Services Built to Close the Gap After Discharge
A complete post-discharge care system designed to reduce readmissions and improve recovery.
Every Patient • Every Touchpoint • Every Outcome
Let’s Reduce Readmissions Together
Through Physician Led TCM, RPM, and CCM.
Follo Health provides a fully managed, physician-led care coordination model that ensures every discharged patient receives consistent, structured follow-up through transitional care management (TCM), remote patient monitoring (RPM), and chronic care managemen (CCM). We operate as an extension of your clinical team, handling outreach, monitoring, coordination, and escalation—so nothing falls through the cracks.
Structured Follow-Up When It Matters Most
A physician-led program focused on the highest-risk period immediately after discharge.
What we do - TCM
- 24–48 hour patient outreach
- Medication reconciliation
- Symptom assessment
- Discharge instruction review
- Care coordination with providers
Value to Hospitals/SNFs/LTACHs
- Reduced readmissions
- Improved CMS performance
- Better patient experience
Why it matters
Most readmissions occur within the first 30 days.
We ensure early detection + intervention before escalation.
Ongoing Support for High-Risk Patients
Continuous care management for patients with chronic conditions.
What we do - CCM
- Monthly patient engagement
- Medication adherence monitoring
- Symptom tracking
- Care plan reinforcement
Target Conditions
- CHF
- COPD
- Diabetes
- Hypertension
Value
- Prevent disease progression
- Reduce repeat hospitalizations
- Improve long-term outcomes
Real-Time Insight Into Patient Health
Continuous monitoring of patient vitals and health data from home.
What we track - RPM
- Blood pressure
- Heart rate
- Oxygen levels
- Weight (CHF monitoring)
What we do
- Identify early deterioration
- Trigger proactive interventions
- Alert care teams when needed
Value
- Prevent emergency events
- Reduce ED visits
- Improve clinical visibility
Reducing Errors. Improving Adherence. Saving Lives.
Structured review and reinforcement of medication regimens post-discharge.
What we do - CCM
- Medication reconciliation
- Identify discrepancies
- Educate patients
- Monitor adherence
Value it Matters
- Safer transitions
- Fewer complications
- Better outcomes
Seamless Communication Across the Care Continuum
Active coordination between providers, facilities, and patients.
What we do - TCM
- Schedule follow-up appointments
- Coordinate with PCPs and specialists
- Ensure continuity between hospital and SNF
Value
- No missed follow-ups
- Better alignment across providers
- Improved patient journey
Identify High-Risk Patients Before They Decline
Using clinical protocols and engagement to identify patients at risk of deterioration.
What we do - RPM
- Monitor symptoms and behavior
- Flag early warning signs
- Escalate care proactively
Value
- Prevent crises
- Avoid unnecessary hospital returns
- Improve outcomes
Why Our Services Deliver Real Results
Physician-Led
Clinical expertise drives every interaction.
Outcome-Focused
Every service is tied to measurable performance.
Fully Managed Execution
We don’t just advise—we execute.
Designed to Work Within Your System—Not Disrupt It
Follo Health integrates seamlessly into your existing workflows.
- No heavy IT lift
- No disruption to discharge processes
- Rapid onboarding
- Scalable across departments
Timeline
- Week 1: Alignment
- Week 2: Integration
- Week 3: Go live
One Platform. Multiple Outcomes.
- ↓ Readmissions
- ↑ Patient Engagement
- ↑ Follow-Up Compliance
- ↓ ED Visits
- ↑ Patient Satisfaction
- ↑ Care Continuity
WHO BENEFITS
Hospitals
- Financial performance
- Quality metrics
- Reduced penalties
SNFs
- Fewer transfers
- Better stability
- Stronger partnerships
Care Teams
- Less burden
- Better coordination
- Improved efficiency
Services That Don’t Just Support Care—They Strengthen It
Follo Health transforms post-discharge care into a structured, accountable, and measurable system—ensuring patients don’t just leave the hospital
They recover. They stabilize. They stay home.