A patient just got out of the hospital. Let’s keep it that way.

Our Care transition program provides clinical support to patients recently discharged from the hospital and reduces the risk of readmission and overall healthcare costs. Fonemed’s care transition program is available as a stand-alone solution or as an extension of a provider’s care. Our care transitions service includes outbound live contact with Fonemed staff, a 24/7 in-bound nurse, consultations, electronic messaging, and live responses to alerts generated from remote biometric monitoring equipment and integration of patient data. Scheduled follow-up calls and clinical assessments ensure compliance with care plans and engage patients to become actively involved in their personal healthcare decisions. Key program features include ensuring patient understanding of their disease process and expected recovery, medication reconciliation, scheduling physician follow-up appointments and educating patients on symptoms of concern.

telehealth solutions for hospital care transition

Proven Results

The core care transition program involving daily interaction with patients costs less than a single home visit by a nurse. Our care transitions programs have consistently shown a reduction of hospital readmission rates for congestive heart failure, pneumonia and heart attacks by at least 10%. Our proactive follow-up programs provide opportunities for provider reimbursement of the post-discharge follow-up call and physician visit. Fonemed nurse care transition support hospital and clinic programs, including nurse advice line , consistently show an ROI of more than 200%. Contact us to learn more about our customization and telehalth service solutions.

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Care Planning

A plan of care with the discharging institution using our best practices for remote care templates if desired

Nurse Triage

24/7 nurse advice line and medical triage services available for any symptomatic patient calls outside dedicated case management coverage hours.

Patient-Centered Care

Ensuring the patient understands plan of care

Follow Up

Educational messages and reminders for follow-up appointments electronically or by Health Service Specialists.


Medication reconciliation.


Great Call, smart phone applications or tablet access (optional).


Physician escalation 24/7 (optional)


Encounter documentation for attending physician and inclusion in medical records

Remote Device Monitoring

Remote device monitoring includes alert management services (optional: Fonemed can supply complete procurement and management of medical monitoring devices through its partners) and biometric monitoring.


Taking Patient’s Care To The Next Level of Engagement