Greenville and the Upstate, SC
Transitional care management support for physician practices in Greenville, SC
The days after a hospital or facility discharge are when patients are most likely to fall through the cracks. Anu Health and Wellness provides a contracted registered nurse to make sure discharge follow-up happens on time, within your practice's workflows.
What the program asks of a practice
Discharge follow-up runs on a short clock
Medicare's transitional care management services depend on timely contact after a patient leaves the hospital or a facility. In general, the program involves:
- Contact with the patient or caregiver within two business days of discharge
- A face-to-face visit with the practice within 7 or 14 days, depending on complexity
- Medication reconciliation no later than that visit
- Review of discharge information and any follow-up that is needed
This is a general summary, not billing guidance. Program requirements are set by CMS and change over time; your practice confirms current requirements and eligibility for each patient.
What your practice keeps
- The patient relationship
- Clinical decision-making
- Patient eligibility determinations
- Applicable Medicare billing
Anu Health and Wellness does not bill Medicare and does not guarantee reimbursement.
Where Anu fits
Someone whose job is the follow-up
In a busy practice, discharge follow-up often depends on someone noticing the notification and finding time to call. When the schedule is full, that window closes quickly.
Anu provides a registered nurse to make the early contact, review discharge instructions and medications with the patient, and help get the follow-up visit on the calendar. Anything that needs a clinical decision goes back to your clinicians.
RN support can include
- Early post-discharge calls to patients or caregivers
- Review of discharge instructions with the patient
- Medication lists gathered for your clinicians' reconciliation
- Help scheduling the follow-up visit
- Documentation to your practice's workflows
Service area
Local to Greenville County and the Upstate
Anu Health and Wellness is based in South Carolina and works with practices in the Upstate and Greenville area, with remote support where appropriate.
Related: Chronic care management support in Greenville, SC · All services
Talk it through with an RN
A short consultation about your patients, your staffing and where follow-up falls behind. Support is scoped to your practice before anything begins.
Anu Health and Wellness provides contracted RN care-management support to physician practices. Services are provided within the RN's scope of practice and according to the policies, clinical workflows and applicable requirements of the contracting practice.