Understanding the Paradigm of Transitional Care

The focus of Transitional Medicine at Care Partners was a direct result of simply finding a better way to provide a level of care for patients with chronic, high risk, health care needs with a responsibility to improving the quality of a person’s life while containing the high cost of unnecessary readmissions and unnecessary medical care. Our model integrates into any hospital system or Insurance Plan with the purpose of reducing readmissions, ED visits and length of stay while simultaneously increasing patient quality of life and satisfaction.
What We Do - Payer & IPA Partnerships

Our medical/social hybrid high patient touch model focuses on patients who are high utilizers and those with the highest risk for admission or readmission
- Reduce Readmission Rates
- Reduce LOS
- Medicare Risk Adjustment Factor Collection
- Root Cause Analysis/Case Study’s

How We Bridge The Gap

CMS penalized over 2,500 hospitals by more than $564 million in 2017 for excessive 30-day hospital readmission rates.





Most Importantly - We CONNECT!
Our Impact

Global Transitional Care
All-Cause Medicare
Readmission Rate
Global Transitional Care
Preventable Medicare
Readmission Rate
*GTC specializes in moderate to high acuity patients at high risk for readmission. **Individual case studies are completed with hospital and post-acute providers to determine readmission cause and whether it is defined as preventable.

Average Number of GTC
provider/patient interactions per month
(By Type)
Post-Acute Providers - The Difference

Medicare Part B Reimbursement | Medicare Part A Reimbursement | Clinical Oversight For Minimum 30 Days | Nurse Practicioners In-Home Patient | Ability To Reach Primary Md Directly & Communicate At Their Level | Episodic/Diagnostic Specific Interaction | Companion Care | Does Not Require A Physician Order | |
---|---|---|---|---|---|---|---|---|
Clinical Transitional Care (GTC) | ||||||||
Home Health Care | ||||||||
Home Care |
We Pride Ourselves On Satisfied Clients

% of patients that strongly agreed with the statement that they would “recommend GTC’s Services”
% of patients that strongly agreed with the statement that they would “happily use GTC’s services again if needed”
In The News

Our Transitional Care Team


Susan Frye
Geriatric Nurse Practitioner
APTCN

Rut Huynh
Family Nurse Practitioner
APTCN

Javanne Brooks
Nurse Practitioner
FNP - C

Katerina Borja
Nurse Practitioner
APTCN

Roggielyz Padilla
Family Nurse Practitioner
APTCN

Nanette Hill
Transitional Care Coordinator
Care Partners Associations




