TRANSITIONAL CARE 

In-Home Visits to Recently Discharged Members:

  • Deploy Providers to member homes within 48 hours of a facility discharge to ensure members understand and follow prescribed care plans.
  • Review and educate members on the importance of following the care plan.
  • Assess and document the current condition of members.
  • Coordinate care of members with other care team members as required.
  • Conduct follow-up visits to members as required until condition is stabilized.