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ConcertoHealth Reduces ‘Hot Spotter’ Patient Readmissions by 49% With Patient3D Population Health Technology and Field-Based Care Teams

Hospital Readmissions Down by 49%, ED Visits Down 23% Thanks to High-Touch Care Model

ALISO VIEJO, Calif., JUNE 4, 2019ConcertoHealth®, the leading full-risk provider of specialized primary care and supporting clinical services for vulnerable, frail and elderly patients, announced today that it has achieved a 32% reduction in hospital admissions, a 37% reduction in bed days, a 49% reduction in readmissions and a 23% reduction in emergency department (ED) visits for patients identified as “hot spotters.”

ConcertoHealth classifies hot spotters as patients most likely to have multiple ED or inpatient admissions due to high utilization, high chronicity or high costs. To address these patients, ConcertoHealth makes available its proprietary population health technology Patient3D to primary care providers (PCP), offering them a panel view that includes a patient’s real-time admission and discharge activity, medications, longitudinal medical history and care management notes, with a special hot spotter indicator flag and underlying rationale.

Once identified, ConcertoHealth’s field-based care team engages these patients, while keeping the patients’ PCPs and health plans apprised through Patient3D, before transitioning them back into the managed care network.

“Our Patient3D technology brings clarity to network providers, particularly when the field team cares for these targeted patients. Insurers experience inverted economics with this small population yet lack the clinical capabilities to change course. By identifying those most at risk for readmission or emergency department use and intervening effectively, ConcertoHealth can be a valued clinical partner to the health plan and network providers,” said Robin Tam, senior vice president, Strategy & Business Development, at ConcertoHealth. “These recent results show we are on the right path to improving patient care while decreasing costs for health plans.”

This patient population requires more than regular doctor visits to maintain their health. They need home visits when they are housebound, transportation to get to the pharmacy, meal assistance, durable medical equipment, and care providers who understand how social and behavioral factors affect health, access to care and quality of life. By utilizing ConcertoHealth’s “wraparound” clinical and administrative resources — including Patient3D —to extend their reach in managing and caring for the most complex patients, providers get help with gaps in patient care, thereby improving outcomes.

“We love using Patient3D in our practice. Not only does it give us access to updated contact and care information, it alerts us to things we should know,” said Faiz Mansour, MD, a primary care practitioner in Bloomfield Hills, Michigan. “For example, we had a patient that had not been seen for about three years, and just a couple weeks ago she was admitted into the ED. Patient3D alerted us and gave us the tools to analyze why she hasn’t been in and look at what we can do to help.”

ConcertoHealth is a hybrid accountable care/management services organization that has taken the best of both disciplines to better serve health plans’ most complex and costly patient populations. Value-based reimbursement provides ConcertoHealth with the flexibility to invest in the resources and activities required to improve network provider performance and address health plan challenges. Additionally, ConcertoHealth optimizes the cost and quality of care and reduces administrative overhead for health plans.

About ConcertoHealth®

ConcertoHealth Inc. is the leading risk-bearing provider of field-based complex care for persistently high-cost and rising-risk populations. The company’s multidisciplinary care teams meet patients where they are, with the care they need, whether in the home or hospital. The ConcertoHealth care model improves overall health quality and outcomes with a track record of reducing hospital admits by 47%, readmits by 40% and ER visits by 16% for the most frail and vulnerable populations in America, benefiting patients, payers and provider networks alike.

The company is headquartered in Aliso Viejo, California, and can be found online at, on Twitter @concertohealth and on LinkedIn

Media Contact
Capwell Communications