Transitions of Care | Memora Health

Intermountain Health Partners with Memora to Scale Care Delivery Programs Across the Enterprise

Memora health
can support:

Memora assists patients and their providers throughout transitions from hospital to home or alternative care settings.

Deliver accessible, actionable, and always-on care so that individuals feel confident in managing their health and care teams know patients have what they need to navigate care journeys.

Surgical Admission

General Inpatient

Care Management

Healing At Home

Episodic Admission

Spotlight Program

Hospital Discharge

Failed transitions of care after a hospital stay can significantly harm patients and lead to costly and disruptive readmissions.

Automate post-discharge education and check-ins that empower patients through each step of their transition from hospital to home or the next care setting. Set the foundation for a road to better health with boosted PCP and preventive care engagement.

Program Goals

Empower Patients

Help patients feel confident in self-managing their care journeys

Advance At-Home Care

Support individuals healing at home with AI-driven assistance

Reduce Readmission Rates

Drive post-discharge care adherence to help patients stay out of the hospital

Impact on Transitions of Care

Memora’s automated post-discharge support empowers patients through their transition while unburdening care management teams. By building patient confidence and enabling self-management, Memora helps boost care plan adherence and reduce the risk of readmissions.

Drive
Operational Efficiency

Reduce manual care team outreach to patients and caregivers
Reduce burden of data collection with automation
Reduce inbound patient calls and messages

Enhanced Clinician &
Patient Experience

Increase patient satisfaction
Increase care team satisfaction and reduce burnout
Increase patient retention within the health system

Support Financial Sustainability

Reduce 30-day readmission rate and associated financial penalties
Increase post-discharge PCP visits
Reduce patient adverse outcomes and related total cost of care

* representative goals of Care Program partners

Book a Demo

Expand Your Care Team Through Automation

Leverage AI with Natural Language Processing to automate program-specific interactions via a white labeled and conversational experience for your patients.

Hello! I can help with questions or concerns, whether they're about your discharge instructions, appointment-related questions, or managing symptoms like fever and pain. Text me whenever you need to. I'll reply instantly.

That is helpful. Can you get me a copy of my discharge plan?

We'll let your care team know that you want a copy of your discharge instructions and they'll contact you soon. You can also use the patient portal to get a digital copy of your discharge instructions and find support, resources, lab results, and upcoming appointments.

Thank you! Just logged into the portal and found them.

We hope you're feeling comfortable & settled back at home. Have you had a moment to review your discharge plan?

Yes, I did.

Is there anything in your discharge plan that confuses you or that you don’t understand?

I’m not sure.

Take a minute to open your instructions, there are a few especially important instructions for managing your home care.
Look for:
- Activity level
- General care
- Diet
- Medication instructions

I’ll check in on you in a few days.

Just checking to see if you’ve scheduled a follow-up visit with a provider?

OK. Following up with a provider within the first week of your discharge can lower your risk of returning to the hospital. Reach out to your provider to set up an appointment as soon as you can. I’ll check on you in a few days.

Thank you!

Can you tell us about what got in the way of picking up your prescriptions?
A. No transportation
B. Too expensive
C. Insurance doesn’t cover
D. I don’t think I need them
E. Something else

No transportation

We understand picking up medications without transportation can be hard, but here are some things that might help.

1. Ask a friend or family member to pick up your medications
2. Fill your prescription(s) at a pharmacy that delivers.
3. Explore local transportation options at this link.

Let us know if you need anything else.

Quick check-in, as promised! Over the next few days it’s helpful to follow your instructions. Let family members or friends be a part of your recovery after discharge. They may be able to pick up medications or take you to appointments. They may remember things that you forget about symptoms, problems, or questions you want to ask. This can help make your recovery process smoother.

Ok thank you. I will have my son help.

I’ll be checking in later to see how you’re settling and if there’s anything I can help with. Remember, you can text this number anytime if you have a question or concern about your care. To reach your care team, please follow the contact instructions given to you.

I’m feeling really stressed

We understand that life can be stressful. It's ok to feel overwhelmed and there are things you can do to feel better. Try taking several deep breaths, talking with a friend, or taking a break to do something you enjoy. Your care team is here to listen if you need help.

How should I prepare for my PCP appointment?

At your PCP follow-up appointment, make sure to bring your discharge instructions, your medication list, and any questions you have so you can talk about the next steps in your care. Your doctor will likely want to know more about what happened in the hospital, any new health concerns, and how your health has been now that you're back home.

Got it. Thank you!

In the last 30 days, have you gone to the emergency department or been readmitted to the hospital?

Thanks for taking the time to answer these questions. We’ll pass this information along to your care team.