Care giver helping patient up off the couch

IMPROVING HOSPITAL TO HOME TRANSTIONS AND REDUCING READMISSIONS

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)