Facilitate
Track
Manage

Transitions in Care

Readmissions can often be avoided with the right continuity as a member transitions between levels of care. Through expert planning, we help prevent disruptive and costly setbacks after a hospital or behavioral health facility stay with well-coordinated Transitions in Care.

Facilitate

Our care coordinators facilitate safe and efficient discharges from a hospital or behavioral health facility, preventing readmissions and improving quality metrics for patient follow-up appointments. Our care coordinators contact patients pre-discharge to provide education and coordinate the transition, assuring that members have follow-up appointments scheduled, the correct medications for the return home and the equipment they need.

Track

Our clinicians stay in touch with members post-discharge and organize additional resources as needed, including nurse reviews for more complex needs. All of this works to keep members on track and eliminate gaps in care that could lead to readmission or other unnecessary utilization.

Manage

Over a given “risk period,” coordinators monitor patient status and needs, addressing any barriers to compliance. Adverse events may trigger a member’s referral to case management, although our seamless approach to staying connected has been proven to minimize the risk of this.


Contact us today to learn more about how Transitions in Care can benefit your health plan and its members.