In-person visits are essential to reducing unnecessary hospital readmissions


In-person visits are essential to reducing unnecessary hospital readmissions

Approximately 3.3 million adults are readmitted to a hospital within 30 days of discharge, contributing to $41.3 billion in hospital costs.¹ Medicare beneficiaries account for the largest proportion of readmissions (55.9%) and an estimated 23% of readmissions are preventable

The Matrix Medical Network Post-Acute Transitions program enables health plans to deliver support directly to members to help them recover effectively and avoid unnecessary readmissions.


An essential component of any readmission reduction program is an in-person visit to those members identified as high risk for complications and the potential for unneeded re-hospitalization.

By conducting in-person visits with those members at the highest risk, Matrix helps to improve the success of readmission reduction efforts.


Through this program, a Matrix clinician conducts a home visit and assessment shortly after care transition.

These visits support the member:

• As they transition back home after a hospital stay resulting in higher member satisfaction
• By increasing member confidence to be an active participant in managing their recovery as they move from the hospital back to the home

Visits can be conveniently ordered, on-demand, by the health plan’s care management team via our web portal.


Ensuring Adherence to Post-Discharge Care and Recovery

Documentation — Medication reconciliation/personal health goal

Complete medication reconciliation and develop health goals and questions for physician as part of simple person-centered record

Coaching — Medication self-management

Utilize medication self-management approach to improve knowledge and understanding of medication regimen

Follow-up — With PCP/specialist

Confirm primary care and/or specialist follow-up appointment is scheduled

Education — Patient knowledge of red flags

Address “red flags” and ensure that patient is knowledgeable about warning signs regarding change in condition and how to respond

The Matrix Post-Acute Transitions Program enables health plans to execute their programs to reduce avoidable hospital readmissions.

The program methodology incorporates analytics through to the delivery of quality assurance reviews with the client.

• Matrix is a proven leader in the delivery of in-home clinical visits on behalf of health plans.
• Our community-based nationwide network has the size and scale to deploy credentialed clinicians for in-person assessments, coaching and education.

Contact us today to see how we can help you close critical care gaps to improve the overall health of your members and help you meet your quality goals.

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