Transitional & Chronic Care Management
Extend Your Care.
Improve Outcomes.
We provide high-quality Transitional Care after discharge. The first 30 days after discharge is when readmission risk is the highest.
Better Transitions. Better Coordination. Better Outcomes.
Focused care. Early intervention. Coordinated support. Better outcomes.
Services We Provide
Comprehensive care management programs designed to close gaps, prevent complications, and improve lives.
High-Quality Transitional Care After Discharge
The first 30 days after discharge is a critical window. Our TCM program provides intensive post-discharge follow-up — medication reconciliation, care coordination, and direct access to your care team — to help prevent complications and support a safe recovery.
For patients recently discharged from a hospital, skilled nursing facility, or inpatient rehab.
Learn About TCMOngoing Support for Complex, Long-Term Conditions
Living with two or more chronic conditions requires more than a quarterly office visit. Our CCM program provides regular care plan reviews, care team access, and proactive health monitoring — covered by Medicare and most private insurers.
For patients managing diabetes, heart disease, COPD, hypertension, and other chronic conditions.
Learn About CCM
We Support Patients With High Readmission Risk Due to Common Conditions Such As:
The first 30 days after discharge is the most critical time to prevent complications and avoid readmission.
Getting Started Is Simple
From enrollment to ongoing care, we make the process straightforward for patients and families.
Enroll or Get Referred
Patients can self-enroll online or be referred by their provider or hospital discharge team. We will verify your insurance coverage and be in touch promptly.
Personalized Care Plan
Your dedicated APRN creates a comprehensive care plan tailored to your conditions, medications, and health goals — in collaboration with your existing providers.
Continuous, Coordinated Care
Ongoing care plan check-ins, care team access, medication management, and specialist coordination — so nothing falls through the cracks.
Partner With Us to Keep Patients on the Path to Better Health
Partner with Proactive Care Partners to keep your patients on the path to better health. Our APRN-staffed care management team works as an extension of your practice — handling the coordination, follow-up, and chronic condition monitoring that keeps your patients healthy between visits.
Compassionate Care. Proactive Approach. Better Outcomes.
Closing gaps. Preventing complications. Improving lives — one day at a time.