Transition Management:
A 30-day program to support patients at
high-risk of readmission following discharge from a hospital or skilled nursing facility
In summary, the Transition Management program includes:
- 30-day support following discharge from a hospital or SNF
- In-home assessment from a pharmacist care manager within 48 hours of discharge
- Focus on medication adherence and reconciliation: what, how and why?
- Customized medication reports created for patients and physicians
- Collaboration with a registered nurse to develop 30-day care plan
- Telephonic support and implementation of care plan to address risks of rehospitalization
- Communication with physicians to alert them of any red flags
- Caregiver support and care coordination as appropriate
- Discharge summary and referral into partner programs for follow-up support
Patient support does not end at the conclusion of the 30-day program. Fully integrated into its partners’ medical management programs, Dovetail works in close collaboration with patients and providers to ensure that the appropriate ongoing support system is in place.