Care Transition Management Program

care transitions

A patient just got out of
the hospital. Let’s keep
it that way.

Care Transition

Our Care Transition Program provides clinical support to patients recently discharged from the hospital and reduces the risk of readmission and overall healthcare costs. Fonemed’s Care Transition Program is available as a stand-alone solution or as an extension of a provider’s care. Our Care Transitions service includes outbound live contact with Fonemed staff, a 24/7 in-bound nurse, consultations, electronic messaging, and live responses to alerts generated from remote biometric monitoring equipment and integration of patient data. Scheduled follow-up calls and clinical assessments ensure compliance with care plans and engage patients to become actively involved in their personal healthcare decisions. Key program features include ensuring patient understanding of their disease process and expected recovery, medication reconciliation, scheduling physician follow-up appointments and educating patients on symptoms of concern.


Our Care Transitions Program Includes

  • A plan of care with the discharging institution using our best practices for remote care templates if desired
  • Ensuring the patient understands plan of care
  • Medication reconciliation
  • 24/7 nurse triage services available for any symptomatic patient calls outside dedicated case management coverage hours
  • Educational messages and reminders for follow-up appointments electronically or by Health Service Specialists
  • Great Call, smart phone applications or tablet access (optional)
  • Physician escalation 24/7 (optional)
  • Encounter documentation for attending physician and inclusion in medical records
  • Remote device monitoring, including alert management services (optional: Fonemed can supply complete procurement and management of medical monitoring devices through its partners)

Proven results

The core program involving daily interaction with patients costs less than a single home visit by a nurse. Care Transitions Programs have consistently shown a reduction of readmission rates for congestive heart failure, pneumonia and heart attacks by at least 10%. Our proactive follow-up programs provide opportunities for provider reimbursement of the post-discharge follow-up call and physician visit. Fonemed Nurse Support programs consistently show an ROI of more than 200%.

Partner With Us

Our goal is to assist healthcare providers delivering patient-centered care benefit from increased trust from patients, improved care coordination and play a substantial role in delivering high quality care when and where it is needed most. If you are looking for a partner that can help improve your organization’s ability to deliver personalized and accountable care in a cost-effective manner, we would love to hear from you.