Amerimed works closely with our partner hospitals and health systems manage the risk of penalties and claim denials due to avoidable readmissions, including embedding Amerimed staff in the facility to meet with patients and their families before discharge to coordinate an in-home/in-person Transition of Care (TOC) visit within 72 hours of arriving home.  

In this TOC visit, our Nurse Practitioners will:

• carefully review the facility discharge orders with the patient and family/caregivers,
• review and reconcile patient medication, 
• review and address Social Determinants of Health challenges within the home environment, 
• coordinate follow-up care with primary and specialist physician offices,
• coordinate any in-home care with home health, durable medical equipment or other provider, 
• and render any appropriate medical care that will support the patients’ progress to recovery and health.

Finally, our team will ensure that all documentation from the TOC visit is submitted to the patient’s regular primary care and specialist providers.

Amerimed is pleased to support our hospital partners in their Hospital Consumer Assessment of Providers and Health Systems (HCAPHS) survey results and other accreditation activities.