Who We Serve

We help Medicaid-enrolled (including Medicaid-managed care plans like Amerigroup and Health Springs) adults ages 50 and older safely return to their home and community life after being discharged from the hospital.

This population is especially vulnerable to hospital readmissions, falling, and poor quality of life as they transition back to their home and community environments following discharge. These complications are avoidable and often result from substandard medical coordination and management, especially in the first 30 days following hospital discharge.

Navigating within a complicated medical system can lend to failure, especially during this sensitive transitional period between the hospital and the home. There are often challenges with patient misunderstanding of discharge instructions, managing changes to medications, complying with follow up physician visits, and feelings of uncertainty when increasing activity to safely meet the demands of daily living.

This page was last modified on June 9, 2015