Transitional Care Management
About 20% of all Medicare beneficiaries discharged from hospitals return to the hospital within 30 days.  The primary causal factors for this readmission figure are ineffective communication, inadequate follow-up and patient non-compliance.  Today, finding new strategies to reduce hospital readmission rates is a common theme among hospitals and payers.  Utilizing our “Care Solutions Way” of Assess….Connect….Follow minimizes the potential readmission of a high-risk patient.
The Transitional Care Management Program of Care Solutions Group is designed to improve continuity of care from the point of discharge from a hospital or skilled nursing facility to the home.  A Care Solutions Group social worker is assigned to each patient and is responsible for assessing each patient, identifying the appropriate risk level and developing the plan of care.
Prior to discharge, Care Solutions Group implements the plan of care by coordinating all community-based care needs through its Credentialed Provider Network. High-risk patients are provided with unique interventions designed to stabilize the patient within the first thirty days post-discharge from the acute setting.
The benefits of the Care Solutions Group Transitional Care Management Program include:
  • Reduced readmission rates and their related costs.
  • Enhanced continuity of care from hospital to home.
  • Improved outcomes including reduced hospitalizations, ER visits and medication use.
  • Continued monitoring and tracking of patient.