Episode Solutions

• Serve as primary clinical contact for patients throughout their episode of care, providing guidance and support from initial engagement through recovery and program graduation. • Respond to patient concerns or symptoms that arise outside of normal provider office hours. • Provide clinical triage and guidance, including: Self-care instructions, Urgent care referral, Escalation to on-call physicians or clinical teams • Offer reassurance and coaching to patients experiencing symptoms or uncertainty overnight • Conduct proactive outreach calls to monitor patient progress and ensure adherence to care plans. • Provide coaching, education, and support to patients and families navigating complex healthcare systems. • Act as a consistent point of contact to help patients avoid unnecessary emergency department visits or hospital readmissions. • Conduct structured post-discharge follow-up and monitoring to identify early signs of complications. • Ensure patients complete timely follow-up appointments with primary care providers and specialists. • Address medication adherence issues. • Escalate clinical concerns to physicians or care teams when early warning signs are identified. • Document all patient interactions, risk factors, and interventions within the care management platform. • Coordinate closely with physicians, discharge planners, case managers, and other healthcare providers to ensure continuity of care. • Facilitate access to services such as home health, rehabilitation, transportation, and durable medical equipment. • Connect patients with community resources and support services when needed.