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Improve patient outcomes and increase shared savings
Support patients’ transitions from acute and post-acute care settings all the way home to improve patient outcomes and increase shared savings. From identification within the acute setting to stabilization in the home, we track the patient’s journey longitudinally and support recovery through clinical and social coordination that drives appropriate utilization, reduces preventable readmissions, and improves outcomes.
Optimize patient recovery and improve engagement
social care needs
Reduce the likelihood of readmissions
Leverage our national network of providers and community-based services to prevent readmissions by giving patients continued support. Our nationwide team of clinical and social care coordinators connect patients to relevant local programs and track all interventions longitudinally to measure the impact of SDOH resolution on health outcomes and performance goals.
Extend the reach of your team
Comprehensive suite of technology, tools and people extends your resources to better assess, engage and track patient progress.
Scalable and sustainable
Telephonic / virtual models minimize staffing impacts and provide flexible support that complements existing program operations.
Clinical and social care needs
Interdisciplinary team provides support for every patient – regardless of risk level – and addresses the needs of the whole person.
Better patient adherence
Personalized approach enables professional discretion to meet each patient where they are and promotes self-efficacy to heal effectively.
Benefit from our experience running one of the largest transitional care programs
By focusing on care plan review, access to home and community based services and reconnecting patients with their primary care and specialty providers, we’ll help you reduce 30-day rehospitalization rates.
Focused on quality
Transparent quality assurance, audit, and readmissions review processes help to reduce variations and ensure adherence to best practices.
Interdisciplinary care teams provide scale and sustain evidence-based, virtual first transitional care programs across large geographies.
Local support and coordination
Augment care coordination with local providers to enable patients’ timely follow-up with local providers, access to healthcare services, and closure of SDOH gaps.