Good clinicians alone aren’t enough to optimize transitions of care. Our unique care model combines highly trained clinical staff who are embedded in the facilities they serve along with evidence-based protocols and a proven, patient-centered, collaborative approach. This approach addresses a wide range of strategic aims from minimizing hospital readmissions to improving patient and staff outcomes to avoiding adverse events. Our model includes:
• In-facility care delivery guided by an evidence-based plan of care
• Active engagement of patients and their family and informal caregivers, including education and support
• Multidisciplinary approach rooted in the award winning Accountable Care Unit that includes the patient, family, and staff as part of the team
• Care coordination with members of the care team including primary care providers and specialists