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Hospital Readmission Management
At Alicare Medical Management (AMM), we have designed a program specifically to help reduce preventable hospital readmissions.
Our Patient Transition Coaching Program is intended to address the post discharge needs of a select group of patients that are at risk for being readmitted to the hospital, specifically:
- Patients discharged post surgically.
- Patients with congestive heart failure.
- Patients with chronic obstructive pulmonary disease.
- Accredited pursuant to URAC standards.
AMM's Patient Transition Coaching Program works as follows:
- Immediately following discharge, a patient is contacted by one of AMM’s Registered Nurse (RN) Health Coaches.
- Our RN Health Coach assesses the patient’s health status and identifies potential problem areas.
- Our RN Health Coach makes certain patients are properly informed about their follow-up care and self-managed requirements, including when and how to take their medications, what potential problems could arise, and when to contact their physician.
- As appropriate, the RN Health Coach will contact the physician for additional information, intervention and follow-up care coordination.
AMM's Patient Transition Coaching Program is available:
- On a Standalone Basis.
- In conjunction with AMM's Utilization Management and Case Management programs.
