Transitional Care Management

Our transitional care and care coordination programs address common gaps in care that arise when patients transition from hospital to home.  Gaps in our current fragmented healthcare system prevent continuity of care among high-risk/high-cost patients. These patients and their family caregivers are faced with the often daunting task of managing their complex medical conditions at home.  Due to reduced compliance, access, resources and understanding of their condition and care plan, such patients are readmitted to hospitals with worsened medical conditions. 

We will work closely with our client’s primary care physician and other providers to devise a tailored care plan that is consistent with their hospital discharge plan. Our goal is to reduce hospital readmissions and prevent unnecessary costs.  Using clear, streamlined communications, enhanced with state of the art telemedicine, this goal can be actualized.