Transitional Care Program 30-Day Readmission Prevention Plan
Our primary goal is to proactively leverage our comprehensive care model & diverse resources to support patients in reducing hospitalizations and preventing readmissions.
24-48 Hour telehealth
Initial NEW PATIENT Telehealth
Upon arriving home, our patients can expect to have an initial Telehealth Visit within 24-48 hours with a nurse practitioner or physician assistant. Their focus will be to see how their patients are feeling and order any additional medications that they may require.
72 Hours TRANSITIONAL CARE
A Telehealth visit with Transitional Care professional upon discharge to follow-up to ensure that everything is going smoothly as we facilitate care at home.
In-Home NURSE Visit
The nurse practitioner or physician assistant will conduct a thorough assessment, ensuring that medications are in order, and arrange further care depending on our patient’s specific care requirements.
PHARMACY CONSULTATION VISIT
Our pharmacist will review medications and simplify complex medication plans, and provide guidance. Check on the interactions of various medications and see if any adjustments need to be made.
FACT: Up to 50% of patients don’t take medications as prescribed, according to the World Health Organization. Poor adherence leads to worsening symptoms, complications, and ultimately, readmission—often within 30 days. In fact, studies suggest that non-adherence alone accounts for up to 10–20% of hospital readmissions.
COMMUNITY HEALTH WORKER
Take the time to understand our patient’s physical and environmental concerns to help them achieve optimal health. Our team can also support your needs related to durable medical equipment or remote patient monitoring to ensure consistent, effective care.
WITHIN 10 DAYS DOCTORS VISIT
At Your Health, our dedicated team of doctors will personally review your chart and ensure that our patients receive the best possible care. The doctors will also conduct an in-person Telehealth Visit within the first 10 days of your care to ensure that you receive the attention and support our patients deserve.
IN-PERSON ON TELEHEALTH VISITING NURSE
As part of our patient’s care team, a visiting nurse will come to your home and communicate directly with the broader care team to ensure seamless coordination of your care
ACCESS TO FULL TEAM OF SPECIALISTS
At Your Health, we have a robust team of specialists who provide additional oversight and referrals when needed. Our services include Wound Care, Diabetes Management, Physical /Occupational Therapy, Pulmonary, Neurology, Cardiology, Pelvic Health, Endocrinology, Nephrology, Urology, Pharmacy, and Palliative Care. Each specialty brings unique insight to support our patients’ health. What sets us apart is our seamless integration with primary care—creating a truly comprehensive and coordinated care experience.
Within 14 Days Behavioral Health
Our patient’s mental well-being is just as important as their physical health in their recovery journey. Stress is proven to delay healing. That’s why, our patients have a telehealth visit with a Licensed Clinical Social who will check in to see how you are feeling emotionally.
30 DAY
GRADUATION
This 30-DAY plan was constructed with DATA-DRIVEN insights from our database that’s proven to reduce patients’ chances of another hospital readmission or ER visit. Even after completing the program, the transitional care team will continue to partner in our patients’ care to ensure health stays on track.
NEXT STEPS
Questions? We’ll be glad to answer anything about our model of care. Please contact us 1-800-491-0909 so we can answer your questions.