Transition Care Management

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Transition Care Management Services

Transition Care Management refers to the coordination and continuity of health care during a movement from one healthcare setting to either another or to home

Transition Care Management remote blood sugar monitoring

Transition care management aims to ensure the successful transition of patients from hospitals, nursing homes, etc., back to their community setting, including rest homes, domiciliary, assisted living, or home, leading to the best health outcomes possible for patients. It involves reducing readmissions during the 30-day transition care management period that begins when the patient is discharged from the acute care setting and continues for the following 29 days.

The care management involves contacting patients within 2 business days from the time they are discharged from the acute care setting and addressing patient status and needs after the scheduled follow-up care. The contact is made via email, telephone, or in-person to bill the patient.

A clinical pharmacist performs our transitional care management services. With our services, you will get:

Our plan will perform following services:

    • All services are performed by clinical pharmacist
    • Complete and accurate medication reconciliation
    • Post discharge support including communication with primary care providers, Patients and caregivers
    • Patient counseling and assistance to achieve best medication therapy outcome
    • Post primary care transition of care visit medication reconciliation and support
    • Follow Up calls to prevent readmission and monitor compliance
    • Communications with hospital and providers to close any therapy gaps
    • High-risk screening tools to avoid complications
    • Follow-up calls to family members to reduce hospital readmission and monitor compliance
What CHS’s Transition Care Management Portal Can Do For You

Whether your patient needs transitional care from nursing home to primary care, transitional care from hospital to primary care, or from hospital to home, you can use our transitional care management services. Using the platform, you can enroll patients, schedule and document follow-up calls, and create a care plan.

Our plan objectives

    • Reduce hospital readmission
    • Maximize adherence
    • Reduce complications
    • Improve patient overall health conditions and reduce adverse events
    • Improve communications between providers and patients
    • Improve satisfactions
    • Schedule in-person appointments
    • Reach more patients by extending care remotely
    • Establish contact with patients within 2 days of their discharge from transition care from hospital to home
    • Simplify your workflow; helping you focus on expanding your business
    • Provide dashboard with real-time information about patient’s health. It makes monitoring their progress over the 30-day post-discharge period easier
Doctor giving presentation to team of interim doctors at conference room
Giving Transitioning Patients Care They Deserve

At CHS, we understand how critical the 30 post-discharge period is for transitioning patients. Especially for older adults who have multiple chronic conditions and need constant care as they often move between care settings. It is essential to deliver quality care to patients during this time. Our HIPAA-compliant portal is made specifically for managing patients transitioning from acute care to other care settings or homes. It automates workflow and streamlines transitional care, reducing the time you would spend doing the whole procedure manually.

With our transition care management solution, you can:

    • Fill the gaps in care during the time of initial patient stay, reducing hospital readmissions
    • Maximize adherence
    • Reduce complications
    • Improve patient overall health conditions and reduce adverse events
    • Improve communications between providers and patients
    • Get satisfactory post-discharge care
    • Lower care costs and generate revenue through easy-to-access billing reports
    • Control primary care costs and the cost of emergency care facilities for your patients
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