Transitional care

Coordinated Care Alliance provides the evidence-based Bridge Transitional Care Program

 

  • Seamless transitions across the continuum of care with bedside visits at the hospital, skilled nursing facility and home

  • Home visits within 24-48 hours of discharge with a home safety risk assessment

  • Person-centered care that connects medical aspects of care with the social determinants that impact health, safety, and well-being in the community

  • Connection to federal, state and culturally diverse community resources 

  • Follow up for 30 days post discharge which includes an average of 25 contacts with the member, member's family and interdisciplinary team utilizing psychotherapeutic techniques such as motivational interviewing