Chronic conditions require consistent monitoring and management. When inpatient care is required to treat or manage a condition, patients have easy access to necessary medications and care from licensed medical professionals. Once the condition (or conditions) are under control, however, the patient may be released into a community setting, either in their own home or an assisted living facility.

Unfortunately, the transition period between the time a patient is discharged from the hospital and when routine care is reestablished in the patient's community setting can be confusing for both the patient and their caregivers

When there is an interruption in care while the patient is being transitioned from inpatient to in-home care, however, it puts the patient at risk for relapse and increases the risk for readmission.

Our program exists to ensure continuity of care during this transition period. By taking responsibility for the patient's health during this time with a focus on facilitating a successful transition, TrueHealth can dramatically reduce the likelihood of readmission.

TrueHealth’s care team is designed to last for 30 days – it begins on the date the beneficiary is discharged from the hospital and continues for the next 29 days. Our services are furnished by healthcare professionals.

The services provided may include:

• Obtaining and reviewing discharge information. This may include continuity of care documents or a discharge summary, for example.

• Connecting and interacting with health care professionals to ensure continuity of care. By determining the primary needs of a patient, the appropriate health care services can be arranged.

• Assess the need for treatments, diagnostic tests, or follow-up on results from previous appointments.

• Assistance with scheduling required appointments with healthcare providers and services. By attending appointments after discharge and receiving the appropriate care, patients will be less likely to be readmitted because of their condition.

• Providing education and support for treatment regimen adherence. This may be especially valuable for the patient, their family, guardian, and/or caregiver. Education that aligns with self-management, daily activities, and independent living in relation to the patient's condition may also be provided.

• Medication management and prescription assistance.