The first 30 days after a hospital stay are when things most often go wrong, new medications, missed follow-ups, symptoms nobody catches. Afiyah's TCM program manages those 30 days for you, starting the day you get home.
The day after discharge, we check in, review the hospital's instructions, and answer your family's questions.
An MD or NP visits at home, a full exam, and every medication reviewed at your kitchen table.
Weekly virtual check-ins to catch changes early, before they become emergencies.
Another clinical visit to confirm recovery is on track, and adjust anything that isn't.
Hospital stays almost always change medications, and mixed-up prescriptions are one of the biggest reasons people end up back in the ER. Your Afiyah clinician sits down with you and reconciles every medication, old and new, so you know exactly what to take and why.
TCM is covered by Traditional Medicare (Part B) and Medicare Advantage plans. Standard Part B cost sharing can apply depending on your plan and any supplemental coverage, so we verify your specific coverage and tell you what to expect before the first visit.
Yes. TCM covers the 30-day transition, we coordinate with your primary care physician and specialists, and hand back a full summary of everything we did.
No, and they work well together. Home health provides nursing and therapy under a physician's orders. Afiyah is the physician: we diagnose, prescribe, and direct the plan, and we refer to home health, palliative care, or hospice when it helps.
Call us, or simply ask your hospital discharge planner for Afiyah Medical before you leave. We accept referrals through Careport (ECIN), Aidin, Aida, and EnsoCare.
Tell us your discharge date, and we'll handle the first 30 days.
Afiyah's physicians pick up your patient the moment they leave, manage the whole 30 day window, and send the results back to you every month. Your team does not add a task, and your facility does not add a cost.
Transitional care is not billed to you, and it is not one message for everyone. Here is what it protects, depending on where you sit.
A named physician owns the first 30 days. Contact within two business days of discharge, a home visit in the first week, and a discharge summary reviewed line by line. Place the referral through Careport (ECIN), Aidin, Aida, or EnsoCare in under a minute.
Your readmission measure follows the resident out the door. When you discharge home or to assisted living, Afiyah takes the handoff, so the bounce back that would land on your VBP score never happens. Fewer returns also protect the hospital referral relationships you depend on.
Residents come back to your building and stay in it. We manage the recovery in the apartment, so your staff stops chasing follow up appointments and your families see a physician, not a phone tree.
Afiyah bills Medicare Part B directly for transitional care. There is no facility fee, no contract minimum, no added headcount, and nothing drawn from your Part A rate.
Send us the referral. That is the entire ask of your staff. From that moment the 30 day window is ours to manage, and you get it back as a summary.
Through Careport (ECIN), Aidin, Aida, EnsoCare, or a single phone call. That is the whole ask.
We reach the patient and family, review the discharge summary, and flag anything urgent.
A full exam where they live, with every medication reconciled against the hospital list.
We send back what we found, what we changed, and what happens next. Nothing to chase.
Every partnership includes a monthly report of readmissions, ER visits avoided, and interventions made, reviewed with a named physician rather than mailed to your inbox. If the number is not moving, we say so and change the plan.
Transitional care applies to a specific window. Knowing it up front saves your team a call.
Not sure whether a patient qualifies? Call us and we will tell you in a minute.
Give us one discharge and watch what happens over the next 30 days. No contract, no facility fee, and a report at the end of it.
Referrals accepted via Careport (ECIN), Aidin, Aida, and EnsoCare.