Care Transition Management

Our Care Transition Program provides assistance to Integrated Delivery Systems, Medical Groups, Accountable Care Organizations, and Health Plans to reduce inappropriate utilization. We provide a comprehensive suite of services that yield a reduction in inappropriate hospital and skilled nursing facility readmissions.  According to a New England Journal of Medicine study, nearly one in five Medicare patients are readmitted within a month after release from a hospital. Our program has a proven record of reducing readmissions during the critical 30-day post-discharge time period. Clients have reported as high as a 40% reductions in hospital readmission rates.

Care Transition Services Include:

  • Medication review, reconciliation and “real-time” adjustment as needed
  • Functional / safety  / skin / caregiver issues and needs
  • Nutrition
  • Cognitive status
  • Pain issues and management recommendations
  • Assessment of Patient prognosis / insight and expectations
  • Advance directives discussions and POLST form status
  • Clinical status of primary diagnosis and key co-morbidities with additional clinical intervention as appropriate
  • Review of functional potential to return to outpatient / ambulatory care track




Services are tailored for patients at high risk for readmission, based on both utilization history and/or prospective clinical risk. Our comprehensive approach includes face to face clinician visits, interim proactive telephonic case management, active discharge planning,  and continuity services for patients who are unable or unlikely to return to ambulatory care physicians.

Appropriate benchmarks are set for each patient and a detailed care plan is implemented in order to repatriate the patient back to their PCP. Housecall Doctors Medical Group focuses on interdisciplinary team communications with case managers and other field-based providers to improve coordination of care.