Care giver helping patient up off the couch


Our Transition of Care Program provides the opportunity to extend care into the home by offering support to your members post-hospital discharge – improving care coordination and reducing readmissions.

Transition of Care Program Collaboration

Our Transition of Care Program helps members who have been admitted to the hospital and have a strong likelihood of a hospital readmission based on diagnoses, co-morbidities and functional health status. We work together to identify admissions and discharges from any acute, observation, long-term acute care (LTAC) hospital or skilled nursing facility (SNF) so our team can deliver an in-home visit post-discharge.

Our clinicians communicate directly with the member's primary care physician's (PCP) office to help ensure care coordination needs are addressed to keep patients safe and stable in in their homes – and out of the hospital.

Our team will:
  • Perform an in-home visit within five days of discharge notification
  • Review hospital discharge information and educate the member and caretakers
  • Complete a full medication reconciliation
  • Identify and address durable medical equipment (DME) and social determinant needs
  • Assess and initiate care coordination for identified needs
  • Communicate with, and deliver the home visit summary to you and the member’s PCP
  • Complete a follow-up (in-home visit or telephonic depending on need)