Post-Acute Transitional Care solutions help healthcare providers manage the critical handoff period following an acute care episode, ensuring patients safely transition to home, skilled nursing facilities, or other post-acute settings. These tools are designed to reduce readmissions, close care gaps, and improve patient outcomes through coordinated, proactive follow-up. They are used by discharge planners, care managers, and transitional care teams to monitor recovery and ensure adherence to discharge plans.

When They Are Used:• Discharge from Inpatient Settings: Coordinating follow-up care after hospitalization or surgery.• High-Risk Patient Monitoring: Supporting patients with complex conditions during the vulnerable post-discharge window.• Care Transitions to SNFs or Home Health: Ensuring smooth handoffs and communication across care settings.• 30-Day Readmission Prevention: Tracking and addressing early warning signs that may lead to avoidable readmissions.

Key Features:• Automated Outreach and Follow-Up: Phone, SMS, or portal-based tools to check in with patients post-discharge.• Care Plan Reinforcement: Delivery and clarification of discharge instructions, medication plans, and next steps.• Risk Stratification: Identification of high-risk patients who need enhanced monitoring or support.• Cross-Setting Communication: Tools for sharing information between hospitals, SNFs, PCPs, and home care teams.• Task Management and Alerts: Workflows to manage follow-up tasks, schedule appointments, and escalate concerns.

These solutions help providers extend care beyond the hospital walls, improving continuity, reducing complications, and aligning with value-based care goals.