Care Management & Transition of Care

Care Management & Transition of Care

Our care management and transition of care multidisciplinary model produces better health outcomes for patients while significantly reducing hospital re-admission and ER utilization rates.

We target patients in facilities that would benefit most from care management and transition of care services. We utilize the expertise of our clinical pharmacists to provide medication reconciliation services as well as comprehensive medication discharge counseling that includes scheduled telephonic or in-person follow-up appointments within 24 to 48 hours post-discharge.

Our group of experts also works in collaboration with other members of the healthcare team to:

• Address gaps in care and facilitate access to other health and social care needs.
• Address health literacy and provide education, coaching, and counseling.
• Support patients, families, and caregivers regarding self-care and healthy lifestyle skills.
• Work closely with prescribers to enhance therapeutic outcomes from drug therapy.

We also offer bundled concierge services including patient education, medication reconciliation, follow-up phone calls, discharge prescription planning and delivery, and home-based medication reconciliation.

Detailed Services

• Medication Reconciliation (MED REC) Services: Our medication reconciliation process is driven by our clinical pharmacists. We partner with patients, providers, primary pharmacies, and caregivers to create a complete, accurate, and current medication list. The goal is to reduce medication errors and adverse drug events at all transitions of care.
• Medication Discharge Counseling Services: We equip patients with a thorough understanding of their discharge treatment regimen and therapy expectations. We evaluate costs for less expensive alternatives and check eligibility for patient assistance programs. Our team follows up by phone or in person within 24 to 48 hours and again at 7 days post-discharge.
• Prior Authorization (PA) Management Services: We manage the entire prior authorization process, including PA submission, follow-up, and appeals for denials; peer-to-peer consultations and medical benefit investigation; patient medication assistance program enrollment; and pharmacist consultation for medication alternatives and therapeutic drug monitoring.
• Personal Care Assistance Services: Our professional caregivers help meet unique non-medical or custodial care needs for individuals too ill or busy to perform activities of daily living. We also provide flexible services to organizations and facilities, including homemaker services and family-caregiver support.
• Non-Emergency Medical Transportation Service: We provide transportation to medical appointments and pharmacies for medication pick-up or delivery. These services reduce transportation-related obstacles to care, enhancing appointment and medication adherence while decreasing loss to follow-up.
• Patient Triage Services: We provide a communication platform for non-urgent health and medication questions via phone or secure messaging, available after hours or post-discharge. Licensed healthcare experts address questions or direct patients to the appropriate level of care, with details of each encounter sent to the primary provider for follow-up.