Afiyah Medical partners with facilities to keep patients healthy where they belong, with embedded physician-led care and a structured 30-day Transitional Care Management program that starts within 24 hours of discharge.
Patients lose ground they never fully regain. Facilities absorb the penalties, the paperwork, and the reputation risk. Most of it is preventable, with the right medical presence in the first 30 days.
Roughly one in seven Medicare patients returns to the hospital within 30 days of discharge, about 15 percent in MedPAC's most recent analyses.
CMS readmission penalties can reduce a hospital's Medicare payments by up to 3%, year after year.
Medication changes, missed follow-ups, and unnoticed symptoms in the first month drive most avoidable returns.
Sources: CMS Hospital Readmissions Reduction Program (HRRP); MedPAC March 2025 Report to Congress; CMS SNF Value-Based Purchasing Program.
Our structured TCM program picks patients up the moment they leave the hospital, so nothing falls through the cracks between discharge and recovery.
Patient and family reached within one day of discharge. Status assessed, discharge summary reviewed.
Comprehensive post-discharge visit, medication reconciliation, exam, and care plan review.
Ongoing care coordination and symptom monitoring, with intervention-driven alerts.
MD/NP follow-up visit to confirm recovery is on track and adjust the plan where needed.
Our monitoring is tuned to the conditions that drive the most avoidable returns, so problems are treated at home, before they become ER visits.
Every partnership includes monthly data tracking, readmission counts, ER visits avoided, and intervention outcomes, reported to your team, every month.
On-site rounding and medical direction for skilled nursing, assisted living, and post-acute settings, present, consistent, accountable.
A structured 30-day transition program for your discharged patients, coordinated with your discharge planners and case managers.
Backed by our home health partnership, patients move seamlessly between physician care, skilled nursing at home, and therapy, one coordinated team.
Afiyah is led by a board-certified internist as Medical Director, supported by nurse practitioners and physician assistants who specialize in care for older adults. That clinical focus, heart failure, hypertension, and diabetes, is precisely the population our TCM program protects. The Medical Director sets Afiyah's protocols, oversees quality, and reviews outcomes with partner facilities monthly.
[Name], MD, Medical Director
Full leadership team and clinical advisory board on the About page.
Speak with our partnership team about embedded physician coverage and Transitional Care Management for your patients and residents.
Accepting referrals via Careport (ECIN) · Aidin · Aida · EnsoCare