to home services

Extend transitional care programs
across the entire episode of care

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Increase shared savings
with comprehensive transition to home programs

Support patients’ transitions from acute and post-acute care settings all the way home to increase shared savings. From identification within the acute setting to stabilization in the home, we track the patient's journey longitudinally and support recovery throughout the entire episode of care to drive appropriate utilization, reduce readmissions, and improve outcomes.

Address the needs of the whole person

Stratify patients based on both episode and individual factors through a clinical model that addresses care needs, whether clinical or social. Our clinical and social care teams assess social determinants of health, follow up with treating physicians, educate patients on chronic conditions, and coordinate with local care teams.

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Reduce the likelihood
of readmissions

Leverage our national network of providers and community-based services to prevent readmissions by giving patients continued support from our social care coordinators and, when appropriate, our nurses and nurse practitioners. Leveraging insights gained from managing $10B in healthcare spend in 2021, we develop comprehensive discharge and post-acute plans to improve savings and outcomes.

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Support clinical and social needs

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Facilitate appropriate care

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Promote patient engagement

Optimize patient recovery
and improve engagement

Focus on episodes and patients with the highest risk of rehospitalization to optimize patient recovery. We identify opportunities pre-discharge, then engage with patients within the first 72 hours at home. Registered nurse care coordinators are assigned to every episode, bringing in nurse practitioners, licensed pharmacists, or physicians as needed on high risk cases to collaborate with the patient’s primary care or specialty provider.

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Strong focus on rapid patient engagement and assessment

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Risk stratification by episode and patient-specific factors

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Frequent patient touch points throughout a 90-day episode
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Ongoing communication with local care teams and PCPs

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Advanced analytics
and reporting

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Rigorous focus on care quality and appropriateness

Understand patient and program-level metrics

Get a better line of sight to operational, clinical, and patient experience metrics at both the patient and program level so you can implement swift interventions and/or recommend corrective actions.

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Operational metrics include:

  • Engagement rate
  • Clinical vs. social outreach rates
  • Completion rates for medication reviews
  • Percent of PCP follow-up visits scheduled

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Outcomes reporting includes:

  • Readmission rate for transition to home and non-transition to home programs
  • Patient experience survey results

Webinar recording

"How two health systems are advancing value-based care with post-discharge strategies,” featuring experiences and learnings from Amita Health and Beaumont Health.



Ready to get started?

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