Our THG care team provides comprehensive, value-based care for your patient while securely communicating with the PCP throughout the patients’ stay. When necessary, a Nurse Navigator is available when a patient is identified as a high risk by the team.
During the patient’s acute stay, the THG team coordinates care with specialists at the hospital once discharged, if necessary.
Home Health Agency
Our THG team initiates the first Home Health certification order. An Informed Patient Choice List is given to the patient. The team will follow up with the initiation of orders.
Skilled Nursing Facility (SNF)
Our THG team secures admission to an SNF. An Informed Patient Choice List is given to the patient. The team will follow up with the initiation of admitting orders.
Our THG team initiates hospice and/or palliative care services.
Primary Care Physician (PCP)
Our THG care team communicates securely during the entire stay as well as continuing any discharge instructions. Additionally, our team will schedule the first Transitional Care Management (TCM) visit back to the patient's PCP within 7-14 days of discharge from the acute setting, when possible.