Transitional care, chronic care management and remote monitoring for health systems
The weeks after discharge decide whether a patient stays home. We run the outreach, follow-up and ongoing monitoring that close that gap, working from the discharge lists and referrals your team shares.
Evidence for transitional care and remote management
lower odds of 30-day readmission with low-complexity transitional care (OR 0.78, 126 trials)1
lower odds of emergency department visits with the same interventions (OR 0.68)1
mortality 31 to 60 days after discharge with vs. without transitional care management2
fewer days lost for heart failure patients living 100 km from their cardiologist3
A closed loop from discharge to long-term care
Transitional care handles the first 30 days. Patients with ongoing chronic conditions then move into CCM and remote monitoring, so the follow-up doesn't stop when the transition period ends.
1. Your team shares discharges and referrals
We work from the discharge lists and clinic referrals you provide, using eligibility criteria you approve.
2. Outreach within two business days
We contact the patient or caregiver, review discharge instructions and ask about symptoms.
3. Follow-up visit scheduled
We help schedule a visit with the patient's clinician within 7 to 14 days.
4. Medication reconciliation
What the patient is taking at home is compared with the discharge list, and discrepancies are routed to the care team.
5. Ongoing chronic care
Eligible patients move into CCM and remote monitoring with weekly check-ins and daily review of readings.
6. Monthly reporting
Your leadership receives monthly performance and outcomes reporting.
Why structured follow-up after discharge works
Readmission risk is highest in the first two weeks, and rural patients face the longest distances back to care. Both point to the same answer: early, structured contact and monitoring at home.
Published results reflect specific program designs and patient populations. Outcomes for any program depend on patient selection, engagement and how escalations are acted on.
Transitional care meta-analysis
Across 126 randomized trials with 97,408 participants, low-complexity transitional care was associated with lower odds of readmission at 30 days (OR 0.78) and 180 days (OR 0.45) and fewer emergency department visits (OR 0.68).1
Transitional care management in Medicare
In 18.7 million eligible discharges, mortality in days 31 to 60 was 1.0% with transitional care management versus 1.6% without.2
Distance increases the benefit
In a pre-specified analysis of the TIM-HF2 trial, the benefit of remote management grew with travel distance; for patients 100 km from their cardiologist, days lost to unplanned cardiovascular admission or death fell by 51%.3
Readmissions are front-loaded
For COPD, 58% of 30-day readmissions happen within the first 15 days after discharge.4
Home telehealth at scale
The VA's national home telehealth program was followed by 19% fewer hospital admissions across 17,025 patients.5
Built for distance.
Rural patients often live far from their clinicians and may not have home internet. Our devices use built-in cellular with multi-carrier coverage, so they connect to the strongest available network without Wi-Fi or a smartphone.
Care is delivered by phone in English, Spanish, Korean, Farsi, Russian and Armenian, and ambulatory clinics in your network can refer patients with chronic conditions directly.
What your staff does
- Share discharge lists and clinic referrals
- Approve eligibility criteria and escalation protocols
- Review monthly reporting
No additional staffing is required on your side.
Questions from hospitals and health systems
How are patients identified?
We work from the discharge lists and referrals your team shares, applying eligibility criteria you approve.
Does this add work for hospital staff?
Very little. Your team shares discharge information, approves protocols and reviews monthly reporting. Our team handles outreach, scheduling help, follow-up calls and ongoing monitoring.
Can our ambulatory clinics refer patients too?
Yes. Clinics in your network can refer patients with chronic conditions directly into CCM and remote monitoring.
Let's talk about your patients.
A short conversation is usually enough to see whether VitalityMed is the right fit for your practice.
- We review your specialty, your patients and what you want to improve.
- You see a sample monthly summary before you commit.
- Getting started takes one onboarding call and your clinical protocols.
Patients and families can call the same number.
Request a conversation
We'll reply by phone or email. Please don't include patient health information.
References
- Tyler N, Hodkinson A, Planner C, et al. Transitional care interventions from hospital to community to reduce health care use and improve patient outcomes: a systematic review and network meta-analysis. JAMA Netw Open. 2023;6(11):e2344825. pmc.ncbi.nlm.nih.gov
- Bindman AB, Cox DF. Changes in health care costs and mortality associated with transitional care management services after a discharge among Medicare beneficiaries. JAMA Intern Med. 2018;178(9):1165-71. pmc.ncbi.nlm.nih.gov
- Rurality, travel distance, and effectiveness of remote patient management in patients with heart failure in the TIM-HF2 trial in Germany: a pre-specified analysis. Lancet Reg Health Eur. 2025. www.thelancet.com
- Nationwide analysis of 1,055,830 index admissions for acute exacerbation of COPD: timing and diagnoses of 30-day readmissions. pmc.ncbi.nlm.nih.gov
- Darkins A, Ryan P, Kobb R, et al. Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14(10):1118-26. pubmed.ncbi.nlm.nih.gov
Page last reviewed 2026-09. This page is for health care professionals and is not medical advice.