Elnera virtual RNs reach patients after discharge and follow them through the period that carries the highest readmission risk, catching problems early and keeping care plans on track.
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The Challenge
Patients go home with new medications, new instructions, and follow up appointments to schedule. Questions surface after the care team has moved on to the next admission. Each avoidable return to the ED adds readmission penalties and pulls capacity from patients waiting for a bed.
How It Works
Elnera receives the discharge plan, medication list, and follow up needs before the patient leaves.
A virtual RN calls the patient after discharge to review symptoms, medications, and instructions while they are fresh.
The RN confirms the patient has the right medications and understands how to take them, and flags discrepancies to the care team.
Check ins on a schedule set with your team confirm appointments are kept, services are in place, and warning signs reach a clinician early.
Every contact is documented for the care team, giving your providers the record they need for Transitional Care Management billing.
The Program
Transitional Care Management supports every transition point, from acute care to rehabilitation, skilled nursing, and home.
The Era Index tracks contact rates, readmissions, follow up appointment completion, and Transitional Care Management revenue for each program.
Outcomes Focus:
How Elnera Works
Assess
We evaluate your environment, workflows, staffing challenges, and operational goals.
Design
We develop a virtual care strategy aligned with your clinical, financial, and operational priorities.
Implement
We support deployment, adoption, workflow integration, and change management.
Scale
We help expand successful programs across additional units, service lines, or facilities.
Sustain
We help optimize performance and ensure long-term success through continuous improvement.
FAQ
Transitional Care Management is the structured follow up a patient receives after leaving a hospital or facility. It covers patient contact, medication review, and coordination of the services the patient needs at home or at the next level of care.
Elnera's follow up and documentation support your providers in billing Transitional Care Management. Our team reviews your current billing setup during the Assess phase.
Experienced Elnera virtual RNs make every clinical contact and escalate to your providers whenever a patient needs attention.
Elnera works within the EMR and communication tools your teams already use.
Tell us where your readmissions stand today, and we will design a follow up program around your patients and your care teams.
Schedule a consultation with our team to start the conversation.
Let's Start the Conversation