“This year, we will manage nearly 12 million care transitions, about twice as many as just 3 years ago.”

In context

“patients we will add this year in fully accountable value-based relationships will have access to support through our home-based platform. Consumers value and benefit from services delivered in the home and we have expanded our capabilities to serve that need. I will highlight four of our key capabilities in this important area. First, patient assessments, in-home clinical visits designed to identify care needs and help patients with other physical and social needs. This year, we expect to make more than 2.5 million visits to patients’ homes and we continue to expand the scope of the clinical services offered in that setting. Next, care transitions. This entails supporting patients into and through post-acute settings, helping people to avoid hospital readmissions after an inpatient stay. This year, we will manage nearly 12 million care transitions, about twice as many as just 3 years ago. This plays an important role in helping people return safely home and in connecting patients with additional in-home support. Third area, senior community care. This is clinical care for seniors who live in skilled nursing and assisted living facilities and dedicated senior housing. Our clinical teams provide additional layers of care and on-call resources, and they coordinate among patients in their primary care provider, facility staff and caregivers, all contributing to strong quality of care and outcomes. And the fourth area of clinical capability is individual care and coordination for Medicare dual and chronic special needs patients. These patients frequently require a more individualized approach to care. On average, these patients are managing nine different chronic conditions and”