Integrated Care

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
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

Let’s take your transitional care to the next level.

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