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 Transitional Care professional is assigned to a patient upon discharge to follow-up to ensure that everything is going smoothly as we facilitate care at home.
In-Home Visit
The nurse practitioner will conduct a thorough assessment and then coordinates care ensuring that medications are in order, and arrange further care depending on our patient specific care requirements.
* 4 Day Goal of Med Review
PHARMACY CONSULTATION VISIT
Our pharmacist will review the patients’ medications, simplify complex medication plans, and provide guidance. They will also check for interactions among the medications and determine if any adjustments are necessary.
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
Community Health Worker takes 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.
DOCTORS VISIT
At Your Health, our dedicated team of doctors will personally review the chart of the patient to ensure the best possible care takes place. The doctors will also conduct a Telehealth Visit to ensure that the patient receives the attention and support they deserve.
VISITING NURSE
As part of our patients’ care team, a visiting nurse will come to the home and communicate directly with the care team to ensure seamless coordination of 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.
Behavioral Health
Our patients’ 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 access to a telehealth visit with a Licensed Clinical Social Worker who will check in to see how you are feeling emotionally.
30 DAY
GRADUATION
This 30-DAY plan was constructed with DATA-DRIVEN insights proven to reduce hospital readmission and ER visit.
NEXT STEPS
Please contact us 1-866-410-2285 so we can answer your questions.