transition of care management

Streamline transitions of care management with naviHealth.

While effective care transitions are critical to improving patient outcomes, reducing readmissions and minimizing costs, transitions of care management (TCM) remain a significant challenge for many hospitals and health systems.

As patients move from one post-acute care setting to another, effective transitional care requires strong collaboration between providers, effective education for patients, and clear communication with their caregivers.

These tasks can be challenging for any organization, but they are increasingly difficult for hospitals and health systems where time and resources are already stretched thin and accountability increases for the quality and cost of care after a patient is discharged. As the industry moves from fee-for-service to value-based care models that require robust TCM services, many healthcare organizations are seeking partners like naviHealth that specialize in transitions of care management.

An Experienced Partner

We’ve spent more than 18 years pioneering ways to improve every aspect of care transitions for health plans, providers and patients. From discharge planning efficiencies to managing risk for payors and providers, naviHealth is equipped to provide you with a tailored suite of capabilities.

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naviHealth: a pioneer in transitions of care management

naviHealth provides products and services for transitions of care management that empower organizations to streamline workflows, improve decision-making, and guide patients to better outcomes. Providing a combination of clinical support, scalable technology and advisory solutions, we help to simplify transition care management to make post-acute care as efficient and effective as possible.

With naviHealth’s transitions of care management solutions, hospitals and health systems are empowered to:

  • Simplify and improve communication with patients and providers.
  • Optimize operational efficiencies, reduce length of stay (LOS) and lower readmissions.
  • Predict the best patient journey using historical data.
  • Leverage experience and expertise from the leading awardee convener for the Bundled Payments for Care Improvement Initiative (BPCI)
  • Save time with automated decision-making tools that allow clinicians to spend more time with patients and less time reviewing data.
  • Reduce PAC spend and excess PAC utilization by referring patients to the appropriate next care setting.
  • Increase satisfaction with consistent patient engagement and transition management tools that alert clinicians to potential problems.

The patient journey may start at the hospital, but that’s only just the beginning.

naviHealth products and services for transitions of care management

At naviHealth, transitions of care management offerings include:

  • Clinical support services – we embed clinicians at hospitals and post-acute facilities where they become an integrated and influential part of the care team. These experienced clinicians can help to guide patients to the appropriate post-acute setting to maximize outcomes, and review data and processes to identify areas for quality and process improvement in transitional care management.
  • Advisory solutions – we offer up-front assessments of clinical workflows, discharge patterns and post-acute care networks, and help to improve efficiencies, optimize workflows, enhance relationships with providers, and allocate resources more effectively.
  • Scalable technologies – our transitions of care management solutions help to automate and standardize the care transition process, streamline discharge planning workflows, and identify high-risk patients.

Learn more about transitions of care management with naviHealth.


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