapeutic treatment and ensuring service responsiveness. We also offer a patient registry with real-time data that focuses care management on the patients that need them most.

  3. Patient engagement and care coordination
    A transitional care coach helps high-risk patients navigate the system, instill hope and promote self-directed care. This pillar utilizes a peer support specialist to help deliver trusted, community-based support from someone who has been through it before. 

  4. Performance measures at a patient and population level
    Red flag alerts quickly identify those who return to the hospital. The alert prompts a care team review, which will identify cause of readmission and adjust treatment strategy to improve care. For the population at large, Key Performance Indicators (KPIs) measure:

    1. Average time to services

    2. 30-day BHS remission rates

    3. Percentage of patients that abandon treatment


The first moments of interaction between a service provider and a person seeking care are critical for activation and engagement throughout the course of treatment. In one current project, Blaze has worked with a partner to reach an 80 percent show rate for behavioral care transitions from hospital to home.  


As someone wrote, “You cannot treat an empty chair.” (Clark, 2010). Reach out today if you are facing challenges in transitional support programs. We are happy to chat.

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