Transition of Care
Post-hospital discharge program to help reduce unnecessary readmissions.
Reducing readmissions
Our program works with individuals, doctors, health plans and even employers to help ensure patients are prepared once they have returned home from the hospital.
Questions answered
We meet in the home to go over discharge information and answer any questions to keep everyone safe.
How our Transition of Care works
Transition of Care provides the opportunity to extend care into the home by supporting individuals after a recent hospital stay. We help those who have been admitted to the hospital and have a strong likelihood of a hospital readmission based on diagnosis, co-morbidities and functional health status.
See how the program works for patients
Alegis Care can deliver an in-home visit post-discharge from any acute, observation, long-term acute care (LTAC) hospital or skilled nursing facility (SNF).
Once Alegis Care is notified that an individual has been discharged, our clinicians work directly with an individual's primary care doctor to ensure care coordination needs are addressed to help keep members safe in their homes and out of the hospital.