Better care transitions unlock value in home-based care

Reverence’s technology helps providers capture incremental fee-for-service reimbursements, supports home health agencies navigating HHVBP, addresses key patient risk factors, and drives actionable early-warning alerts for chronically ill patients.

80% of serious medical errors involve handoff miscommunications

Discharge into home health care models is particularly fraught due to fragmentation of providers and databases and lack of care model standardization. A better model is possible.

Our Executive Overview details the steps that can be taken to improve care transitions, and where and how leading technology can fit in.

Who we support

We support SNFs and hospitals in facilitating and monetizing better discharges — and home health agencies in value-based referral management and process optimization

Discharging providers

(SNFs, hospitals)
Reduced readmissions
Incremental fee-for-service revenue
Bridge to taking risk
Improved referral reputation

In-home providers

(Home health, home care)
Referral vetting / assessment
HHVBP preparation
Bridge to taking risk
Improved quality measures

Ready to learn more?

Our technology

Reverence pairs leading technology with clinical playbooks empowering care coordinators and non-clinical care aides to facilitate effective transitions of care.
Central Care Base
Digital workspace facilitating unified view of patient, coordination of care team, and real-time communication
Dynamic Care
Management
Referral diagnostics and patient-specific planning with task assignment and data-driven checklists
Automated Data Flow
Data integration across sources that enhance Central Care Base effectiveness
Value-Based Analytics
Real-time patient-specific and population level data improves risk-identification and care management

Our impact

Better information-sharing enabling real-time alerts and reduced readmissions.

Current

Static discharge papers
Manual to review & excludes key operating considerations blocking success
Limited to no assessment of referrals
Home health agencies largely “flying blind” in the patients they accept — presenting a strategic risk in HHVBP context
Medication plan rapidly outdated
Static documentation functions poorly within context of most discharges, when medications commonly change in real time
Informal role for family
Relies on family members “figuring out” how best to engage with paid health workers
Fragmented oversight & monitoring
No single PoV on patient risk factors and/or supporting operating model
Higher incidence of readmissions
Informational and operational gaps frequently lead to preventable readmissions
Discharge → Action Plan
Discharge papers converted to care plan + holistic action plan supporting key operating details (transport, food, RPM, etc.)
Clear understanding of impact potential
Structured dataset enables real-time assessment of referrals and understanding of patient-specific impact potential
Dynamic medication monitoring
Playbooks guide care advocates drive through daily & weekly medication monitoring procedures, dramatically improving accuracy of meds plans
Empowered family caregivers
Unpaid caregivers provided tools & coaching to facilitate real-time insight-sharing, alerts, and best-practice caregiving methods
Bird’s-eye view for care advocate
Consolidated care-team contacts; follow-up appointment tracking
Real-time alerts → timely interventions
Holistic, end-to-end approach facilitates timely alerts and rapid, in-home interventions where required, keeping patients stable and out of acute care settings
Join Us

Get started with Reverence today

Whether you are a mission-driven professional looking to rewrite the playbook for home-based care or a provider group seeking to optimize how you manage in-home care models, we are here to help.

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