Our Services
Service 04 of 6
Care Management & Transition of Care
Seamless care transitions that significantly reduce costly hospital readmissions through pharmacist-driven discharge support, comprehensive medication reconciliation, and proactive patient follow-up — ensuring patients receive the right care at the right time in the right setting.
Care transitions — particularly hospital discharge — represent one of the highest-risk periods in a patient's healthcare journey. Medication errors, lack of follow-up, and poor communication between care settings lead to preventable readmissions that cost the healthcare system billions annually. Prime Care Health Solutions delivers structured, evidence-based transition of care programs that close these dangerous gaps.
Pharmacist-Led Transition Support
Our pharmacists and care coordinators engage patients at the point of discharge, conducting comprehensive medication reconciliation, identifying discrepancies, and ensuring patients understand their post-discharge medication regimens. We schedule and facilitate timely primary care follow-up appointments and maintain communication with receiving providers.
Our 30-day post-discharge program includes structured outreach calls, medication adherence monitoring, symptom surveillance, and escalation pathways — dramatically reducing 30-day readmission rates for high-risk patients.
Measurable Impact
- Reduction in 30-day hospital readmission rates
- Improved medication adherence post-discharge
- Higher rates of timely post-discharge follow-up appointments
- Reduced emergency department utilization within 30 days of discharge
Programs & Services Under This Solution
Transition of Care (TOC) Programs
Structured post-discharge programs providing pharmacist and care coordinator support during the critical 30-day post-hospitalization window — including discharge medication review, follow-up appointment facilitation, and symptom monitoring.
Medication Reconciliation
Comprehensive medication reconciliation at care transitions — comparing discharge medication lists to preadmission and current medications, identifying discrepancies, and resolving potentially dangerous errors with the patient's care team.
Discharge Medication Counseling
In-depth patient and caregiver education on newly prescribed discharge medications — including purpose, dosing, side effects, storage, and special instructions — improving comprehension and adherence from day one post-discharge.
Patient Triage & Follow-up
Structured post-discharge contact protocol including 48-hour, 7-day, and 30-day outreach calls to assess patient status, identify emerging issues, reinforce education, and facilitate timely escalation when clinical deterioration is detected.
Hospital Readmission Reduction
Risk-stratified readmission prevention programs targeting high-risk patients with complex conditions — heart failure, COPD, pneumonia, joint replacement — aligned to CMS Hospital Readmissions Reduction Program (HRRP) requirements.
Complex Case Management
Intensive case management for patients with multiple chronic conditions, social determinants of health challenges, and high healthcare utilization — coordinating medical, behavioral health, social services, and community resources for whole-person support.