A Seamless Transition,
Every Step of the Way
Our Hospital-to-Home™ Integrated Care Program empowers you to seamlessly and safely transition patients home, reducing costs, readmissions, and length of stays—while enhancing patient satisfaction and outcomes. With high-touch, attentive telehealth monitoring from qualified healthcare professionals and accessible, technology-enabled platforms, let us help you bring healthcare home.
Hospital to Home
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Beyond Traditional Transitional Care
Community Wellness Hospital-to-Home™
Integrated Care Program Includes
Transitional Care Management Plus (TCM+)
- Enhanced patient follow-up via phone & Zoom from our clinical care team within hours of discharge
- Virtual visits from Qualified Healthcare Professionals
- 24/7 clinical support with acute vital sign monitoring & triage management
- Regionally-hired clinical coaches (not an outsourced call center)
Remote Patient Monitoring Plus (RPM+)
- FDA-approved, BlueTooth-enabled devices set up at discharge
- Clinically-trained care team to improve medication adherence and manage health & wellness goals
Onsite Transition Navigator
- Community Wellness provided resources within your discharge team
- Help to identify eligible patients and facilitate patient throughput via enrollment, onboarding, and equipment distribution
CMS Billing
- Simple, direct billing processes to CMS
- No upfront hospital costs