We’ve developed a program to help patients navigate care transitions from hospital to home. On behalf of our clients, we implement an end-to-end post-acute care management program that manages patients post hospital discharge throughout the care continuum. With the program, we work with network providers – including hospitals, Skilled Nursing Facilities (SNFs), Inpatient Rehabilitation Facilities (IRFs), and home care providers – to connect a patient’s journey across care providers, identify paths for care that help optimize clinical outcomes, and identify patients most at-risk for hospital readmissions so we can help them get the follow-up care they need. The program also coordinates the services patients need to transition to care at home safely, via home health, durable medical equipment (DME), and home infusion providers.