ACO Partnerships

Aligned on outcomes. Aligned on cost.

Built for value-based care. The days after discharge drive a disproportionate share of avoidable cost. Our high-intensity in-home program targets exactly that window — supporting patients, addressing the SDOH drivers of utilization, and keeping PCPs in the loop.

Why It Fits Value-Based Contracts

Targets the highest-cost post-discharge window with high-intensity support
SDOH barrier removal: transportation, medication access, food insecurity, home safety, health literacy
PCP engagement and care continuity across the episode
Documentation designed to support CCM (99490), TCM (99495/99496), and RPM billing workflows

Data, not promises. We track 30-day readmission rate, medication reconciliation completion, visit adherence, and patient satisfaction across every episode — and share the results with our partners.

How It Works

Refer in seconds via our online form.
We acknowledge your referral within 4 business hours and coordinate with your team.
First in-home visit within 24–48 hours of discharge.
14-day high-intensity program (30-day extended support available) with the care loop closed.

Ready to partner?

Send your first referral today — we acknowledge every referral within 4 business hours.

Refer a Patient Now