Transitional (Post Acute) Care Management

Provide safe transitions in care during acute illness or chronic condition exacerbation.

Ensure patient care coordination during post hospital or nursing facility to ensure patient remains in compliance with plan of care, as well as adjust care plan to prevent readmission or decline in function.

Increase communication and coordination between service providers in a community.

Great transparency and data collection.

Ensure referrals, coordination of information to specialty services.

Medication reconciliation, prescriptions refilled as necessary.

Get connected to the right service to help you with your needs.

Decrease wait time to services.

Improve quality of care - client satisfaction on services will be monitored and feedback collected.

24/7 access to community resources - continued management during acute and chronic management.

Easily navigate services.

Do not need to repeat your needs to multiple organizations.

Once established, we have a telemedicine application to better accommodate for in home health care and chronic condition management and ongoing education.

Ubuntu Health is an outcome-focused technology solution that builds coordinated care networks of health and social service providers powered by patient-centered coordination and electronic referral management software. You can find out more here.

We know how valuable your health is and we provide transparency and commitment to providing you with your health information.

Every patient is provided access to patient portal to easily navigate your results, education, referrals and messaging with provider for any new issues.