The Guardian Healthcare Transitional Care Model

 

Identify

Through multiple predictive modeling systems and in-home patient assessments, Guardian Healthcare clinicians are able to identify patients at high risk for preventable readmissions and emergency department visits

Collaborate

Transitional Care Coordinators help facilitate the coordination of care and collaborate with the patient and caregiver, physician, hospital, health plan, and other healthcare facilities 

Integrate

Evidence-based clinical pathways are integrated into patient-specific care plans, leading to improved outcomes and increased patient and caregiver satisfaction

Educate

Comprehensive patient and caregiver education, including signs and symptom awareness, medication management and reconciliation to encourage patient engagement

Follow Up

Ensure timely follow up physician appointments occur post-discharge, coupled with Guardian Healthcare telehealth services to complement in-home patient visits


Report

Real-time hospital and health plan-specific outcome reporting. Patient readmission notification reporting within 24 hours

       Transitional Care Model of Success