Transition of care
Coordinate safer transitions beyond the discharge
Bring discharge tasks, provider placement, documentation, and follow-up into one coordinated workflow. Help patients move to the next setting with fewer gaps in care.
- PlacementAccepted · Mesa Gardens
- RecordsSent · 11:20 AM
- EquipmentWalker ordered · awaiting delivery
- TransportationScheduled 2:00 PM
- Follow-upPCP visit within 7 days · to schedule
Capabilities
- Discharge coordination
- Placement tracking
- Care handoffs
- Follow-up scheduling
- Post-discharge monitoring
Outcomes we help you pursue
- Fewer readmissions
- Shorter hospital stays
- Safer care transitions
- Lower total cost of care
- Better patient outcomes
Transition challenges
A discharge can stall when placement, equipment, records, or follow-up remain unresolved. Give the care team a shared view of what is complete, what is missing, and who will act next.
Discharge to follow-up workflow
Organize discharge needs, send referrals, track provider responses, and coordinate the handoff. Continue follow-up after discharge so barriers and uncompleted services remain visible.
- Placement confirmed
- Records shared
- Equipment arranged
- Follow-up scheduled
- Post-discharge check
Core capabilities
Use shared task lists, placement tracking, document exchange, and outreach reminders to coordinate the transition. Escalate overdue work and record the actions taken to resolve barriers.
- PlacementAccepted · Mesa Gardens
- RecordsSent · 11:20 AM
- EquipmentWalker ordered · awaiting delivery
- TransportationScheduled 2:00 PM
- Follow-upPCP visit within 7 days · to schedule
Care team roles
Hospital teams, receiving providers, health plans, and other authorized participants can coordinate their responsibilities. Define ownership at each handoff so follow-up has an accountable team.
Outcome evidence
Track discharge delays, referral completion, follow-up completion, and return-to-hospital events where encounter data are available. Use these measures to evaluate continuity, avoidable utilization, and cost.
Skilled nursing · discharge and acceptance
Elapsed discharge and acceptance time from about 48 hours to 8
An Ensign Services case manager replaced a manual, paper-heavy discharge process with a dashboard showing which agencies accept a patient's insurance.
Ensign Services Read story →
Behavioral health · discharge coordination
Discharge coordination time cut from 3 hours to 30 minutes
Case managers at Aurora Behavioral Health moved from phone tag with destination facilities to real-time notifications and two-way communication.
Aurora Behavioral Health Read story →
Integrations
Connect relevant admission, discharge, referral, and patient information through supported interfaces. Align the workflow with your current clinical and operational systems.
Frequently asked questions
More answers on our FAQs page.
Walk through a recent transition with us
We will help identify where shared tasks and earlier follow-up could reduce delays.