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Integrated Transitional Care

Home Visit M.D. coordinates clinical services of multiple health professionals, paraprofessionals, and medication management from an acute environment to the home setting. We help prevent confusion in communication and re-admissions by clarifying and addressing the patient’s needs before hospital discharge, care immediately after discharge and routine follow ups.

Home Visit M.D. works with Accountable Care Organizations (ACOs), Physician-Hospital Organizations (PHOs), Independent Practice Associations (IPAs), and groups of doctors, hospitals and other care providers to decrease and contain costs associated with treating their high-risk/high-cost patients. Our programs are designed to help:

  • eliminate medical errors and duplicating services
  • achieve accountable care benchmarks and goals
  • increase revenues stemming from shared-savings programs
  • decrease or eliminate revenue losses associated with extended hospital stays and readmissions (AKA BOUNCEBACKS)

Home Visit M.D. assists patients from health facilities to home care with our Integrated Transitional Program. Our services range from a home visit to aggressive long-term care that raises quality of life. We help reduce initial admissions, re-admissions, urgent care, emergency visits and acute hospital stays while lowering healthcare costs.

Home Visit M.D. Offers

  • In Home Assessment
  • Other Medical Specialties
  • Self-Management Education
  • Medication Therapy Management
  • Case Management Services
  • Acute physician visits at residence within 24 hours of Discharge or Acute Complaints
  • Physician Access via Cell Phone – 24/7
  • Electronic Health Record Management


Physician at Patien'ts Home



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