Engagement process
Five steps. The right care, at the right tier.
From hospital discharge through ongoing engagement — staffed so the right person sees the right signal at the right time.
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The model
A continuous thread, not a sequence of handoffs.
Each step is staffed by the right tier of care, so escalation only happens when escalation actually helps the patient.
01Hospital / SNF discharge
Hospital / SNF discharge
Patient discharged with:
- CHF
- AMI
- Stroke
- Hip / Knee
- Other
02Post-discharge
Post-discharge
Four-week program — live call/text assistance, RPM setup, and assessment:
- Discharge instruction
- Medications
- Recovery
- Diagnosis questions
- Appointments
- Service / patient experience
Daily reviews of RPM readings and on-demand virtual visits.
03Triage
Triage
Tier 1
- TMX RN
- Virtual assist
Tier 2
- In-home visit
- Nurse Navigator EMT-B / EMT-P
04Physician consult
Physician consult
Tier 3
- Physical or hospital intervention
- Service or complex requirement
- Call, virtual visit, or appointment
05Follow up
Follow up
Transition to ongoing patient engagement:
- AWV (annual)
- CCM (monthly)
- Care plan management
- Care gap closure
- Preventative screening
- RPM (daily)
- Patient education & consultation
Walk the model with us.
Bring a patient population. We'll show you exactly what each step looks like.