Transitional Care

Transitional care is any planned or unplanned movement from an inpatient or facility setting back into the community or vice versa. Transitional care takes place beyond the boundaries of our comprehensive care centers.  Our transitional care team goes beyond traditional clinical coordination to assess all aspects of a member’s life to prepare for this move.

We go into hospitals and other facilities to meet with our members and their caregivers to help restore them to the most appropriate care setting more quickly and efficiently, with a lowered chance for readmission.

Navigating Changes

AbsoluteCare’s Transitional Nurse Care Managers (TCMs) help our members during this time and post-discharge to:

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  • Reduce readmissions and unnecessary time in the hospital
  • Participate in discharge planning to ensure it is safe and achievable
  • Help them adhere to the discharge plan and medication regimen: care is then transitioned back to their primary care manager
  • Assist with coordination of the treatment plan, regardless of whether we are the PCP of record
  • Improve their overall satisfaction with their healthcare
  • Evaluate their home environment and connect them with other resources and partnering programs

Transitional Care Coordination

Transitional Care Managers—informed by real-time alerts from health information exchanges (HIEs) and reports from the facilities, payers, caregivers, the family, or the member—partner with members to ensure they are connected with the appropriate programs, services, specialists, and other SDoH needs. They help members overcome any barrier to receiving necessary care.

The type of alert (e.g., observation, admission, discharge, transfer) determines the TCM’s course of action:

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  • Follow the member during inpatient care or transition to a new level of care
  • Address inpatient issues
  • Coordinate services for a safe discharge
  • Review discharge plan, documents, and medication list
  • Collaborate with the facility discharge planner, member, and caregiver
  • Facilitate peer-to-peer call with inpatient team to advocate for member needs, provider concerns, or unnecessary utilization prevention, as needed
  • Advocate for member needs

Measure of Success

How do we measure success? We regularly track KPIs.

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  • Admission rate per thousand
  • Average length of stay
  • Readmission rate
  • Completed hospital follow-up visit within seven days post-discharge

Beyond Medicine, Beyond Centers

So much of what we do takes place beyond brick and mortar of our chronic care centers, especially when it comes to transitional care. But this work goes hand in hand with:

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• Physical health

• Substance use challenges and mental and behavioral health

• Social determinants of health