Hospitals & Health Systems

Reduce 30-Day Readmissions. Strengthen Care Transitions. Protect Revenue.

Unplanned 30-day readmissions directly impact hospital margins, quality scores, and referral relationships. Effective Transitional Care Management (TCM) is no longer optional — it's essential.

We partner with hospitals and health systems to deliver end-to-end transition care programs that reduce readmissions, improve follow-up compliance, and strengthen value-based performance — with minimal operational and financial burden on your organization.

Hospital Building

A Comprehensive Transitional Care Management (TCM) Solution

Our program is aligned with requirements from the Centers for Medicare & Medicaid Services and built to systematically close post-discharge gaps.

What We Cover Across the 30-Day Window

Immediate Post-Discharge

Within 48 Hours
  • Patient outreach and clinical assessment
  • Medication reconciliation and adherence check
  • Identification of red flags and escalation protocols

Follow-Up Coordination

  • Scheduling and ensuring timely PCP or specialist visits
  • Ensuring TCM visit completion within required timelines
  • Coordination with hospital-employed or community physicians

Ongoing 30-Day Clinical Oversight

  • Structured clinical check-ins
  • Symptom monitoring and deterioration alerts
  • Chronic condition stabilization
  • Behavioral health screening (as applicable)

Medication & Adherence Support

  • Reconciliation against discharge instructions
  • Adherence education and reinforcement
  • Barrier identification (cost, access, confusion)

SDOH Support

  • Identification of transportation, food, or caregiver barriers
  • Connection to community resources
  • Social risk escalation workflows

Real-Time Documentation & Compliance

  • TCM-compliant documentation
  • Audit-ready workflows
  • Structured reporting for hospital leadership

Anchored by a Physician Group

Our transition care model is physician-led and anchored by an affiliated provider group. This ensures:

  • Clinical oversight and escalation authority
  • Medicare-compliant TCM billing workflows
  • Structured coordination with hospital teams
  • Clinical credibility with patients and referring providers

We function as an extension of your discharge and care management teams — not as an external call center.

Physician-Led Model

Clinical oversight at every step

Commercial Model Designed for Hospitals

We structure our engagement to create little to no financial burden on your health system:

Revenue Generated

Through compliant TCM billing

Flexible Partnership

Models tailored to your needs

No Additional FTEs

No need for hospital staff expansion

Scalable

Across all service lines

Our goal is alignment — not added cost.

Impact for Hospitals & Health Systems

Reduce 30-Day Readmissions

  • Proactive follow-up
  • Early detection of complications
  • Escalation before ED utilization

Improve Quality & VBC Performance

  • Support for value-based contracts
  • Strengthen bundled payment outcomes
  • Improve referral relationships

Strengthen Hospital-Physician Alignment

  • Timely follow-up visits
  • Clear communication loops
  • Better discharge-to-community continuity

Why Hospitals Choose Us

Structured, CMS-aligned TCM workflows
Physician-anchored model
Strong follow-up visit compliance
Medication and SDOH support
Reduced administrative burden
Measurable reduction in readmission rates

Transition Care That Actually Closes the Loop

Discharge is not the end of care — it's the highest-risk moment in the patient journey.

We ensure every discharged patient receives structured follow-up, medication support, social risk assistance, and clinical monitoring — so they stay stable at home instead of returning to the hospital.

Let's build a transition care program that protects both your patients and your margins.

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