Supporting Transitions of Care

Virtual Transitional Care Management Clinic

Backed by

Combinator

Supporting Transitions of Care

Your bridge from the hospital to home.

Backed by

Combinator

Supporting Transitions of Care

Virtual Transitional Care Management Clinic

Backed by

Combinator

Supporting Transitions of Care

Virtual Transitional Care Management Clinic

Backed by

Combinator

Built by researchers and providers from

Covered by Insurance, including Medicare & Medicaid

How We Help

Contact patients during and after hospitalization

Contact patients during and after hospitalization

Simbie navigators maintain continuous contact with patients, ensuring they always know who to reach.

Simbie providers contact patients during hospitalization
to establish a 24/7 point-of-contact via text or call,
ensuring patients always know who to reach out to.

Conduct prompt post-discharge follow-up visits by day 4

Conduct prompt post-discharge follow-up visits by day 4

Check patient status, thorough medication reconciliation, & follow up on pending labs or reads.
Check patient status, thorough medication reconciliation, & follow up on pending labs or reads.

Providers become temporary PCP until handoff

Providers become temporary PCP until handoff

Simbie providers serve as the temporary PCP while we identify a permanent one & ensure handoff.
Simbie providers serve as the temporary PCP while we identify a permanent one & ensure handoff.

Benefits to Health Systems

Reduce 30-day Readmissions Rates

Multiple touchpoints after discharge reduces risk.

Reduce Length of Stay (including Observation Patients)

Eliminate delayed discharge from lack of PCP referral; ensured follow-up enables discharge of obs patients.

Save Costs of Building Internal Discharge Clinic

Save FTE resources by outsourcing transitional care.

How it Works

1
1
1

Refer patients with upcoming discharge through EMR, phone, or fax.

2
2
2

Simbie provider contacts patient and conducts virtual follow-up visit 3-4 days post-discharge.

3
3
3

Simbie follows with patient through all follow-ups and can become temporary PCP.

Evidence-Based Interventions

Problems
Solutions

60%

Of patients don't understand some element of their medications at discharge.
12-18 hour phone call to reinforce instructions, thorough medication reconciliation in follow-up visit within 4 days.

33%

Of readmissions happen by the 7th day post-discharge, 50% by day 14.
All patients are called and seen in a clinical follow-up visit by day 4 post-discharge.

50%

Of patients can't get in to see a provider within 7 days of discharge.
Night and weekend availability in multiple languages, able to be rescheduled by texting or calling any time.

Evidence-Based Interventions

Problems

60%

Of patients don't understand some element of their medications at discharge.

33%

Of readmissions happen by the 7th day post-discharge, 50% by day 14.

50%

Of patients can't get in to see a provider within 7 days of discharge.
Solutions
12-18 hour phone call to reinforce instructions, thorough medication reconciliation in follow-up visit within 4 days.
All patients are called and seen in a clinical follow-up visit by day 4 post-discharge.
Night and weekend availability in multiple languages, able to be rescheduled by texting or calling any time.

High Touch Hospital-to-Home Transitions

Night/Weekend Availability
Evening and weekend follow-up appointments are available for patients.
Advance Care Planning
Ensuring advance care plans are in place, documented, & verified to prevent unnecessary admissions.
Medication Reconciliation
Medication instruction reinforcement within 12-18 hours of discharge & reconciliation by day 4.
Covered by Insurance
Free to health systems because it is covered by Medicaid and Medicare.
Multilingual Providers
Language concordant care. Spanish, Mandarin, Tagalog, and more languages represented.
Care Coordination
Simbie navigators continuously communicate patient follow-up schedules and reschedule as needed, preventing missed appointments.

Frequently Asked Questions

Frequently Asked Questions

Frequently Asked Questions

How much does Simbie cost?

What are the contractual obligations?

Is Simbie HIPAA compliant?

What EMR does Simbie use?

How much does Simbie cost?

What are the contractual obligations?

Is Simbie HIPAA compliant?

What EMR does Simbie use?

How much does Simbie cost?

What are the contractual obligations?

Is Simbie HIPAA compliant?

What EMR does Simbie use?

How much does Simbie cost?

What are the contractual obligations?

Is Simbie HIPAA compliant?

What EMR does Simbie use?

Backed by
  • Combinator

Combinator

Partner With Us

Partner With Us

Partner With Us

Provide your patients with high quality transitional care.
Provide your patients with high quality transitional care.

Reduce Length of Stay

Prevent Readmissions

Save Costs of Internal TCM Clinic

Increase Quality Incentive Payments

© 2024 Simbie Health. All rights reserved.

hello@simbiehealth.com

1111B S Governors Ave #6351 - Dover DE, 19904

© 2024 Simbie Health. All rights reserved.

hello@simbiehealth.com

1111B S Governors Ave #6351 - Dover DE, 19904

© 2024 Simbie Health. All rights reserved.

hello@simbiehealth.com

1111B S Governors Ave #6351 - Dover DE, 19904