Transition well from hospital to home – self-manage and recover better

Self-mange & recover better

As the only physician specialists in multi-condition rehabilitation, we use specialized telehealth technology to train patients how to improve their underlying determinants for rehospitalization. 

Patients who are hospitalized are often exposed to weakening risk factors that increase vulnerability not only to a re-hospitalization but also to long-term disability. These risk factors include relative immobility, flare-ups of pre-existing chronic disease, poor nutrition, multiple medications, high stress environments and disrupted sleep. These “weakeners” increase vulnerability to rehospitalization and to disability have been called “post-hospital syndrome”. 

Similar to pre-hospital frailty, post-hospital syndrome remains the #1 most important post-acute syndrome not routinely assessed or holistically managed within clinical care. This has resulted in poor overall outcomes that include increased rates of hospital readmissions and self-reports of reduced quality of life.

Post-hospital patients who are fit in the setting of diabetes have been shown to have a 550% lower risk for re-hospitalization than those who are less fit. Most patients over age 50 have either diabetes, pre-diabetes or blood sugars that are higher than optimal. 

As formal  telehealth partners with the nation’s 4th largest pharmacy network in the US ( we’re now able to dispense and scale multi-condition rehabilitation throughout the US and around the world to reverse the frailty and vulnerability that occurs as a result of a hospitalization.

We’re a NEW home-based referral source needed to help primary care teams go beyond traditional medication management for transitional care. We achieve the outcomes that matter most to aging patients:

Functioning well at home while preventing the things that get in the way like a rehospitalization