A holistic approach to transitional care.
After years of working in the transitional care field alongside medical professionals, we’ve learned that a focused approach leads to results— such as an annual readmission rate of just 8%. Our devoted team comprised of Transitional Care Coordinators, Nurse Practitioners, and Ministry Professionals serves as an extension of patients’ care, helping us to engage early and often once patients return home.
of readmissions happen within 3 to 5 days of discharge
of readmissions are driven by medication issues
of readmissions are driven by social risk factors
Aligned with a specific hospital, our team operates in close collaboration with case management, nursing, and hospital medicine to seamlessly deliver an integrated solution to patients within the hospital's service area.
We also recognize the paramount role played by community medical providers such as Primary Care Physicians (PCPs), Specialists, and Home Health Agencies such as yourself. To ensure a holistic approach, we've established effective communication protocols with each stakeholder that begins before a patient is ever discharged. This guarantees unparalleled collaboration and continuity during the crucial 30-day transitional care period.
Care through Collaboration
Amy Marler, VP Strategic Partnerships with Accent Care
"Partnering with Segue’s exceptional team of providers has enabled our visiting Home Health Team to provide collaborative care and improve quality outcomes for the patients we serve. Segue’s team of practitioners allows our home health clinicians another set of expert eyes on the patients we care for in the home setting. There is no doubt that our partnership with Segue has given us the ability to provide exceptional care to those who need us most."
Focused Ministry Overlay
Our holistic approach to transitional care means that care goes beyond just the physical needs to the mental and spiritual as well. Central to this approach is our dedicated ministry team—an integral part of our care ecosystem. This team not only equips our staff with the tools for compassionate care but also establishes direct connections with patients to address all aspects of their recovery.
Within our ministry framework, we meticulously address various categories of needs, recognizing that well-being encompasses more than just medical attention. From medications to food assistance, home needs to essential medical supplies, our ministry team is attuned to the multifaceted requirements that contribute to a patient's recovery journey. Most importantly, prayer is a cornerstone of our ministry, ensuring that spiritual and emotional needs are met in harmony with physical care.