Improving Outcomes Through Effective Transitions of Care
Health plans across the country are under increasing pressure to reduce avoidable utilization, improve quality performance, and lower the total cost of care. Few opportunities offer greater impact than effective transitions of care, where timely intervention can improve outcomes, reduce readmissions, and help patients successfully recover at home.
Supporting patients through these critical transitions has long been a core component of Upward Health’s care model. Through our established Transitions of Care program, we have helped health plans improve outcomes and reduce avoidable utilization among high-risk populations.
Building on this foundation, Upward Health expanded its Transitions of Care capabilities in California through Transitional Care Services, a CalAIM Population Health Management requirement focused on care coordination.
Upward Health’s Transitional Care Services provide comprehensive support before, during, and after a hospital discharge. Our Nurse Care Managers meet patients in person at the hospital, coordinate care throughout the discharge process, conduct post-discharge follow-up, and help connect patients with the clinical and community-based resources they need for a safe transition home. When timely primary care follow-up is unavailable, Upward Health providers can see patients within 7 days of discharge.
Our approach extends beyond traditional inpatient transitions of care. We review acute care utilization daily, conduct outreach to patients following both inpatient admissions and emergency department visits, and follow patients through individualized care planning for up to 90 days to help ensure a successful transition back to the community.
Transitional Care Services support health plan priorities by helping to:
✓ Reduce avoidable readmissions
✓ Lower emergency department utilization
✓ Improve continuity of care after discharge
✓ Support quality and compliance goals
✓ Deliver meaningful ROI for high-risk populations
“At Upward Health, care transitions have never been a separate program, they’ve always been part of how we care for patients,” said Tiffany Carter, Vice President of Clinical Operations at Upward Health. “Transitional Care Services build on a proven clinical model that combines nurse-led care coordination, timely provider intervention, and ongoing patient engagement to support recovery, improve outcomes, and reduce avoidable utilization.”
To learn more about Upward Health’s Transitional Care Services, contact us at info@upwardhealth.com.
About Upward Health
Upward Health is an in-home multidisciplinary medical group that partners with health plans and other risk-bearing entities to address the needs of high- and emerging-risk patients. Using a unique, in-home, whole-person care approach to meeting a patient’s needs, Upward Health delivers and coordinates care that improves outcomes and the quality of life for every patient it serves. It has a Net Promoter Score of 91, among the highest in the healthcare industry, and ranks No. 4 on the 2025 Inc. 5000 list of the fastest-growing private companies in the nation. To learn more, visit www.upwardhealth.com.
Media Contact: Ashley Kurpiewski, akurpiewski@upwardhealth.com