Our unique model follows an individual after their acute event all the way home. We track the person’s journey longitudinally, from identification within the acute setting to stabilization in the home, utilizing data from our exclusive network of high-performance post-acute facilities and agencies to drive superior post-acute outcomes. We support recovery through a comprehensive transition to home plan, offering a full range of clinical and social care coordination and next site of care services to ensure appropriate utilization.
From identification within the acute care setting to stabilization in the home, we support patients’ whole-health needs at each point of their care journey to drive more healthy days at home.
We utilize data from post-acute facilities and agencies within our network, with deep engagement at the facility level to ensure patients’ care plans align with best clinical practices.
Our unmatched data analytics, modeling, and segmentation capabilities ensure patients are supported and tracked longitudinally as they transition to the next site of care. Intelligent workflows are applied to ensure proper utilization at each patient touch point.
Clinical and social care coordination is fully integrated within each patient’s comprehensive transition to home plan, identifying and addressing social needs that may impact recovery. This begins with an outreach call within 48-72 hours of discharge to fully assess any unfulfilled needs.
Our in-home services, staffed by the nation’s largest network of field-based clinicians ensures patients are properly supported and stabilized once they return home. We assess health conditions and risk alongside clinical services to drive continuity of care and improve outcomes.