Transition Management

According to the Department of Health and Human Services, one in five patients who leave the hospital will be readmitted within 30 days. Studies indicate that up to 76 percent of these readmissions may be preventable. Effective population health requires that preventable readmissions be minimized, which can only be achieved when patients are managed across the full continuum of care, particularly after they are discharged from a hospital or a rehabilitative facility.

IHMG's Transition Management service provides the bridge for patients as they transition from one level of care to another or between hospital discharge and follow up with their primary care provider. Our team works with hospitals to:

  • Pre-discharge consultation
  • Collaborative management with the primary care provider or medical director of patients discharged to a post-acute facility
  • Home visits for patients discharged to their own homes or assisted living communities, ensuring patients understand and follow discharge instructions, and manage clinical issues that could be exacerbated before patients are seen by their primary care provider

Throughout the process, our team facilitates timely communication between the patient, primary care provider, hospital case manager and health plan, managing the timely exchange of information regarding a patient's clinical situation. When care is managed through IHMG's Transition Management services, patients receive the most effective care, which helps avoid readmissions and avert unnecessary visits to the emergency room.