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AliCare | 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.

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